The ASA publishes the Manual for Anesthesia Department Organization and Management¹ that includes sections on physician responsibilities for medical care and on medical-administrative organization and responsibilities. Included are the ASA Guidelines for the Ethical Practice of Anesthesiology, which incorporate sections on the principles of medical ethics; the definition of medical direction of nonphysician personnel (including the specific statement that an anesthesiologist engaged in medical direction should not personally be administering another anesthetic); the anesthesiologist’s relationship to patients and other physicians; the anesthesiologist’s duties, responsibilities, and relationship to the hospital; and the anesthesiologist’s relationship to nurse anesthetists and other nonphysician personnel. Further, beyond summaries such as this textbook chapter, reference to the great body of material created and presented by the ASA is an excellent starting point to help young anesthesia professionals during training prepare for the increasing rigors of starting and managing a career in practice. On the ASA web site, within the “For Members” area, the “Practice Management” section is functionally a gold mine that includes extensive information on the organization, administration, and business of anesthesia practice with reference to an extensive catalog of webinars and podcasts, as well as a compendium of chapters from the annual ASA Practice Management Conference.² Likewise, there is a great deal of information on the ASA web site concerning the most recent governmental regulations, rulings, and billing codes. Further, the ASA Newsletter contains the monthly columns “Washington Report” and “Practice Management,” which disseminate related current administrative, organizational, and financial developments (and which are reprinted on the ASA web site).

In addition to the ASA and the American Association of Nurse Anesthetists, most anesthesiology subspecialty societies and interest groups have web locations, as do most journals. Particularly, the web site of the Anesthesia Patient Safety Foundation, www.apsf.org, has been cited as especially useful in promoting safe clinical practice. Electronic bulletin boards allow anesthesiology practitioners from around the world to exchange ideas in real time on diverse topics, both medical and administrative. One of the original sites that remains available is “GASnet,” and a web search (“anesthesiology + bulletin board”) reveals a great number of sites that contain a variety of discussions about all manner of anesthesiology-related topics, including practice organization, administration, finance, and management. In addition, references to the entirety of the medical literature are readily accessible to any practitioner (such as by starting with www.nlm.nih.gov to access Medline). A modern anesthesiology practice cannot reasonably exist without readily available high-speed Internet connections.

The documentation for the credentialing process for each anesthesia practitioner must be complete. Privileges to administer anesthesia must be officially granted and delineated in writing. This can be straightforward or it can be more complex to accommodate institutional needs to identify practitioners specially qualified to practice in designated anesthesia subspecialty areas such as cardiac, infant/pediatric, obstetric, intensive care, or pain management. Specific documentation of the process of granting or renewing clinical privileges is required and, unlike some other administrative records, the documentation likely is protected as confidential peer review information. Any questions about complex sensitive issues such as this should be referred to an experienced attorney familiar with applicable federal and state law. Verification of an applicant’s credentials and experience is mandatory. Because of another type of legal case, some examples of which have been highly publicized, medical practitioners may be hesitant to give an honest evaluation (or any evaluation at all) of individuals known to them who are seeking a professional position elsewhere. Obviously, someone writing a reference for a current or former coworker should be honest. Sticking to clearly documentable facts is advisable. Stating a fact that is in the public record (such as a malpractice case lost at trial) should not justify an objection from the subject of the reference. Whether such potentially “negative” facts can be omitted by a reference writer is complex. Including positive opinions and enthusiastic recommendations, of course, is no problem. Some fear that including facts that may be perceived as negative (e.g., the lost malpractice case or personal problems such as a history of treatment for substance abuse) and/or negative opinions will provoke a retaliatory lawsuit (such as for libel, defamation of character, or loss of livelihood) from the subject of the reference. Further, however, there have been cases of the facility doing the hiring suing reference writers for failing to mention (perceived as concealing) negative information about an applicant who later was charged with substandard practice. Because of the complexities and even apparent contradictions, many reference writers in these questionable situations confine their written material to brief, simple facts such as dates employed and position held. As always, questions about complex sensitive issues such as this should be referred to an experienced attorney familiar with applicable federal and state law.

