Saying 'No' to Your Surgeons
Here are three scenarios where you may have to do what many managers dread: say 'no' to the very surgeons who bring cases to your facility.

Capital equipment
When doctors ask for equipment, I ask them to present supporting information that would help our board when considering the request. Specifically, I need data on the number of cases being sent elsewhere because our facility doesn't have the equipment. I need to know the payer mix for the cases, so we can determine if our reimbursements will make the equipment affordable. I ask for actual historical data, not opinions. Lastly, I ask for contact names of various vendors who could bring in the equipment on a trial basis.

Physicians often tend to think in evidence-based terms, so you are speaking their language by asking for this sort of data. Sometimes they will defer the requests themselves if it's apparent that the numbers don't add up.

At our facility, the physician, if an owner, may present the request directly to the board. If the physician is not an owner, the administrator presents the information. I find it helpful, however, to ask the physician to help present the request in person, even if I coordinate the effort. Physicians tend to relate well to other physicians regarding budgetary considerations, and they may react better to a decision not to fund equipment if another physician is involved.

Contact Ann Geier at '[email protected]').

Staffing
Requests that deal with staffing can be more difficult to handle, because these situations are often delicate. Let's deal specifically with requests to work exclusively with certain staff members or a certain surgical team. It's virtually impossible to guarantee that certain staff will always be available, so don't make promises you can't keep.

What if the surgeon is overly demanding, rude and ungrateful, no matter how hard the team tries to help? I have personally been involved in a situation where a very difficult surgeon would only work with one surgical tech. After months of putting up with verbal abuse, the tech requested to be given a break from this surgeon, a request I granted. The surgeon was angry when another experienced tech scrubbed the first case and went ballistic when the "preferred" tech was seen elsewhere in the facility. This became a situation that the medical director had to deal with.

For more routine situations, you need to ask yourself these questions and then talk with your physicians.

• Is the request reasonable for the schedule? Remember that there will be conflicts where the employee is needed in another OR. There will be sick days and vacation days - not just for the requested staffer(s) but also for their coworkers.
• Is the request in the best interests of the patient? Sometimes, it's critical that an experienced team works with the surgeon. However, it is not always possible to assemble the same team, so contingency plans are necessary.

At our facility, we all agreed that all staff members needed to be trained and comfortable with the more complex procedures and equipment. We therefore started rotating staffers into the cases, first working side by side with experienced staff, and then going solo. After training, the staffers are rotated regularly into the cases. In this way, the surgeon learns to work comfortably with more than one team, or at least a different configuration of team members.

• Is the request fair to the employees? If the staff refuses or requests not to work with a particular surgeon, you need to investigate the reasons, perhaps by going into the OR yourself and witnessing the interactions between the surgeon and the staff. It also involves talking to the surgeon. Be polite but be truthful in telling the surgeon about staff complaints. If you can't resolve the issue, the next step may involve a one-to-one meeting between the surgeon and the medical director.

Additional OR time
Honoring requests for OR time can necessitate overtime pay for staff, inhibit the use of "prime days" and affect the efficiency of your schedule. You need to use two key tools to properly handle these requests.

• Reports on OR usage. Is the physician a high-volume user of the center who truly needs additional time? Is there another surgeon who consistently under-utilizes the allocated time? You can't dangle extra OR time as an incentive to bring more cases to the center, but if you have hard data that shows that a certain surgeon fills block times to capacity, you need to take the request seriously, or he will go elsewhere. Conversely, if OR usage lags in either volume or efficiency, you can present the data directly to the requesting surgeon, and your denial of the request cannot be refuted.
• Guidelines. Work with your board and/or medical director to establish written guidelines to clarify your scheduling processes; for example, the circumstances under which you'll offer non-emergency overtime to staff.

Unfortunately, even if the request is reasonable, the center's schedule may be too inflexible. But be creative and involve your staff in the discussion. Staffers may offer to change their schedules to allow you to accommodate the physician's request.

Docs are people, too
I have found that if doctors realize that time and effort were spent on their requests, they usually respect the outcome, even if it's negative. Physicians who do not put the good of the facility over their own self interest are the exceptions rather than the rule.