Working with a difficult anesthesia group: a hospital guide

Most hospital leaders know the pattern. Add-on cases meet resistance. Surgeons and nurses complain about anesthesia, and anesthesia complains back. Data requests sit for weeks.

A difficult anesthesia group is a real operating problem. It is also, often, a symptom. Some complaints from anesthesia clinicians are accurate warnings about staffing, schedules or burnout. Some behavior is simply unprofessional. The work is telling the two apart, then using the right tool for each.

Separate legitimate concerns from behavior problems

Start by assuming some of the complaints are right. Anesthesia has been short-staffed for years. In an American Society of Anesthesiologists (ASA) analysis, the share of facilities reporting an anesthesia staffing shortage rose from 35% in early 2020 to 78% in late 2022.¹

The people doing the work are stretched. In a November 2022 survey of attending anesthesiologists, 67.7% were at high risk for burnout. Perceived lack of support at work was the factor most strongly linked to it.² In American Medical Association (AMA) data for 2025, 42.2% of anesthesiologists reported at least a moderate likelihood of leaving their organization within two years, the second-highest rate of any specialty.³

So pushback on a late add-on may be a staffing problem, not an attitude problem.

The AMA's Code of Medical Ethics draws a useful line. It says disruptive behavior is different from criticism offered in good faith to improve patient care, and from collective action by physicians.⁴

Ask one question about each complaint. Is it about the system, such as staffing, the schedule or the timing of cases? Or is it about how people treat each other: raised voices, refusals, ignored pages? System problems are operations work. Conduct problems belong to the medical staff. Most hard situations have some of both. Work them separately.

Find the root cause in the data

Before the next hard meeting, build your own picture. Five questions cover most cases.

• Does staffing match demand, by hour? Compare staffed locations with cases actually running, by hour and weekday.
• Is the schedule set up to fail? Late block release, cases booked past staffed hours and add-ons stacked late in the day land on the same few people.
• Is late-day room creep happening? Rooms planned to close mid-afternoon that routinely run into the evening breed resentment.
• Is the group losing people? Ask for open positions, locum tenens use and turnover. A group that cannot recruit will resist anything that adds hours.
• Who leads the group? A chief with no protected time or authority cannot fix much. Sometimes the problem is a leadership gap, not a culture.

The Joint Commission makes the same point from the other side. Its alert on behaviors that undermine a culture of safety traces them to both individual and systemic factors, including productivity demands and cost containment pressure.⁵ Fixing the system will not fix every person. It will remove a lot of fuel.

Fix the operating rhythm

Most friction lives between meetings. Close the gaps with structure.

Hold a joint operations meeting. Meet monthly with the same people: the group's leader, the perioperative director, a surgical leader, nursing leadership and a hospital executive who can make decisions. Review last month's metrics, open issues and decisions owed.

Share one set of metrics. Agree on definitions for first-case on-time starts, turnover time, room utilization by hour, add-on wait times, day-of-surgery cancellations and response time on data requests. Both sides should see the same numbers from the same source. This is the core of our anesthesia performance monitoring work.

Set one escalation path. Medicare already requires anesthesia services to be provided "under the direction of a qualified doctor of medicine or osteopathy."⁶ We suggest making that director the single point of contact on the anesthesia side. Name one counterpart on the hospital side. Surgeons and charge nurses should know whom to call.

Write down the rules for add-ons and after-hours. Define urgency classes and how quickly each must start, the cutoff for next-day scheduling, what call coverage includes and the expected response time. Once the rule is written, the 4:45 p.m. argument becomes a simpler question: was the rule followed?

Use the contract for group performance

The contract governs the group as a business. Use it for what the group promised.

Under Medicare's conditions of participation, the governing body is responsible for services furnished under contract and must ensure they are provided in a safe and effective manner.⁷ Monitoring is part of that duty, not a sign of distrust.

Three provisions do most of the work:

• Performance standards. Make them measurable and tie them to what the group controls: coverage of agreed locations, response times, on-time starts where anesthesia is the cause, timely reporting.
• Data rights. Spell out access to staffing, billing and quality data, in a set format, on a set schedule. If data requests are a recurring fight, a missing clause is often the reason.
• Cure periods. Written notice of a specific failure, a defined period to fix it and a clear consequence if it is not fixed. This protects both sides from surprises.

Document group-level issues as they happen: the standard, the date, the effect and the notice you gave. If your agreement is thin on these points, fix them at renewal, starting with our questions to ask before renewing. Termination and exclusivity terms carry legal consequences, so involve counsel.

Handle individual conduct through the medical staff

When the problem is one person's behavior, the contract is the wrong tool. Individual conduct belongs in the medical staff's professional conduct and peer review processes.