Because there should be no hesitation for a reference writer to include positive facts and opinions, receipt of a reference that includes nothing more than dates worked and position held can be a suggestion that there may be more to the story (although some entities have adopted such a policy in all cases simply to eliminate any value judgments as to what is positive or negative information). Receipt of such a “dates/position only” reference about a person applying for a position should usually provoke a telephone call to the writer. A telephone call is likely advisable in all cases, independent of whatever the written reference contains. Frequently, pertinent questions over the telephone can elicit more candid information. In rare instances, there may be dishonesty through omission by the reference-giver even at this level. This may involve an applicant who an individual, a department or group, or an institution would like to see leave.

In all cases, new personnel in an anesthesia practice environment must be given a thorough and documented orientation and checkout. Policy, procedures, and equipment may be unfamiliar to even the most thoroughly trained, experienced, and safe practitioner. This may occasionally seem tedious, but it is a sound and critically important safety policy. Being in the midst of a crisis situation caused by unfamiliarity with a new setting is not the optimal orientation session.

After the initial granting of clinical privileges to practice anesthesia, anesthesia professionals must periodically renew their privileges within the institution or facility (e.g., annually or every other year). There are moral, ethical, and societal obligations on the part of the privilege-granting entity to take this process seriously. State licensing bodies often become aware of problems with health professionals very late in the evolution of any difficulties. An anesthesia professional’s peers in the hospital or facility are much more likely to notice untoward developments as they first appear. However, privilege renewals are often essentially automatic and receive little of the necessary attention. Judicious checking of renewal applications and awareness of relevant peer review information are absolutely necessary. The anesthesia professionals or administrators responsible for evaluating staff members and reviewing their practices and privileges may be justifiably concerned about retaliatory legal action by a staff member who is censured or denied privilege renewal. Accordingly, such evaluating groups must be thoroughly objective (totally eliminating any hint of political or financial motives) and must have documentation that the staff person in question is in fact practicing below the standard of care. Court decisions have found liability by a hospital, its medical staff, or both, when the incompetence of a staff member was known or should have been known and was not acted upon.³ Again, questions about complex sensitive issues such as this should be referred to an experienced attorney familiar with applicable federal and state law.

A major issue in the granting of clinical privileges, especially in procedure-oriented specialties such as anesthesiology, is whether it is reasonable to continue the common practice of “blanket” privileges. This process in effect authorizes the practitioner to attempt any treatment or procedure normally considered within the purview of the applicant’s medical specialty. These considerations may have profound political and economic implications within medicine, such as which type of surgeon should be doing carotid endarterectomies or lumbar discectomies. More important, however, is whether the practitioner being evaluated is qualified to do everything traditionally associated with the specialty. Specifically, should the granting of privileges to practice anesthesia automatically approve the practitioner to handle pediatric cardiac cases, critically ill newborns (such as a day-old premature infant with a large diaphragmatic hernia), ablative pain therapy (such as an alcohol celiac plexus block under fluoroscopy), high-risk obstetric cases, and so forth? This question raises the issue of procedure-specific or limited privileges. The quality assurance (QA) and risk management considerations in this question are weighty if inexperienced or insufficiently qualified practitioners are allowed or even expected, because of peer or scheduling pressures, to undertake major challenges for which they are not prepared. The likelihood of complications and adverse outcome will be higher, and the difficulty of defending the practitioner against a malpractice claim in the event of catastrophe will be significantly increased.

