Inside OR Manager Human resources ORs modifying on-call ...€¦ · Some of HCA Healthcare’s...

April 2013 Vol 29, No 4

The monthly publication for OR decision makers

Safer Surgery: Six steps that aim for excellence in sterile processing

ORs modifying on-call practices to recruit and retain nursing staff

Fourth in a series on ten elements of safer surgery.

It’s axiomatic that sterile pro-cessing is critical to safe and ef-fective surgical care. The sterile

processing department (SPD) is like an “engine room” for the OR, where the staff produce the sterile

instruments and other equipment needed for surgical cases.

An OR with a volume of 75 cases a day can require upwards

of 50,000 individual instruments, many with complex and intricate parts. Any flaw in cleaning and reprocessing is a potential threat to patients. It’s a demanding job, and one that is often unsung.

Surgical departments striving for safer care include sterile pro-cessing as colleagues and allies.

OR Manager interviewed 4 SPD leaders about their efforts to build bridges with their surgical colleagues, embrace continuous improvement, and focus on cus-

On-call requirements in pe-rioperative services can be a barrier to recruiting

younger RNs and in retaining older nurses. Covering the daily surgical schedule with fatigued staff who have worked during the night can be a safety issue or a staffing issue if the call team is too tired to work the next day.

In the OR Manager succession planning survey (December 2012 issue), OR managers and directors said call is one of their biggest obstacles in recruitment of periop-erative nurses.

Hospitals are exploring and adopting call alternatives to help their staff members with better

work-life balance and to retain their experienced nurses.

OR Manager spoke with surgi-cal services managers at 5 hospi-tals to find out how they are man-aging this perennial challenge.

Staff embrace alternative call Some of HCA Healthcare’s facili-ties began instituting dedicated call teams nearly 10 years ago. The teams are on call Monday through Friday from 3 pm to 7 am and are typically guaranteed 40 hours of pay per week regardless of how many hours they work.

Human resources

Patient safety

Continued on page 6

Inside OR Manager

OR MANAGER CONFERENCEKeynoter advocates for a ‘transparency revolution’ .......5

PATIENT SAFETYA ‘cockpit checklist’ reduces defects in instrument sets ........................8

PATIENT SAFETYAutomating sterile processing for safety, efficiency .................................10

HUMAN RESOURCESNew on-call plan helps to stabilize the staff and budget .............................14

PATIENT SAFETYTeam training, checklist equal better outcomes in pilot .....................................16

OR PERFORMANCEPhone calls go away with a low-cost tracking system ...18

OR PERFORMANCEBetter business performance is a critical competency ........20

CMS proposes modifying ASC rule requiring staff radiology services ............. 22

Faster procedures benefit patients and bottom line ................. 23

Continued on page 12

Safer Surgery

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3OR Manager Vol 29, No 4April 2013

Editorial

www.ormanager.comPUBLISHER, AI HEALTHCARE GROUP

Carol Brault • 301-354-1763 • [email protected]

MANAGING EDITORPat Patterson • 303-756-0579 • [email protected]

EDITORElizabeth Wood • 301-354-1786 • [email protected]

CLINICAL EDITORJudith M. Mathias, MA, RN

EDUCATION COORDINATORJudy Dahle, MS, MSG, RN

CONTRIBUTING WRITERPaula DeJohn

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[email protected]

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ART DIRECTORDavid Whitcher

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Last month, we wrote about the long history of unneces-sary preoperative testing for

healthy patients.This month, we’re happy to re-

port that some leading medical societies are publicly calling for physicians and patients to rethink certain kinds of testing.

The recommendations are part of the Choosing Wisely campaign, an effort to encourage physicians and the public to think and talk about care that offers little benefit.

The campaign, which partners with Consumer Reports, aims to help patients choose care that:•issupportedbyevidence•doesn’tduplicateother tests or

procedures•isfreefromharm•istrulynecessary.

In February 2013, 17 societies named a new set of more than 130 tests and procedures to ques-tion. Four societies took stands on preop testing:•TheAmericanAcademyofOph-

thalmology: Don’t perform pre-operative medical tests for eye surgery unless there are specific medical indications.