The Joint Commission requires leaders to develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety, and to create and implement a process for managing those behaviors. For years this sat in the Leadership chapter at LD.03.01.01.⁵ Since January 2026, hospitals find it in the National Performance Goals chapter at NPG.02.03.01, elements of performance 12 and 13.⁸

The same Sentinel Event Alert, first issued in 2008 and updated in 2021, covers overt behaviors such as verbal outbursts and passive ones such as refusing assigned tasks or not returning pages. Its suggested actions include:⁵

• Start with informal, non-confrontational conversations, and move to action plans and progressive discipline only if patterns persist.
• Enforce the code consistently, regardless of seniority or clinical discipline.
• Document all attempts to address the behavior.

The AMA adds a fairness check: one incident may not warrant action, but reports can reveal a pattern, and due process matters.⁴ Medicare rules also require the medical staff to periodically appraise its members.⁹

In practice, route conduct concerns to the chief medical officer or medical staff leadership, not the contract manager. CRNAs and anesthesiologist assistants may be credentialed through a separate pathway, so follow your bylaws. Tell the group's leader, too. A well-run group wants to know.

Keep notes factual: date, time, place, what was said or done, who was present and any effect on a patient or case. Record behavior, not character.

Know when friction means it is time to renegotiate or run an RFP

Structure fixes most friction. When it does not, watch for these signals:

• The same standards are missed after notice and a cure period.
• The group's leaders will not, or cannot, take part in the operating rhythm.
• Data you need to manage the contract is still withheld.
• The economics no longer work, for you or for the group. A group that cannot recruit at its current rates will keep pushing back.

Renegotiation is usually the first step. If the group has already put an ultimatum in writing, start with what to do in the first 30 days. Sometimes the right answer is a market test. If you are heading that way, plan the transition before you announce anything. Our transition plan for changing anesthesia groups lays out the steps.

What not to do

Don't criticize the group in public. Complaints aired in front of surgeons and staff spread fast and make repair harder. Keep criticism in the joint meeting and in writing.

Don't make side deals with individual clinicians. Arrangements that bypass the group can conflict with the contract, undercut the group's leaders and create new disputes. Talk to counsel before any direct arrangement.

Don't cut coverage without a plan. Closing rooms or threatening termination to make a point puts patients and surgeons in the middle. Change coverage only when a staffing plan is ready.

Don't mix the tools. Don't use the contract to punish one clinician's conduct, or peer review to settle a business dispute.

A strained relationship with an anesthesia group rarely fixes itself, and it rarely needs a fight. It needs a clear diagnosis, a steady operating rhythm and the right tool for each problem.

Sources

1. American Society of Anesthesiologists, "Anesthesia Workforce Shortage Poses Threat to Health Care," ASA News Release, June 2024. https://www.asahq.org/about-asa/newsroom/news-releases/2024/06/anesthesia-workforce-shortage-poses-threat-to-health-care ↩

2. Afonso AM, Cadwell JB, Staffa SJ, Sinskey JL, Vinson AE, "U.S. Attending Anesthesiologist Burnout in the Post-Pandemic Era," Anesthesiology, January 2024. https://pmc.ncbi.nlm.nih.gov/articles/PMC10751072/ ↩

3. Sara Berg, American Medical Association, "Physicians in These 10 Specialties Are Less Likely to Quit," AMA, May 2026. https://www.ama-assn.org/practice-management/physician-health/physicians-these-10-specialties-are-less-likely-quit ↩

4. American Medical Association, "Code of Medical Ethics Opinion 9.4.4: Physicians with Disruptive Behavior," AMA Code of Medical Ethics, undated. https://code-medical-ethics.ama-assn.org/ethics-opinions/physicians-disruptive-behavior ↩ ↩²

5. The Joint Commission, "Sentinel Event Alert 40: Behaviors That Undermine a Culture of Safety," Sentinel Event Alert, July 2008 (updated June 2021). https://www.jointcommission.org/en-us/knowledge-library/newsletters/sentinel-event-alert/issue-40 ↩ ↩² ↩³

6. Centers for Medicare & Medicaid Services, "42 CFR 482.52: Condition of Participation: Anesthesia Services," Electronic Code of Federal Regulations, current text. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-D/section-482.52 ↩

7. Centers for Medicare & Medicaid Services, "42 CFR 482.12: Condition of Participation: Governing Body," Electronic Code of Federal Regulations, current text. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-B/section-482.12 ↩

8. The Joint Commission, "National Performance Goals, Effective January 2026 for the Hospital Program," Joint Commission, September 2025. https://digitalassets.jointcommission.org/api/public/content/9ca80055182b4274842a5780a94f2c82?v=149a13a9 ↩

9. Centers for Medicare & Medicaid Services, "42 CFR 482.22: Condition of Participation: Medical Staff," Electronic Code of Federal Regulations, current text. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.22 ↩