There is no clear answer to the question of procedure-specific credentialing and granting of privileges. Ignoring issues regarding qualifications to undertake complex and challenging procedures has clear negative potential. On the other hand, stringent procedure-specific credentialing is impractical in smaller groups, and in larger groups encourages many small “fiefdoms,” with a consequent further atrophy of the clinical skills outside the practitioner’s specific area(s). Each anesthesia department or group needs to address these issues. At the very least, the common practice of every applicant for privileges (new or renewal) checking off every line on the printed list of anesthesia procedures should be reviewed. In addition, board certification for physicians is now essentially a standard of QA of the minimum skills required for the consultant practice of anesthesiology. Subspecialty boards, such as those in pain management, critical care, and transesophageal echocardiography, further objectify the credentialing process. This is now significant because initial board certification after the year 2000 by the American Board of Anesthesiology (ABA) is time-limited and subject to periodic testing and recertification (see Maintenance of Certification below). Many states, some institutions, and even some regulatory bodies have requirements for a minimum number of hours of continuing medical education (CME). Documentation of fulfilling such a standard again acts as one type of quality assurance mechanism for the individual practitioner, while providing another objective credentialing measurement for those granting licenses or privileges.

Anesthesiology may be the medical specialty most involved with published standards of care. It has been suggested that the nature of anesthesia practice (having certain central critical functions relatively clearly defined and common to all situations and also having an emphasis on technology) makes it the most amenable of all the fields of medicine to the use of published standards. The original intraoperative monitoring standards⁵ are a classic example. The ASA first adopted its own set of basic intraoperative monitoring standards in 1986 and has modified them several times. The text of all ASA standards, guidelines, statements, practice parameters, practice advisories, and other documents is readily available on the ASA web site home page under the “Practice Management” or “Patient Quality and Safety” tags.

The Standards for Basic Anesthetic Monitoring document includes clear specifications for the presence of personnel during an anesthetic episode and for continual evaluation of oxygenation, ventilation, circulation, and temperature. These ASA monitoring standards very quickly became part of the accepted standard of care in anesthesia practice. This means they are important to practice management because they have profound medicolegal implications: a catastrophic accident occurring while the standards are being actively ignored is very difficult to defend in the consequent malpractice suit, whereas an accident that occurs during well-documented full compliance with the standards will automatically have a strong defense because the standard of care was being met. Several states in the United States have made compliance with these ASA standards mandatory under state regulations or even statutes. Various malpractice insurance companies offer discounts on malpractice insurance policy premiums for compliance with these standards, something quite natural to insurers because they are familiar with the idea of managing known risks to help minimize financial loss to the company.

With many of the same elements of thinking, the ASA adopted “Basic Standards for Preanesthesia Care.” This was supplemented significantly by another type of document, the ASA Practice Advisory for Preanesthesia Evaluation.⁶ Also, the ASA adopted “Standards for Postanesthesia Care,” in which there was consideration of and collaboration with the very detailed standards of practice for PACU care published by the American Society of Post Anesthesia Nurses (another good example of the sources of standards of care). This also was later supplemented by an extensive Practice Guideline.⁷

A slightly different situation exists with regard to the standards for conduct of anesthesia in obstetrics. These standards were originally passed by the ASA in 1988, in the same manner as the other ASA standards, but the ASA membership eventually questioned whether they reflected a realistic and desirable standard of care. Accordingly, the obstetric anesthesia standards were downgraded in 1990 to guidelines, specifically to remove the mandatory nature of the document. Because there was no agreement as to what should be prescribed as the standard of care, the medicolegal imperative of published standards in this instance has been temporarily set aside. From a management perspective, this makes the guidelines no less valuable because the intent of optimizing care through the avoidance of complications is no less operative. However, in the event of the need to defend against a malpractice claim in this area, it is clear from this sequence of events that the exact standard of care is debatable and not yet finally established (an extremely important medicolegal consideration). A different ASA document has since been generated, Practice Guidelines for Obstetrical Anesthesia, with more detail and specificity as well as an emphasis on the meta-analytic approach.⁸

An important type of related ASA document is the Practice Guideline (formerly “Practice Parameter”). This has some of the same elements as a standard of practice but is more intended to guide judgment, largely through algorithms with some element of guidelines, in addition to directing the details of specific procedures as would a formal standard. Beyond the details of the minimum standards for carrying out the procedure, these practice parameters set forth algorithms and guidelines for helping to determine under what circumstances and with what timing to perform it. Understandably, purchasers of health care (government, insurance companies, and MCOs) with a strong desire to limit the costs of medical care have great interest in practice parameters as potential vehicles for helping to eliminate “unnecessary” procedures and limit even the necessary ones.