•American Society for ClinicalPathology: Avoid routine pre-operative testing for low-risk procedures without clinical in-dication.

•American Society of Echocar-diography: Avoid echocardio-grams for preoperative/periop-erative assessment of patients with no history or symptoms of heart disease.

•Society of Thoracic Surgeons:Patients who have no cardiac history and good functional sta-tus do not require preoperative stress testing prior to noncardiac thoracic surgery.Earlier, the American College of

Radiology recommended against preop chest x-rays for low-risk pa-tients, and the American College of Cardiology and American So-

ciety of Nuclear Cardiology took positions on cardiac imaging be-fore surgery.

Still to weigh in are the Ameri-can College of Surgeons and the American Society of Anesthesiolo-gists.

Getting the word outMany clinicians won’t find this earth shattering. Evidence on un-necessary preop testing has been in the literature for years. Much of the unnecessary testing seems to be a result of miscommunication. Surgeons order tests because they worry their cases will be canceled if they don’t. Yet anesthesiologists say they don’t require many of the tests.

This conversation needs to be taken to the national level.

Choosing Wisely is helping to make the issue of unnecessary care more visible not only to phy-sicians but also to the public.

It is heartening to see the physi-cian community engage the pub-lic in a national discussion about what truly is—and isn’t—needed for good care.

There’s a long history in this country of equating more care with better care. Campaigns like Choosing Wisely help convey the message—stated in terms patients can understand—that the best care is really evidence-based care. ❖

—Pat Patterson

Download a pdf of all of the lists at www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf.

“

“Is this test

really necessary?

Untitled-3 1 3/7/13 11:15:59 AM


OR Manager Conference

Marty Makary, MD, MPH, now a prominent cancer surgeon at Johns Hopkins,

says he once took a year off from medical school because the culture didn’t feel right to him—“it wasn’t telling patients the truth.” He had witnessed wide variations in qual-ity and the medical community’s lack of response. He later returned and says he finds deep rewards in patient care. He also brought back a passion for improving the culture and has become a lead-ing advocate for patient safety and transparency.

Dr Makary will keynote the OR Manager Conference September 23-25, 2013, at the Gaylord Na-tional Resort in National Harbor, Maryland, near Washington, DC.

Now in its 26th year, the confer-ence offers 9 all-day seminars on Monday, September 23, followed by 2 more days of educational ses-sions and exhibits with special tracks for new managers, OR busi-

ness managers, and ambulatory surgery centers.

What does it take to create a culture of safety?

An advocate for what he says are com-mon-sense efforts to improve quality, Dr Makary will draw on firsthand stories to il-lustrate the decisions that await policy makers and hospitals in creating an environment that is more truthful, more responsive, and less prone to errors.

Checklist pioneerA leading expert on surgical qual-ity and a pioneer in the use of sur-gical checklists, Dr Makary is au-thor of the eye-opening 2012 book, Unaccountable, which starts with dramatic stories of bad practice and cover-ups he has seen.

He also tells posi-tive stories of hos-pitals that have ad-dressed disruptive behavior, clinicians and professional groups that seek to understand wide variations in prac-tice, and organiza-tions that support teamwork and inter-nal error reporting.

The book calls for a “transparency

revolution,” challenging clinicians to sign a “transparency pledge” in which they agree to disclose errors to patients and money they have received from industry, among other things.

Dr Makary also calls for public reporting of hospital performance, using measures professional soci-eties have endorsed. Among pro-posals he favors are use of vid-eos for coaching and peer review, monitoring behaviors like checklist use, and providing patients with all options for their care.

Dr Makary was lead author of the original publications on the surgery checklist and led the World Health Organization’s workgroup on developing surgical quality metrics.

He is the author of over 150 publications on medical quality and health policy. He currently has a grant to implement an inter-vention to decrease surgical com-plications in 100 hospitals and serves on the leadership council of the American College of Sur-geons National Surgical Qual-ity Improvement Program (ACS NSQIP). ❖

The OR Manager Conference brochure is polybagged with this issue. Learn more and register at www.ormanager-conference.com.

