The Collaborative-Autonomous Team (CAT) Model of Care in Anesthesiology

Why It Matters: The specialty of anesthesiology has been plagued by scope of practice battles for a century. In our organization, we decided we can do something better than continue old tensions. Both professions need a model of care that works for the healthcare system, and most importantly, for patients.     

What is the Collaborative Anesthesiology Team (CAT)?

Practically, The CAT is local, optimal teams of CRNAs, MDs, or both.  It is the anesthesiology version of “the right provider, at the right time, for the right patient”.

·      The best mix of providers is based on:

·      Resources (i.e. the characteristics of the local available providers)

·      Needs of the patients and facility.  

·      Remember - all anesthesia providers are licensed.  They’re not all the same.  That’s why we don’t design models of care predominantly around licensure – we design them based on creating value for patients.  

·      The CAT emphasizes value.  In contrast to the “Anesthesia Care Team” (ACT) - a model that inherently limits value and increases costs, all anesthesia providers are encouraged to use their entire skillset – and expand it – to the benefit of patients.  

·      Conceptually, the CAT is based on the idea that if true professional collaboration is to exist, each needs to recognize the other’s autonomy.  Once that occurs, then sincere interprofessional collaboration can occur.  Collaboration and autonomy are not mutually exclusive – in fact, they are both necessary if anesthesiology professionals are going to meet the challenges of the future. 

Last, the CAT is a model that respects both of the major professions in anesthesiology.  CRNAs and MDs are not the “same”, but they do have significant, at times complete, overlap, in the scope of services offered.  However, rather than emphasizing differences, we emphasize interprofessional collaboration between CRNAs, between MDs, and between both professions.  Our focus isn’t politics – it’s value.

The CAT is local, optimal teams of CRNAs, MDs, or both.  It is the anesthesiology version of “the right provider, at the right time, for the right patient”.

What are the factors in designing the CAT?

When our organization thinks about how to create a local team, we consider three factors.  

·      Resources: availability, skills of individuals, and experience.

·      Needs: type of facility and surgeries, acuity.

·      Culture: what are surgeons and staff accustomed to? 

Each of these aspects are deserving of their own conversation.  For this introductory article, the key characteristic is that whatever the makeup of the providers, the concept is the same: a team not focused on hierarchy, but on outcomes.

The CAT emphasizes value.  In contrast to the “Anesthesia Care Team” (ACT) - a model that inherently limits value and increases costs, all anesthesia providers are encouraged to use their entire skillset – and expand it – to the benefit of patients.  

Who “runs the board”? 

Depending on the facility, our organization often uses an “Anesthesia Coordinator” (AC) (similar to a “float”) role that is available to “run the board” - make assignments, assist in emergencies, place blocks, offer breaks, and so on.  It is not limited by profession.  In facilities where acuity is high, the AC plays an important role in patient safety and must be filled by an experienced individual with a broad array of clinical skills and knowledge.  The AC role also requires strong interpersonal and communication skills, as they facilitate patient flow and work with surgeons and OR staff.  

How does this differ from the ACT? 

·      Intent and operation.  Designed by a trade group, the Anesthesia Care “Team” is inherently designed to limit CRNAs from their full contribution to patient care.  Thus, the word “team” is a misnomer.  Can you imagine if a football team tried to compete while only allowing their linebackers to use one arm?  That’s the metaphorical version of trying to use the ACT.  Teams don’t limit value – they maximize value.  

·      No artificial limits on scope.  ACT practices, by definition, limit the privileges of CRNAs (PNBs, neuraxial, etc.) to limit their ability to practice (or potentially, compete effectively) in the future.  This is a scarcity approach that damages morale and in the long-term, drives up costs for the local facility and the healthcare system. 

·      Costs and Compliance.  The ACT inherently drives up costs from duplicative services and is prone to Qui-tam and False Claims Act lawsuits (like this example, or this one, or this one, or this one) When everyone is maximizing value at the local level, we decrease costs and increase access, and we reduce risk by avoiding compliance issues.

When everyone is maximizing value at the local level, we decrease costs and increase access, and we reduce risk by avoiding compliance issues.

What are some examples of the CAT in action?

The CAT is profession-neutral and biased towards value, so there are many ways to structure the CAT, depending on resources and needs.  

We’ve implemented: 

·      Solo CRNA or Solo MD (office or 1 OR ASCs)

·      All-CRNA models

·      Side-by-Side models (no “AC” – everyone in their own room)

·      1 AC available for multiple sites (CRNA-only)

·      1 AC available for multiple sites (Interprofessional group)

In our sites that include physicians, the idea is to maximize value, so if that physician is ideal in the AC role, they play that role – or if they are most suited for providing the service directly (usually, subspecialty cases), they play that role as well.  Demonstrating our commitment to quality and outcomes over politics, we also work with separate, all-MD groups to cover facilities as well.  These are non-political relationships where we have found the “win-win” to provide value for our surgeon colleagues and the facility. 

Bottom Line: During and After COVID, the country needs all anesthesiology professionals to make their full contribution to patient care.  That’s what maximizes value.  Collaborative-Autonomous Teams – whatever their makeup – are the future.  

Moving forward, I’ll share our organization’s experience with the CAT, and what it means for other parts of the specialty: leadership, reimbursement, healthcare policy (i.e. supervision, AAs) and competition both between and within anesthesia professions.  

Last notes:

• Using interprofessional collaboration in anesthesia isn’t new. However, we see the need to formalize the concept, so that hospital and ASC administrators can more easily understand how we are increasing value for their facilities.  
• While the CAT deals with local decisions, I'm often asked about statutory changes. The answer is simple: the law should allow professionals to practice at their full scope. Then, appropriately, decisions should be made at the local level. For instance, I am currently legally authorized to offer advanced cardiac anesthesiology services - but I don't, because as I professional I am self-limiting, and my local department wouldn't "assign" this case to me, given my paucity of experience. This is similar, in principle, to how medical doctors are authorized for the "unlimited practice of medicine" but their practice is rightly limited by a variety of bodies (certifying bodies, credentialing committees, case assignments by department leaders, etc). Again, similarly, this principle applies to statutory independence for CRNAs, as well - of course the law should recognize CRNAs as full professionals. This clearly means "independent" practice - i.e. responsible for themselves. Further, claims that full practice authority for CRNAs eliminates MDs from practice hasn't been substantiated, and CRNAs have practice independently for years. In most healthcare settings, a team is required - and that team should have autonomous team members who collaborate for the best possible patient outcomes.

Updated: 10/1/21, 9/6/22

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