The ASA has been very active in creating and publishing practice guidelines. The first published parameter (since revised) concerned
the use of pulmonary artery (PA) catheters.⁹ It considered the clinical effectiveness of PA catheters, public policy issues (costs and concerns of patients and providers), and recommendations (indications and practice settings). Also, the ASA Difficult Airway Algorithm was published in an updated form in 2003.¹⁰ This thoughtful document synthesizes a strategy summarized in a decision tree diagram for dealing acutely with airway problems. The difficult airway algorithm has been discussed extensively in the literature, including suggestions regarding the role of supraglottic airways and, more recently, adding the various airway video imaging technologies. This illustrates that all the ASA practice guidelines involve fluid concepts that are subject to reconsideration, reinterpretation, and revision as experience and technology evolve. Undoubtedly, the difficult airway algorithm has great clinical value and helps many patients. However, there is concern that, as with many modern things, that it starts to outdate as soon as it is published. Such considerations are important, both clinically and because all these documents are readily noticed by plaintiffs’ lawyers as relevant to establishing the applicable standard of care.

An important and so-far undecided question is whether guidelines and practice parameters from recognized entities such as the ASA define the standard of care. There is no simple answer. This will be decided over time by practitioners’ actions, debates in the literature, mandates from malpractice insurers, and, of course, court decisions. Some guidelines, such as the concepts in the US Food and Drug Administration (FDA) preanesthetic apparatus checkout, are accepted as the standard of care. There will be debate among experts, but the practitioner must make the decision as to how to apply practice parameters and guidelines such as those from the ASA. Practitioners have incorrectly assumed that they must do everything specified. This is clearly not true, yet there is a valid concern that these will someday be held up as defining the standard of care. Accordingly, prudent attention within the bounds of reason to the principles outlined in guidelines and parameters will put the practitioner in at least a reasonably defensible position, whereas radical deviation from them should be based only on obvious exigencies of the situation at that moment or clear, defensible alternative beliefs (with documentation).

The most recent type of document has been the “practice advisory,” which can seem functionally similar to a guideline, but appears to have the implication of more consensus compromise than previous documents driven more by meta-analysis of the relevant literature. Examples of ASA Practice Advisories include “Intraoperative Awareness and Brain Function Monitoring,” “Perioperative Management of Patients with Cardiac Rhythm Management Devices: Pacemakers and Implantable Cardioverter-Defibrillators,” “Perioperative Visual Loss Associated with Spine Surgery,” and “Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging.” At any given time, there are several additional topics under consideration and new advisories being prepared, indicating that anesthesia professionals would be wise to keep up to date on the documents published.

The potential QA and medicolegal implications of these documents are so important to anesthesia professionals and their practices that the ASA has what is essentially a guideline for the guidelines in its 2008 update of the “Policy Statement on Practice Parameters” in which the distinction is made between evidence-based documents and consensus-based documents with explanations of the background and formulation processes for each.

On the other hand, practice protocols, such as those for the fast-track management of coronary artery bypass graft patients, that are handed down by MCOs or health insurance companies are a different matter. Even though the desired implication is that practitioners must observe (or at least strongly consider) them, they do not have the same implications in defining the standard of care as the other documents. Practitioners must avoid getting trapped. It may well not be a valid legal defense to justify action or the lack of action because of a company or facility protocol. As difficult as it may be to reconcile with the payer, the practitioner still is subject to the classic definitions of standard of care.