Keynoter advocates for a ‘transparency revolution’

Marty Makary, MD, MPH

Advisory Board

Mark E. Bruley, EIT, CCE Vice president of accident & forensic investigation, ECRI, Plymouth Meeting, Pennsylvania

Lori A. Coates, BSN, RN, CNOR, manager, perioperative surgical services, Weiser Me-morial Hospital, Weiser, Idaho

Stephanie S. Davis, MSHA, RN, CNOR Vice president of surgical services opera-tions and service line group, Hospital Cor-poration of America, Nashville, Tennessee

Franklin Dexter, MD, PhD Professor, Department of anesthesia and health management policy, University of Iowa, Iowa City

Brian Dolan, MHSA, RHIA, CHDA, SSGB, director, business operations, surgical services, University of Kansas Hospital, Kansas City, Kansas

Lorna Eberle, BSN, RN, CNOR Director, perioperative services, Provi-dence St Peter Hospital, Olympia, Wash-ington

Linda R. Greene, MPS, RN, CIC Director of infection prevention, Roches-ter General Hospital System, Rochester, New York

Jerry W. Henderson, MBA, RN, CNOR, CASC Assistant vice president, perioperative ser-vices, Sinai Hospital, Baltimore, Maryland

Lisa Morrissey, MBA, RN Associate chief nurse, perioperative ser-vices, Brigham and Women’s Hospital, Boston, Massachusetts

John Rosing, MHA, FACHE Vice president and principal, Patton Healthcare Consulting, Milwaukee, Wis-consin

Kathryn Snyder, BSN, MM, RN, CGRN Nurse manager, endoscopy/bronchos-copy/motility departments, University of Virginia Health System, Charlottesville, Virginia

Martha Stratton, MSN, MHSA, RN, CNOR, NEA-BC, Director of nursing, surgical services, AnMed Health, Anderson, South Carolina

David E. Young, MD Medical director, perioperative services, Advocate Lutheran General Hospital, Park Ridge, Illinois

6 OR Manager Vol 29, No 4 April 2013

Patient safety

tomer service. These are their sug-gestions for achieving excellence in sterile processing.

One: ‘Heart of patient care’These SPD managers make sure their staffs know the essential role they play in patient care.

Rudy Gonzales, MSN, RN, CNOR, CRCST, CHL, has led his department at the Louisiana State University Health Science Cen-ter in New Orleans in recovering from the complete destruction of the SPD at the former Charity and University Hospitals after Hur-ricane Katrina. He’s participating in the building of a new replace-ment University Medical Center to open in 2015.

Gonzales says he tells his staff: “The doctors can cure disease, the nurses can care for the patients, but if they don’t have the right equipment, they can’t do their jobs effectively. We never want to have something we’ve done to af-fect the patient.”

Sue Klacik, BS, CRCST, FCS, who manages central sterile (CS) services at St Elizabeth Hospital, a

350-bed Level 1 trauma center in Youngstown, Ohio, conveys the same message: “My staff know they are every bit as important as the team in surgery.”

She makes sure the staff are empowered. “If at 2 am, they see something that doesn’t look right for a case the next day, they contact surgery to see if there’s a problem and discuss a way to re-solve the issue.”

Valuing the staff carries through to compensation. These leaders make sure their staff’s pay is competitive with that of other area hospitals.

Two: Stay in touch with the OR’s needs Visibility and customer service are leading strategies these lead-ers employ to make sure they’re meeting the OR’s needs.

Keep communication open“I’ve learned over the years that if you don’t want to hear from the OR, they will lose trust in you be-cause you are not addressing the issues,” says Mark Duro, CRCST, FCS, manager of the Central Ster-ile Processing Department at New England Baptist Hospital in Bos-

ton, a leading orthopedic center performing 25 to 30 joint replace-ments a day.

When there is an issue in the OR, depending on how serious it is, Duro goes directly to the room. Less critical issues are reported on a communication sheet that records the date, time, personnel involved, the issue, suggestions for possible solutions, and a sig-nature. Duro reviews the sheets once a week and addresses the issues.

