Last Updated January 9, 2025
Kathleen Wessel, Vice President of Business Management and Operations at the AHA, is joined by Lisa Jordan, Chief Administrative Officer – Medical Foundation & Vice President of Professional Services, City of Hope, and Leslie Basham, President & CEO- Surgical Directions. Together they discuss workforce challenges in the anesthesia department at City of Hope, as well as the solutions that ultimately revitalized their services.
Transcript
Kathleen Wessel
The everyday components of management such as scheduling and compensation can greatly contribute to the success or challenges of a clinical department. Welcome to AHA Associates Bringing Value, a podcast from the American Hospital Association. In this series of podcasts, we speak with AHA Associate Program business partners, check in on their efforts, and learn how they support AHA hospital and health system members. I am Kathleen Wessel, Vice President of Business Management and Operations at the AHA. And today I am pleased to be joined by Lisa Jordan, Chief Administrative Officer, Medical Foundation, and Vice President of Professional Services for City of Hope, and Leslie Basham, President and CEO for Surgical Directions. In this episode, we’ll delve into the workforce challenges in the anesthesia department at City of Hope, as well as the solutions that ultimately revitalized their services. Welcome to the podcast.
Lisa Jordan
Thank You
Leslie Basham
Thank you for having us. We’re glad to be here.
Kathleen Wessel
Okay. I want to start off today’s discussion starting with you, Lisa, but can you tell the listeners about your professional backgrounds, and for both of you, how have your teams worked together?
Lisa Jordan
Sure, Kathleen. Thank you. I have been in healthcare in some capacity, finance management, rev cycle, a number of things for more than 30 years. For the past 11 years, I have overseen physician administration and management in our MSO and our academic departments at City of Hope, including in my area, responsibility is physician and APP staffing and recruitment, including in anesthesiology. And about five, six years ago, Leslie, I believe that’s right. We were facing some pretty big challenges in anesthesiology. We needed some help, we needed some expertise in the industry and that led us to Surgical Directions. We engaged in a consulting agreement with them.
Leslie Basham
And so, hello, I’m Leslie Basham. I’m the President and CEO of Surgical Directions, and some of my background is I’ve been with Surgical for about seven years. We work with health systems across the country. We’ve worked with about 500 different hospitals, health systems to build world-class procedural care, perioperative, and anesthesia services across the United States. We got connected with City of Hope to help them, particularly, with this anesthesiology opportunity. Prior to joining Surgical, I worked at a large global consulting firm, and prior to that, I was in investment banking.
Kathleen Wessel
Excellent. So Lisa, what specific signs or challenges within your anesthesia department led you to realize that significant change was necessary and what specifically were the tipping points?
Lisa Jordan
Well, the tipping point seemed to come on rapidly. We were facing a workforce that was ready to start leaving. It happened pretty suddenly, but if we really look back, there were signs all along. The City of Hope, if you’re not familiar with it, it is a leading cancer institution. We’re one of the top five cancer institutions in the country, and we’re really known for our bone marrow transplants. We’re the largest transplant center in the country. About eight to 10 years ago, eight years ago, we made an intentional effort to grow our solid tumor programs. As a result, we actually more than doubled our size in surgery throughout Southern California. With that, though, we didn’t add ORs and we really thought our anesthesiology staff could handle the increased volume. Our operating hours were extended into the night because we didn’t have it horizontally to extend, so they were extended into the night, and we increased our OR hours over a short period of time by more than 50%.
So it was pretty dramatic increase. Our ORs went from a utilization percentage of 50% to 85 to 100% on any given day. I mean, we got really busy really fast. The anesthesiologists that we had—many of them 15, 20 years, they’ve been here a long time—were on a peel-off schedule, where they all started at 7:30, but the first one in would be the first to leave and it would change every day. So often, a couple of anesthesiologists were leaving at 1:30, 2:30 in the day. When all of this happened, it changed. They started working from 7:30 in the morning to 7:30 at night, and then we extended it to 9, we extended it to 11. It was really, really tough on our doctors. We also have a compensation model that is productivity-based, or we had one before we went to shift-base, and so the anesthesiologists weren’t actually getting compensation recognized for these longer days. The way that ASA units work, you could have one really long complex case that takes you 15 hours and you’re going to earn less than you would if you had three short two-hour cases. So that was a problem. We worked with our chair of anesthesiology. We spoke to him about some sort of shift-based model, and he came back and wanted to add 20 anesthesiologists and 30 CRNAs, which was a really tough thing for us to swallow.