The other types of standards associated with medical care are those of the Joint Commission, which is the best-known medical care quality regulatory agency. As noted, these standards were for many years concerned largely with structure (e.g., gas tanks chained down) and process (e.g., documentation complete), but in recent years they have been expanded to include reviews of the outcome of care. Joint Commission standards also focus on credentialing and privileges, verification that anesthesia services are of uniform quality throughout an institution, the qualifications of the director of the service, continuing education, and basic guidelines for anesthesia care (need for preoperative and postoperative evaluations, documentation, and so forth). Full Joint Commission accreditation of a health-care facility is usually for 3 years. Even the best hospitals and facilities receive some citations of problems or deficiencies that are expected to be corrected, and an interim report of efforts to do so is required. If there are enough problems, accreditation can be conditional for 1 year, with a complete reinspection at that time. Being ready for a Joint Commission inspection (which is unannounced and can come at any time) starts with verification that essential group/department structure is in place; an excellent outline/checklist exists.¹ The process of “constant preparation” ultimately involves a great deal of work, but because the standards usually do promote high-quality care, the majority of this work is highly constructive and of benefit to the institution and its medical staff.

“Peer review organizations”¹¹ were established in the 1980s and 1990s in every state, usually affiliated with state medical associations and/or state licensing agencies both to monitor quality of medical care and perform utilization reviews (URs), which were oriented to reducing health-care costs. These functions have migrated in recent years largely to the government insurers Medicare and Medicaid and have become fixated essentially exclusively on cost issues. Also, each private health insurance company has utilization review functions, whether internal or contracted out to a company that performs that function for the insurer.

The most likely interaction between a UR agency or office and anesthesia professionals will involve a request for perioperative admission of a patient whose care is mandated to be outpatient surgery (this could also occur in dealing with an MCO). If the anesthesiologist feels, for example, that either (1) preoperative admission for treatment to optimize cardiac, pulmonary, diabetic, or other medical status or (2) postoperative admission for monitoring of labile situations such as uncontrolled hypertension will reduce clear anesthetic risks for the patient, an application to UR for approval of admission must be made and vigorously supported. All too often, however, such issues surface a day or so before the scheduled procedure in a preanesthesia screening clinic or even in a preoperative holding area outside the OR on the day of surgery. This will continue to occur until anesthesia providers educate their constituent surgeon community as to what types of associated medical conditions may disqualify a proposed patient from the outpatient (ambulatory) surgical schedule. If adequate notice is given by the surgeon, the patient can be seen far enough in advance by an anesthesiologist to allow appropriate planning.

In the circumstance in which the first knowledge of a questionable patient comes 1 or 2 days before surgery, the anesthesiologist can try to have the procedure postponed, if possible, or can
undertake the time-consuming task of multiple telephone calls to get the surgeon’s agreement, get UR approval, and make the necessary arrangements. Because neither alternative is particularly attractive, especially from administrative and reimbursement perspectives, there may be a strong temptation to “let it slide” and try to deal with the patient as an outpatient even though this may be questionable. In almost all cases, it is likely that there would be no adverse result (the “get away with it” phenomenon). However, the patient might well be exposed to an avoidable risk. Both because of the workings of probability and because of the inevitable tendency to let sicker and sicker patients slip by as lax practitioners repeatedly “get away with it” and are lulled into a false sense of security, sooner or later there will be an unfortunate outcome or some preventable major morbidity or even mortality.

The situation is worsened when the first contact with a questionable ambulatory patient is preoperatively (or possibly even already in the OR) on the day of surgery. There may be intense pressure from the patient, the surgeon, or the OR administrator and staff to proceed with a case for which the anesthesia practitioner believes the patient is poorly prepared. The arguments made regarding patient inconvenience and anxiety are valid. However, they should not outweigh the best medical interests of the patient. Although this is a point in favor of screening all outpatients before the day of surgery, the anesthesia professional facing this situation on the day of operation should state clearly to all concerned the reasons for postponing the surgery, stressing the issue of avoidable risk and standards of care, and then help with alternative arrangements (including, if necessary, dealing with UR or an MCO).

