ROTATION: TRANSITION TO PRACTICE
TYPE: REQUIRED – Satisfactory completion of all aspects of this rotation is necessary for graduation from this residency program.
DURATION: 3 months
FACULTY:  Harshdeep Wilkhu, MD (clinical coordinator), Otto Albuschat, MD (Didactics) plus the following participating faculty:  Nikolaus Gravenstein, MD, David Bjoraker, MD, Dietrich Gravenstein, MD, Michael Mahla, MD, Sno White, MD, Gang Zheng, MD (there may be others on occasion).  In addition, Mr. Michael Nyland, our Associate Director for Medical and Health Administration will play a key role in the billing and coding portion of the educational program.
PREREQUISITES: Completion of Clinical Base Year, CA-1 and at least nine months of the CA-2 year

I. GOALS:

The Transition to Practice rotation is a 3-month rotation in the CA-3 year that will closely simulate a private practice environment.  Four operating rooms in the Shands OR suite will be designated each day to be assigned to residents working in this rotation.  Five residents will be assigned to this rotation for a three month period.  An additional practitioner or two(CRNA or AA) will be assigned to work with the group when a group member is on vacation or has night float duties.  These five individuals will form a Private Anesthesiology Group that will be tasked with the following:

• Clinical coverage of the four transition to practice operating rooms
• Improve clinical, work flow and time management skills to become a maximally efficient and competent anesthesiology clinician
• Management of their own work schedules, including late coverage of these operating rooms each day
• Learning to appropriately bill and code for all anesthesiology services provided in these operating rooms
• Learn to manage case flow in these four rooms to get the most productivity in the least time.  This private practice will be “competing” with the coexisting academic practice.
• Learn to interface with other health care personnel to produce the most competent, caring, and efficient operating room unit possible

 

The five residents assigned to this rotation will form their own private practice group and develop a group administration (i.e. president and financial officer).  They will manage their own daily work schedule and clinical assignments to the four operating rooms designated for this rotation.  Two residents from the group at a time may be on vacation or assigned to the night float team at any one time.  No additional  vacation / leave / or night float time will be permitted from this rotation.  In general, it will be expected that at least 4 residents will be available for this rotation each day.    One resident from the group will be assigned each day as the floor runner.  This resident will manage all case flow in the four rooms assigned to this rotation.  This resident will also be responsible for preoperative preparation and postoperative care for all patients in these four rooms.  In addition, the floor runner will be responsible for working with all CRNA / AA practitioners to develop and implement anesthetic plans with only observational input from the faculty member covering the room.  Finally, this resident, along with the faculty, will be responsible for giving breaks as needed to each practitioner. 

 

II. OBJECTIVES:

Quality Practice:  The resident will independently develop and implement safe and appropriate anesthetic plans for each case assigned in his / her room.  The resident will implement the plans for induction, maintenance and emergence with only observational involvement from attending anesthesiologists.  Anesthesiology attendings will only intervene in the management of these cases when medically necessary – residents will remain responsible for communication about ongoing medical / surgical issues with attending anesthesiologists as always.  These cases will not be used for teaching new techniques.  Anesthesiology residents in this rotation will be CA-3 residents or advanced level CA-2 residents only who are thought to be ready to transition to practice.  First year residents are not eligible for this rotation. 

Efficiency: 

• The first patient should be on the operating room table by 0730 or 0800 depending on the room with all paperwork complete.  The anesthesiology resident must make certain that appropriate preoperative evaluation and counseling have occurred.  The nursing staff must assure that all other paperwork is completed in time to meet this goal.
• For routine ASA I and II patients, the resident will be able to induce anesthesia and turn over the case for surgical activity in 10 minutes or less from the time the patient is placed on the operating room table.  More complex cases may take somewhat longer, but the goal should be 10 minutes.
• The patient should emerge promptly from anesthesia, and transport to the recovery area should occur in less than 10 minutes from the application of the dressing.
• Turnover time from leaving the OR to the next patient on the table ready for induction should be no more than 20 minutes.
• In the case where the resident is not efficient or appropriately moving along, the anesthesiology attending will intervene and speed things up.  The goal will be to have such interactions disappear by the end of the rotation. 

Coding / billing:  The resident on this rotation should learn to properly code and bill for all procedures performed in the transition to practice room.  Each resident will meet with Mr. Nyland for an orientation to billing and coding.  Residents will be given protected time for this orientation, and a CRNA or AA may be assigned to a room covered by this rotation to facilitate this education.  In addition, they will be provided with specific reading material they will be expected to master during the rotation.  The floor runner each day will be responsible for assuring proper billing / coding for all previous day cases and will meet with billing / coding personnel to assure optimal coding that is fully Medicare compliant. 