Participate in daily huddlesEvery day at 1:30 pm, Klacik or a CS coordinator joins a huddle in the OR to review the next day’s schedule and determine needs. At 3 pm, she huddles with the CS staff.

“We talk about what’s hap-pening tomorrow,” she says. “We discuss which trays to watch for. If loaner trays aren’t in, we start calling the vendor.”

If necessary, she adjusts staff-ing to meet the requirements of the next day’s surgical schedule.

Round in the ORKlacik and CS coordinators round in the surgery department throughout the day. “If surgery has a question or comment, they can stop and tell us,” she says. “They know we are accessible, and we can nip problems in the bud.”

Safer Surgery seriesThis series of articles covers Ten Elements for Safer Surgery developed by Advocate Health Care, a 10-hospital system in the Chicago area.

Previous articles in the series focused on:• ORgovernance:January2013• Safersurgicalscheduling:February2013• Presurgicalassessment:March2013.

All-day seminarAn all-day seminar on the Ten Elements for Safer Surgery will be presented at the OR Manager Conference September 23-25, 2013, at the Gaylord National Resort in National Harbor, Maryland. For more information, go to www.ormanagerconference.com.

Safer SurgeryContinued from page 1

“

“They know

we’re accessible.


Patient safety

Attend OR staff meetingsDuro attends OR staff meetings to share information. At one point, the OR was reporting holes in sterilization wrappers. An OR staff member asked, “Why not use containers?” Duro had a chance to explain that many instrument sets have not been validated by the device manufacturer for the use of sterilization containers.

“We have to follow the man-ufacturer’s instructions for use (IFU) for everything—not just the equipment but also the packaging material,” he told them, noting that failure to follow the IFU can incur liability.

Three: Educate, educateEducation of CS techs is the back-bone of a safe, efficient sterile pro-cessing program, Klacik empha-sizes.

“I can’t stress how important education is in this job,” she says. With today’s demands, “techs need to be technically trained and

to have critical-thinking skills.”Klacik, an approved CRCST in-

structor, also serves as the educa-tor for the department. “We teach the standards and recommended practices, along with the rationale behind them,” she says. She also provides in-service education on all new equipment, including the IFU.

At St Elizabeth, certification of CS techs is a condition of employ-ment. Klacik teaches the classes herself. The hospital purchases the books, and education is con-ducted on work time.

Four: Provide the right working conditionsKlacik ensures the SPD staff have the proper equipment and work environment to do their jobs well.

“At our work stations, we have the correct conditions—the right lighting, equipment like magnify-ing glasses, quality monitors, and other tools,” she says.

IFUs are available on PCs

throughout the department, which provide access to onesourcedocs.com, an online database of manu-facturers’ instructions.

At New England Baptist, sterile processing is almost completely automated. In planning the de-partment, which opened 3 years ago, Duro and his team scoured the US and Europe for the latest in technology (related article, p 10).

Five: Support the staff and hold them accountableAccountability goes hand in hand with education.

“If someone has made an error, we bring it to their attention so the error doesn’t occur again,” Klacik says. “They know what they do affects patient care, and they are meticulous.”

Gonzales, who now has a mas-ter’s, relies on the bedrock values he learned in the Army: “Make sure your staff have what they need to do the job, make sure they’re trained, and make sure their pay is correct. Then most things will work out.”

Six: Foster continuous improvementAt Virginia Mason Medical Cen-ter in Seattle, which has pioneered Lean management in health care, the director of sterile processing, Sam Luker, MBA, CRCST, and his team have a constant focus on eliminating waste and mis-take-proofing sterile processing (related article, p 8). Every day begins with a daily “newspaper” reporting on defects that reached the OR the previous day. Encour-aged by a Japanese sensei, the de-partment recently began working on a process to create just-in-time instrument sets built to order for surgeons performing the next day’s cases. ❖

—Pat Patterson

Ten components for safer surgeryThe components of Advocate Health Care’s Safer Surgery initiative:

1. Perioperative governing body

2. Single path for surgical scheduling

3. Preanesthesia testing (PAT) with standardized protocols/hospitalists

4. Document management system for scheduling and PAT

5. Excellence in sterile processing

6. Crew resource management

7. Implementation of a critical safeguards checklist

8. Daily huddle

9. Error reporting

10. Just culture

Source: Advocate Health.