Potential liability in this regard is the other side of the standard of care issue. Particularly concerning is the question of postoperative admission of ambulatory patients who have been unstable. It is an extremely poor defense against a malpractice claim to state that the patient was discharged home, only later to suffer a complication, because the UR process or an MCO deemed that operative procedure outpatient and not inpatient surgery. As bureaucratically annoying as it may be, it is a prudent management strategy to admit the patient if there is any legitimate question, thus minimizing the chance for complications, and later haggle with the UR bureaucracy.

Beyond the administrative liability implications, precisely what type of support personnel should maintain and service major anesthesia equipment has been widely debated. Some groups or departments rely on factory service representatives from the equipment manufacturers for all attention to equipment, others engage independent service contractors, and still other (often larger) departments have access to personnel (either engineers and/or technicians) permanently within their facility. The single underlying principle is clear: The person(s) doing preventive maintenance and service on anesthesia equipment must be qualified. Anesthesia practitioners may wonder how they can assess these qualifications. The best way is to unhesitatingly ask pertinent questions about the education, training, and experience of those involved, including asking for references and speaking to supervisors and managers responsible for those doing the work. Whether an engineering technician who spent a week at a course at a factory can perform the most complex repairs depends on a variety of factors, which can be investigated by the practitioners ultimately using the equipment in the care of patients. Failure to be involved in this oversight function exposes the practice to increased liability in the event of an untoward outcome associated with improperly maintained or serviced equipment.

Replacement of obsolete anesthesia machines and monitoring equipment is a key element of a risk-modification program. Ten years is sometimes cited as an estimated useful life for an anesthesia machine, but although an ASA statement repeats that idea, it also notes that the ASA promulgated “Guidelines for Determining Anesthesia Machine Obsolescence” in 2004 that does not subscribe to any specific time interval. Very old anesthesia machines likely do not meet certain of the safety standards now in force (such as vaporizer lockout, fresh gas ratio protection, and automatic enabling of the oxygen analyzer). Further, it appears likely that this technology will continue to advance, particularly because of the adoption of anesthesia workstation standards by the European Economic Union that are affecting anesthesia machine design worldwide. Note that some anesthesia equipment manufacturers, anxious to minimize their own potential liability, have refused to support (with parts and service) some of the oldest of their pieces (particularly gas machines) still in use. This disowning of equipment by its own manufacturer is a very strong message to practitioners that such equipment must be replaced as soon as possible.

Should a piece of equipment fail, it must be removed from service and a replacement substituted. Groups, departments, and facilities are obligated to have sufficient backup equipment to cover any reasonable incidence of failure. The equipment removed from service must be clearly marked with a prominent label (so it is not returned into service by a well-meaning technician or practitioner) containing the date, time, person discovering, and the details of the problem. The responsible personnel
must be notified so they can remove the equipment, make an entry in the log, and initiate the repair. As indicated in the protocol for response to an adverse event,¹³ a piece of equipment involved or suspected in an anesthesia accident must be immediately sequestered and not touched by anybody—particularly not by any equipment service personnel. If a severe accident occurred, it may be necessary for the equipment in question to be inspected at a later time by a group consisting of qualified representatives of the manufacturer, the service personnel, the plaintiff’s attorney, the insurance companies involved, and the practitioner’s defense attorney. The equipment should thus be impounded following a catastrophic adverse event and treated similarly to any object in a forensic “chain of evidence,” with careful documentation of parties in contact with and responsible for securing the equipment in question following such an event. Also, major equipment problems may, in some circumstances, reflect a pattern of failure due to a design or manufacturing fault. These problems should be reported to the FDA’s Medical Device Problem Reporting system²⁰ via MedWatch on Form 3500 (found at www.fda.gov/medwatch/index.html, or telephone 800-FDA-1088). This system accepts voluntary reports from users and requires reports from manufacturers when there is knowledge of a medical device being involved in a serious incident. Whether or not filing such a report will have a positive impact in subsequent litigation is impossible to know, but it is a worthwhile practice management point that needs to be considered in the unlikely but important instance of a relevant event involving equipment failure.