So, that was tough. And then during all of this time, Covid happened. Doctors started demanding work-life balance. We had doctors coming out of training programs that were used to restricted hours. Just the whole market was changing. There weren’t enough anesthesiologists for us to even hire to keep up with our staffing demands, so we were forced to turn to locums like many of our competitors were doing. Those locums are 450 to 500 bucks an hour, and on top of that, all of our anesthesiologists were also getting offers to go make 450-500 bucks an hour. So enter the locums into our system, working alongside our doctors, making 200 bucks an hour. They talked, it blew up, and that’s why we ended up in a crisis and needed Surgical Directions
Kathleen Wessel
Following that path, I could see how that happened. So, Leslie, when Surgical Directions first engaged with City of Hope, what was the process for identifying the most critical issues to address?
Leslie Basham
Yeah, I mean, Lisa did a great job laying it out, but we first needed to make sure that we really understood what was happening. And so with Lisa, we made sure we sat down and spoke with the physicians, understood the concerns that they were up against with surgeons, and as Surgical Directions, we have benchmarks and we’re working with anesthesia groups across the country. So we also wanted to say, well, what’s happening at City of Hope, what’s happening in Southern California, and what’s happening across the country, so that we could better understand how we design something that could work better for this growing volume with the restricted space, restricted number of operating rooms. And so we looked at a lot of data. We did heat maps about how many operating rooms they were running at what times, at what probability throughout the day and throughout the year.
And we constructed different types of models. We have a tool that sort of optimizes anesthesia models and shifts based on what could be the best for that particular hospital and for those physicians, right? Some physicians, as Lisa mentioned, want to work really long shifts but have more days off, and some want to work shorter shifts that allow them to have time to get back to their child’s soccer game, for example. And so we had to start thinking through some of those things. So it was really understanding the situation, listening to the physicians, and looking at what was happening in the country. Lisa said it, well, you’re not just competing with Southern California because of the locum and travelers. You’re competing with the market across the country. And so we had to make sure that we understood what the competitors were doing, what they were offering, and what was happening more broadly so that we could design something that really helped City of Hope achieve their mission of world-class cancer care in a way that did not create so much burnout and attrition in a market that you really can’t afford attrition, right? There’s just not that many other people that could come to work, especially in that environment where it’s such complex, important care for the patients.
Kathleen Wessel
That makes complete sense. You both mentioned various improvements. What were some of the key strategies that you’d employed to ensure that these changes were successfully implemented and accepted by the staff? I bet that was a huge lift.
Lisa Jordan
So the very first thing we did is we took this seriously. It was all hands on deck. Our executive leadership, myself, my colleagues, we came in and we met with the anesthesiologists a lot. Before we hired Surgical Directions, we sat down with them to listen to what was happening to them. Then I think it sent a very strong message to them to hire an outside consulting firm to come in and help us assess the situation. So opening up those lines of communications were really important. I have to tell you, too, the closer you are to operations, the more you see the reality of this; our executives that get further and further and further away from what’s happening on a day-to-day basis, I find sometimes think about how it’s been for a long time. So I think they needed some education too about how the market has really changed. It’s not like it’s not just a temporary thing. There really is a wholesale shift here. So hiring that firm was very important because it was an independent voice of what was happening.
Then the things that we heard that were really bothering the physicians was their time, and we were not paying them for their time. We were paying them for what they were producing, and that wasn’t matching the time. So we made a wholesale shift to shift-based work. That was a huge change for us. What helped us with Surgical Directions, which balanced the cost, is the plan that the chair came up with was based on he thinks he needs a doctor there until the latest possible time that a case may go. And so that was really inflating the staffing model. With Surgical Directions coming in, they could assess how often that really happens and maybe you staff up to a lesser time at night. And we created overtime pay, which was, let me tell you, that’s something totally new for us. But we did make that investment, and it changed and lowered the actual number of staff that we needed.
The other thing that was huge for us, we didn’t use CRNAs in the past, and there was a resistance to do so. But we invested heavily in it, and it has definitely worked out. The physicians manage that workforce. Nursing does not manage that workforce. And I think that was another very important thing that happened. And then the last strategy, this is tough in our market—it’s tough to make margin today. There’s a lot of pressure on costs. And so we’re constantly trying our best to be as efficient as possible. And I think what we’ve learned with our physicians is we’ve got to find that cost savings somewhere else. We just have to make the investment in the physicians.
It is too precious of a resource, and when it goes sideways, things can go upside down really, really quickly. So instead of staffing on the margin, we need to, and our strategy is, to staff in case of some issues. So those are the major things that really happen to us. And I would say the shift-based schedule, also, we incorporated a target where people would work between 45 and 50 hours on average per week, and they have the ability to trade certain things. So there are so many night shifts they’re supposed to take or so many weekend shifts, and we assign value to that, that they can trade with each other. So there may be someone who’s younger or wants to make a lot more money, they may take all the weekend shifts that they can. And someone who is new father, mother, whatever, doesn’t want to work like that. So that was very, very big for us too.