Competencies Taught and Evaluated

Patient Care Skills

• Develop and implement appropriate anesthetic plans with minimal input from faculty.
• Improve efficiency of anesthetic management to meet the following goals:
  • The first patient should be on the operating room table by 0730 or 0800 depending on the room with all paperwork complete.  The anesthesiology resident must make certain that appropriate preoperative evaluation and counseling have occurred.
  • For routine ASA I and II patients, the resident will be able to induce anesthesia and turn over the case for surgical activity in 10 minutes or less from the time the patient is placed on the operating room table.  More complex cases may take somewhat longer, but the goal should be 10 minutes.
  • The patient should emerge promptly from anesthesia, and transport to the recovery area should occur in less than 10 minutes from the application of the dressing.
  • Turnover time from leaving the OR to the next patient on the table ready for induction should be no more than 20 minutes.
• Independently evaluate and manage patient comorbidities to assure the patient is ready for their surgical procedure.  Appropriately utilize consultants as needed and interact with the primary surgical service to assure proper communication.

Medical Knowledge:

• Demonstrate medical knowledge - both general medical and anesthesiology-related - appropriate for an independent practitioner of the specialty of Anesthesiology. 

Professionalism

• Maintain professional demeanor and interactions with staff and patients despite the increased production pressure (speed) associated with efficiency and rapid turnover
• Demonstrate consultant level skills in all interactions with physicians involved in patient care. 
• Interact with and learn to manage non-physician anesthesia providers (CRNAs and AAs).  Effectively balance appropriate physician directed patient management with practitioner's professional needs and desires for some degree of autonomy

Interpersonal and Communication Skills

• Interact with nursing and paraprofessional personnel to assure smooth, efficient operation of the 4 OR TTP suite.
• Interact with colleagues in the TTP rotation to assure that each individual knows their role each day and carries it out in an efficient fashion. 
• Develop team skills with the 4 other TTP group members to assure a pleasant, efficient working environment.
• Take ownership of the management of each patient so that the primary interaction with the patient is resident-based, not faculty based.  Demonstrate consultant level skills in all interactions with the patient and the patient's family.
• Develop management / interaction skills that will help the physician interact with and supervise non-physician anesthesia providers.

Systems-Based Practice Skills

• Learn about different Anesthesiology group practice models - and potentially experiment with several different models during the 3-month rotation.
• Develop efficient OR management skills
• Effectively manage patient flow in the four TTP operating rooms
• Manage / interact with ancillary personnel to assure efficient operation of the 4 TTP operating rooms
• Appropriately code all anesthesia related procedures for each patient
• Working with our Departmental personnel, gain an understanding of the process of developing a fully medicare compliant bill for each patient.

Practice-Based Learning Skills

• Attend educational conferences developed specifically for the TTP group
• Each group is expected to take initiative in developing part of their own educational program by:
  • Choosing topics for presentation
  • Preparing the topic and presenting the topic or  obtaining speakers outside the group to present the desired topic

 

III.  EVALUATION TO DETERMINE GOAL ACHIEVEMENT

 

You are evaluated every week by all attendings who worked with you. The attending physicians will complete a Departmental Resident Evaluation Form, which is reviewed by the Clinical Competence Committee. Your advisor informs you of any problems identified, and serious problems will be discussed with you immediately after they occur. You will also be specifically evaluated by the Dr. Dangler and the results of your evaluation will be discussed with you.

 

Each GROUP of residents assigned to this rotation will also be evaluated in the following areas:

• Ability to work together to accomplish daily work tasks in a competent and efficient fashion
• Ability to work with other health care personnel
• Ability to appropriately code and bill for all services provided
• Evaluative input in these areas will be provided by OR nurses, scrub technicians, anesthesiology technicians, preop area / recovery personnel, billing / coding personnel, and Mr. Michael Nyland (360 degree evaluation)
• Each GROUP will be evaluated for productivity.
• A 360 degree evaluation for each resident will be completed by:
  • All group members
  • Nursing personnel associated with the group
  • Faculty members associated with the group

 

IV.  Resources available to accomplish the above Goals and Objectives (see General Shands Operating Room Rotation)

 

• Semo JJ, Esq.  Starting out:  A Practice Management Guide for Anesthesiology Residents.  The American Society of Anesthesiologists, 2001.
• Systems Based Practice Section of the Classic Articles Library
• Health Care Systems Section of the Classic Articles Library
• TTP section of the Classic Articles Library

RETURN TO INDEX FOR GOALS AND OBJECTIVES
Revised 7/2006