The fundamental mechanism of medical malpractice insurance changed significantly some years ago because of the need for insurance companies to have better ways to predict their “losses” (amounts paid in settlements and judgments). Traditionally, medical liability insurance was sold on an “occurrence” basis, meaning that if the insurance policy was in force at the time of the occurrence of an incident resulting in a claim, whenever within the statute of limitations that claim might be filed, the practitioner would be covered. Occurrence insurance was somewhat more expensive than the alternative “claims-made” policies, but was seen as worth it by some (many) practitioners. These policies created some open-ended exposure for the insurer that sometimes led to unexpected large losses, even some large enough to threaten the existence of the insurance company. As a result, medical malpractice insurers have converted almost exclusively to “claims-made” insurance, which covers only claims that are filed while the insurance is in force. Premium rates for the first year a physician is in practice are relatively low because there is less likelihood of a claim coming in (a majority of malpractice suits are filed 1 to 3 years after the event in question). The premiums usually increase yearly for the first 5 years and then the policy is considered “mature.” The issue comes when the physician later, for whatever reason, must change insurance companies (e.g., because of relocation to another state). If the physician simply discontinues the policy and a claim is filed the next year, there will be no insurance coverage. Therefore, the physician must secure “tail coverage,” sometimes for a minimum number of years (e.g., 5) or, more often, indefinitely to guarantee liability insurance protection for claims filed after the physician is no longer primarily covered by that insurance policy. It may be possible in some circumstances to purchase tail coverage from a different insurer than was involved with the primary policy, but by far the most common thing done is to simply extend the existing insurance coverage for the period of the tail. This very often yields a bill for the entire tail coverage premium, which can be quite sizable, potentially staggering a physician who simply wants to move to another state where his or her existing insurance company is not licensed to or refuses to do business. Individual situations will vary widely, but it is reasonable for anesthesiologists organized into a fiscal entity to consider this issue at the time of the inception of the group and record their policy decisions in writing, rather than facing the potentially difficult question of how to treat one individual later. Other strategies have occasionally been employed when insuring the tail period, including converting the previous policy to part-time status for a period of years, and purchasing “nose” coverage from the new insurer—that is, paying an initial higher yearly premium with the new insurer, who then will cover claims that may occur during the tail period. Whatever strategy is adopted, it is critical that the individual practitioner is absolutely certain through personal verification that he or she is thoroughly covered at the time of any transition. The potential stakes are much too great to leave such important issues solely to an office clerk. Further, a practitioner arriving in a new location is often filling a need or void and is urged to begin clinical work as soon as possible by others who have been shouldering an increased load. It is essential that the new arrival verify with confirmation in writing (often called a “binder”) that malpractice liability insurance coverage is in force before there is any patient contact.

Another component to the liability insurance situation is consideration of the advisability of purchasing yet another type of insurance called umbrella coverage, which is activated at the time of the need to pay a claim that exceeds the limits of coverage on the standard malpractice liability insurance policy. Because such an enormous claim is extremely unlikely, many practitioners are tempted to forgo the comparatively modest cost of such insurance coverage in the name of economy. As before, it is easy to see that this is potentially a very false economy—if there is a huge claim. Practitioners should consult with their financial managers and advisors, but it is likely that it would be considered wise management to purchase “umbrella” liability insurance coverage.

Medical malpractice insurers are becoming increasingly active in trying to prevent incidents that will lead to insurance claims. They often sponsor risk management seminars to teach practices and techniques to lessen the chances of liability claims and, in some cases, suggest (or even mandate) specific practices, such as strict documented compliance with the ASA “Standards for Basic Anesthetic Monitoring.” In return for attendance at such events and/or the signing of contracts stating that the practitioner will follow certain guidelines or standards, the insurer often gives a discount on the liability insurance premium. Clearly, it is sound practice management strategy for practitioners to participate maximally in such programs. Likewise, some insurers make coverage conditional on the consistent implementation of certain strategies such as minimal monitoring, even stipulating that the practitioner will not be covered if it is found that the guidelines were being consciously ignored at the time of an untoward event. Again, it is obviously wise from a practice management standpoint to cooperate fully with such stipulations.