Leslie Basham
I’ll just add onto that too. I think sometimes it’s scary to make these changes. So one thing we did is connect City of Hope to other institutions that other hospitals that were also in CRNA or care team models and talk through how those changes worked or other shift models. I think that peer-to-peer conversation as well is very important so that people are less intimidated by that change. And I think that really helped. And then it’s just educating everybody. I mean, as we talked about, the surgeons have a particular perspective. Anesthesiology is a particular perspective. The executives have a different perspective. And how do we help everyone understand the other person’s perspective as well and design a common ground. Let’s take the financial piece, procedural care. Surgical care generates usually around 70% of a hospital revenue. It’s a very important driver of care for patients and financials for a hospital system.
Anesthesiology is—using a baseball analogy—usually the catcher of revenue and the surgeons are the pitcher, so they only can do what is brought into the OR. So you need anesthesiology to drive that big revenue engine for the health system. So to help think about it in all those different aspects and put them together, it’s about the care for the patient, but it’s sustainably giving care, which means you need to be able to make payroll associated with that. And so we brought people together and showed them how others had done it, and I think that was really important to the success of this initiative.
Kathleen Wessel
So Lisa, what are some of the greatest impacts that you’ve seen since implementing the new anesthesia care team model and the physician shift schedule? It seems like there’s probably quite a bit.
Lisa Jordan
Absolutely. I mean, the work hours dramatically changed. So most of the physicians are indeed working between 40 and 50 hours a week regularly. There’s not many that are extended beyond that. So that really stabilized our workforce and our physicians really appreciate the CRNAs. So it is an admired workforce. We’ve hired some really strong ones, not only by the anesthesiologists. I mean many of the surgeons are requesting the CRNAs in their rooms. They trust them, and they have a very strong working relationship together. When you’ve got problems in your OR, the world knows about it. So we had a hard time recruiting. We don’t have a hard time recruiting anymore. I think we’ve been able to solve that. And we actually have quite a few CRNAs seeking us out to work here. So that was a big impact. But the greatest impact is that the physicians have a much more reasonable schedule, and they’re not showing up every day wondering when they’re going to go home. And I think it’s made a tremendous impact on how they feel about City of Hope. This is a really special place. It’s a different place. This is high acuity, very, very sick patients. Everyone’s rowing in the same direction to cure cancer. It’s a special place to work, and it has allowed them to be able to reconnect with a mission, I think.
Kathleen Wessel
Yeah, what a wonderful outcome. I’ve got one more question for you both, and it’s really around how do you ensure that the solutions that you’ve implemented will continue to provide benefits long term?
Lisa Jordan
I do not think we can ever rest on our laurels and think everything is going to continue the same. It is a constantly changing environment. We have to figure out—they’re precious; they train for many, many years, and it’s a shrinking workforce. So we have to constantly think about how we can have our physicians do more, more and not burnout. So I never want to take our eye off that ball, keep our ear close to the marketplace, and stay in constant communication with the doctors. That’s very, very important. And we do that by conversation, but we also do that in analytics and keep a close eye on work hours, on work productivity, and on cost. It’s very important. This isn’t an area you can just sit by.
Leslie Basham
I’d add too, what was designed so well was providing optionality, right? People love choice, and when they have some choice over their schedule and when they work and where they work, it allows people to feel bought-in to the solution and it grows with you. So, the model that we created and the structures that we created from team care, with physicians and CRNAs, and the shifts and the overtime, it helped people be able to grow as volume grow and the market is still changing. Lisa is right in saying that you can’t rest on your laurels—the issues that created that major tipping point are still happening. And so we need a model that can continue to adjust as the market still contracts, the anesthesiology market still has these friction points, and as people’s needs change, as their lives change. And so I think why this has been more sustainable is that there’s more levers you can pull. Right now, we have CRNAs and shifts and overtime and different options, so there’s more levers to pull, but also people have some choice in how that works through that trade system. And so it just lets City of Hope evolve without having to make a huge giant change again when the world is changing and surgical care is changing every day. And I think that’s really helped. And clearly the communication and the culture help people make good choices, and they want to provide that great cancer care.
Lisa Jordan
One of our keys to success that really helped us is we have an incredible partner with the chair of anesthesiology. He’s a good man. He’s Dr. Jamie Sullivan. He’s been with us for a very long time and just a very empathetic, caring individual. He really is the one that has created such an incredible culture between our CRNAs and our anesthesiologists, and a lot of the success that we have had is because of Dr. Sullivan. So I do want to acknowledge him for that. Thank you.
Kathleen Wessel
I want to thank both of you for joining the podcast and sharing these takeaways with other AHA members. It’s been incredibly valuable. For our listeners, if you’d like to learn more about the AHA Associates Program or anything that you’ve heard on this podcast today, please visit at sponsor.aha.org. This has been an Associates Bringing Value podcast, brought to you by the American Hospital Association. Thanks for joining us.
Lisa Jordan
Thank you.
Leslie Basham
Thank you.