Checklists are a common safety strategy in the OR. Why not have a checklist

for the sterile processing depart-ment (SPD)?

A “cockpit checklist” has helped reduce defects in instru-ment sets at Virginia Mason Med-ical Center in Seattle, Washing-ton, by serving as the final quality assurance audit before a set enters the sterilizer.

The checklist was introduced after packaging mistakes were found to be the most common type of defect in sets reaching the OR.

At Virginia Mason, a mecca for Lean management in health care, the search for and correction of defects is relentless. The hospital has wholeheartedly adopted the Toyota Production System pio-neered by the Japanese.

Like all departments, ster-ile processing regularly engages in Lean activities such as kaizen (continuous improvement) events and rapid process improvement workshops (RPIWs) to mistake-proof processes and eliminate waste.

Checking the ‘newspaper’Every morning when the director of sterile processing, Sam Luker, MBA, CRCST, and his leadership team arrive for work, they check the “newspaper,” the defect sta-tus report from the previous day. A defect is any flaw in a sterile instrument set discovered in the OR. The defect rate is the number of defects divided by the number of cases.

“Whenever we discover a de-fect, we analyze the data, initiate mistake-proofing protocols, and solicit Everyday Lean Ideas (ELIs)

from our front-line operators, so we can quickly correct the prob-lem,” he says.

The cockpit checklist, he adds, “is probably the most effective mistake-proofing strategy we’ve implemented so far.”

After the checklist was intro-duced, the defect rate for set pack-aging fell from 3% a few years ago to 0.12% in December 2012. That’s just 2 packaging defects for the 1,552 cases the ORs performed that month, which used approxi-mately 20,409 sets.

Among packaging defects the checklist catches are missing locks and chemical indicators, loose fil-ters and retention plates, and mis-labeled sets.

Luker says he realized the power of checklists after hearing a talk by aviator and patient safety expert John Nance about his book, Why Hospitals Should Fly.

He says, “We immediately planned a 5-day RPIW on defect reduction for surgical instrument sets where front-line operators and leaders worked together to develop and refine the cockpit checklist.”

How the checklist worksAfter a set is assembled but be-fore it is containerized, the set is placed on a staging cart at the “cockpit check station.” There a sterile processing tech reviews the checklist to verify items such as the chemical indicator, filter, and correct label (sidebar).

After all items are verified, the set is containerized and placed on the cart to go into the sterilizer.

The checklist project is reported in the March 2013 Joint Commis-sion Journal on Quality and Pa-tient Safety.

Building trust with the ORThe checklist is just one of the strategies Luker and his team have employed to improve cus-tomer service with the OR. Others include:

BarcodingEvery instrument set is barcoded, as are some instruments critical to a set, such as the carpal tunnel re-lease instrument from the set for that procedure.

“The system won’t let the tech complete the set until that item is


A ‘cockpit checklist’ reduces defects in instrument sets

Patient safety

Safer Surgery

Cockpit checklistTo ensure quality and safety in every set, please verify the following:

1. Chemical indicator placed in set.

2. Instrument set, recipe, and production label all match.

3. Filters are placed in lid and bottom of container if needed.

4. Verify that retention plates fit snugly against the filters.

5. Examine the set for orderliness.

6. Write “FIM” (filter, indicator, matching) at top of recipe and include Tech #. (Verify successive check.)

7. Place lid on container.

8. Place locks on container.

9. Apply tape tail to production label.

10. Write Tech # on tape tail and place label on container. (Verify successive check.)

Source: Virginia Mason Hospital & Medical Center, Seattle.


scanned, showing it is present,” Luker notes.

Rapid response lineThe OR can call the SPD’s rapid response (RR) line during a case to report a defect, such as a dirty suction in an ENT set. A sterile processing leader is dispatched to the OR immediately.

“It’s always about customer service,” Luker says. “We want to make sure the OR gets to interact with our team member and that we get the documentation we need for analysis and accountability.”

At times, the situation can be resolved on the spot. In a recent example, the OR called the RR line when a surgeon found an in-strument wasn’t functioning as expected. When Luker went to the OR, he discovered the sur-geon was using a delicate laparo-scopic instrument to try to grasp a tube, which the instrument wasn’t designed to do. The surgeon was

provided with the correct instru-ment.

The information about the de-fect is brought back to the SPD, posted on the status board, and reported to the team so the defect can be addressed in real time.

Visibility boardThe daily status report is used to update a poster-sized monthly “visibility board” complete with pink stickers to highlight the de-fects and the categories in which they are occurring. A color-coded dot indicates the process in which

the defect occurred and the level of seriousness based on risk as-sessment. For example, a red dot indicates potential for major harm or case delay, an orange dot in-dicates potential for minor harm or case delay, and a yellow dot indicates no potential for harm or case delay.

Accountability for SPD staffIf the defect involves an SPD tech, the supervisor meets with the tech to review the incident, discuss contributing factors, and assess any education and training oppor-tunities. The department educator is involved if education/training needs are identified. The conver-sation is documented using an online “important conversations” form. To close the loop, copies are submitted to the SPD director, manager, supervisor, educator, quality assurance coordinator, and the tech.

Sushi, anyone? Consistent with Virginia Mason’s Lean culture, the SPD holds reg-ular continuous improvement events.

Japanese sensei (Lean masters or teachers) visit hospital depart-ments to counsel them on im-provements.

“Instrument sets should be like sushi, made just in time, not put on the shelf to sit for a year,” one sensei recently challenged.

Says Luker, “We thought that made sense. We have hundreds of ‘sleeping sets’ that sit idle in our storage area. That is an inefficient use of space and inventory.

“If we can build sets to order—say, give Dr Smith just the instru-ments needed to perform that particular procedure scheduled—we could reduce what we have to

Patient safety


The “visibility board” is a status report that shows defects in instrument sets, the process involved, and the seriousness.

“

“It is always

about customer service.

Lean management and auto-mation have come together to create a sterile processing

department (SPD) that can effi-ciently process the 700 to 1,000 instrument sets a day needed to support a caseload that is primar-ily orthopedic.

The SPD at New England Bap-tist Hospital in Boston is one of the few in the US to be fully au-tomated. The hospital performs

15,000 surgical cases a year, with 80% of those in orthopedics.

Because of the department’s capacity and efficiency, an en-tire total hip or knee setup can be turned around and back to the OR in 3 1/2 to 4 1/2 hours, says Mark Duro, CRCST, FCS, manager of the Central Sterile Processing De-partment.

“We’ve removed the human element from many of our func-tions, but we still have safe-guards,” Duro says.

Harnessing technologyDuro, who has a keen interest in automation, says he’s always on the lookout for technology that would cut waste and streamline the department’s operations. That was particularly true during a complete renovation 3 years ago. With 20 years of experience in sterile processing, he helped lead the team that planned the new department, researching au-tomated systems and going on site visits.

Because of the automation, the workflow is different than in traditional SPDs, Duro explains. Each tech builds a sterilizer load at his or her workstation. “Our techs don’t move. Everyone is as-sembling kits.

“The only time they leave is to

push a whole cart of trays over to the sterilization area,” he notes.

There, the assigned tech scans the trays on the cart and parks the cart in front of the sterilizer, where it is pulled in automatically after being identified by a photo sensor. After the cycle is finished, the cart is automatically ejected into the storage area where techs put the sets away.

Here are features of the auto-mated system.

An automated SPDThe department is organized in 3 zones—decontamination, prep and pack, and sterilization—as

recommended by the Association for the Advancement of Medical Instrumentation (AAMI).•When dirty case carts return

from the OR, they are placed on a rotary conveyor system, which Duro says is common in Europe. The conveyor is inte-grated with the washer-disin-fectors and tied into the instru-ment tracking system. Settings are automated.

•To avoid cross-contamination,only a pass-through window—but no door—connects the de-contamination area with the clean areas.

•Theinstrumenttrackingsystem


Automating sterile processing for safety, efficiency

Patient safety

Safer Surgery

(Top) The case cart conveyor at New England Baptist Hospital in Boston is integrated with the washer-disinfec-tors. (Bottom) The sterilizers load and unload automati-cally. A green light signals when the sterilizer unloads.


is also integrated with the ster-ilizers and with the biological indicator (BI) incubator. If any parameter falls outside the pre-scribed limits, the system stops and doesn’t proceed until the problem is resolved. An exam-ple is a set that requires an ex-tended cycle or has an unusual parameter.

•A bank of lights signalswhenaction is needed, saving phone calls and interruptions. A red light flashes when the eleva-tor arrives from the OR. A blue light means the cart washer is ready to be unloaded. A green light means a sterilizer has automatically unloaded. The lights are triggered by photo sensors.

•All instrument sets are bar-coded. To document which sets are in a load, all of the sets are scanned before they go into the sterilizer—no handwritten doc-umentation is required.

•Sterilizers areonanautomated

pass-through. When a cart of sets is parked in front of the sterilizer, the tracking system signals the sterilizer. A door to the sterilizer pass-through au-tomatically opens, the cart is pulled in, and the cycle starts. At the end of the cycle, the cart is unloaded automatically, trip-ping another photo sensor that triggers the green signal light.

•Thesterilizers,oncepermissionis given, connect to the instru-ment tracking system and report the load’s parameters. The BI incubator, also integrated with

the tracking system, prompts the staff to gather the appropri-ate data from the BI.“If any of our systems, such as

a washer or sterilizer, don’t meet the parameters, the system does not allow the process to go for-ward,” Duro says. If a sterilizer’s temperature drops from the in-tended 270ºF to 269.9ºF, for ex-ample, the system will only let the cart go back into the processing area; it will not go forward into storage.

Getting the resourcesDuro believes the hospital’s in-vestment in automation for sterile processing reflects its view that the department is essential for safe care.

“To make sure we are doing the best job possible and to make sure our surgeons have the best tools they can have, it’s almost a slam dunk to see that everything starts with processing,” he says. ❖

—Pat Patterson

Patient safety

“

“Sterilizers

load automatically.

reprocess and store as well as the number of instruments we pur-chase.”

Just-in-time setsWhen interviewed, Luker and his team were preparing for a 5-day 3P (production preparation pro-cess) workshop. In industry, a 3P focuses on new product develop-ment. In this case, the “product” is instrument sets, specifically just-in-time sets.

The workshop included 5 front-line SPD techs, each tied up for 40 hours.

How can the department free up that much staff?

“Our culture and our leaders are totally committed to Lean,” Luker responds. That includes supporting him by allowing over-time and use of per-diem person-nel during these projects.

"Front-line techs are considered essential to improvement efforts," he notes. “They do the work all day, and as the ‘process experts,’ they generally have the best ideas for resolving issues. Our job as leaders is to draw out the best mis-take-proofing ideas and facilitate their implementation.” ❖

—Pat Patterson

ReferenceNance J J. Why Hospitals Should

Fly. Bozeman MT: Second River Healthcare Press, 2008.

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Human resources

“This relieves day shift staff from working on call during the night and still having to work the next day,” says Stephanie S. Davis, MSHA, RN, CNOR.

Because the call team reduces some of the overtime paid to regu-lar staff, the return on investment is usually a wash, notes Davis, who is vice president of surgical services operations and service line group for HCA.

OR staff at one HCA facility, TriStar Hendersonville Medical Center, Hendersonville, Tennes-see, are “ecstatic that they no lon-ger have to take call during the week,” says Holly Smithey, BHA, RN, director of surgical services.

The 148-bed facility, which is in a competitive health care market about 25 miles north of Nashville, has 8 ORs.

Regular staff have staggered schedules so that some work until 5 pm and some until 7 pm to match the surgical volume.

“We try to avoid having the call team, which starts work at 3 pm, relieve on elective, scheduled cases. We want them to handle the add-on cases,” notes Smithey.

Patient safety issue“For me, it’s a patient safety issue,” says Smithey. Regular staff are scheduled to work Monday through Friday. Previously, when they had to work until midnight on call or had to come back dur-ing the night, there was a strug-gle to have enough staff the fol-lowing day if they went home. If staff who had been on call stayed, there was concern that their lack of sleep could contribute to an error.

Smithey says when budgets are tightened, and she’s challenged to

defend the call team and its value to the facility, she uses the patient safety issue as the lead of the dis-cussion.

“I think any of us, given the option, would choose to have a well-rested team for our surgery versus a team that has been here 16 hours,” she says.

Win-win for call team, staff, and surgeonsThe call team members love their jobs, and the staff loves having the call team. “It’s a win-win,” says Smithey.

The current team members are all male and enjoy being home during the day. Two are stay-at-home dads.

“They love working together and have a lot of synergy,” she says.

The team consists of 1 RN and 2 RN first assistants (RNFAs). The first assistants can scrub or first assist, which adds flexibility. The OR also sends a first assistant to obstetrics when there is a stat ce-sarean section.

Occasionally, call team mem-bers volunteer to work during the day to keep their skills up on some elective procedures that they don’t often see in the eve-ning. They also help the regular staff, who are assigned to week-end call, when someone needs to give away their call. Staff take call only every eighth weekend.

Another positive aspect of the call team is they are motivated to start cases promptly and to be efficient because when the case is done, they can go home.

From a surgeon satisfaction standpoint, “it’s huge,” says Smithey. “Surgeons know if they have an after-hours case they will be working with an experienced group who are going be as ready as they are and as motivated as they are to get the patient in the OR, get the surgery started, and get the surgery completed so they can all go home.”

A recruitment and retention toolBefore introducing a call-team system at St Vincent Carmel Hos-pital, Carmel, Indiana, the hospi-tal was having trouble hiring OR staff, says Lu McKee, RN, director of surgical services. “The system has been a huge help for recruitment and reten-tion,” she says.

St Vincent is a 100-bed hospital with 10 ORs in a competitive mar-ket 10 miles north of Indianapolis.

During the week, 2 RNs take call from 7 pm to 7 am, Monday through Friday. Their positions are salaried, and they typically work about 10 hours a week.

OR staff still take backup call from 3 to 7 pm or 5 to 8 pm about once every 2 weeks.

On weekends, 1 RN works in the OR from 7 am to 7 pm, Satur-day and Sunday, and then takes call from 7 pm to 7 am. That RN is paid hourly weekend-option time plus benefits.

There also is a group of 4 surgi-cal technologists (STs) and RNs who rotate weekend call. They are paid normal time plus a stipend for weekends.

“These are people who want to take call; staff who don’t want

“

“It’s a

patient safety issue.

On-call practicesContinued from page 1


Human resources

to take call don’t do this,” says McKee.

The system, which has been in place nearly 8 years, also has in-creased surgeon satisfaction be-cause surgeons say they no lon-ger hear complaints from staff who don’t want to be there, says McKee. “The new system makes everyone happy. Our staff turn-over is minimal.”

12-hour night shift replaces callUMC Mountainside Hospital, Montclair, New Jersey, added a 12-hour (7 pm to 7:30 am) night shift to replace call. The night shift consists of 2 teams, an RN and an ST, on 3 nights each, Sun-day through Friday night. The regular staff still cover weekend call (Saturday 7 am through Sunday 7 pm), though the hospital is considering having a scheduled team and an on-call team for Saturdays.

The night-shift team finishes cases, does emergency cases, tests autoclaves, and puts supplies away from the previous day. They also pick cases for the next day and set up and open the first cases of the day when the patients arrive.

“This saves time in getting the first patient into the OR. We haven’t had a nursing delay in getting the first case started in a long time,” says Pat Cavalcante, BS, RN, CNOR, director of surgi-cal services.

UMC is a 320-bed hospital with 7 ORs plus an ambulatory sur-gery and minor procedure room. Because patient volume is grow-ing, Cavalcante says the hospi-tal is recruiting another full-time 3-to-11 pm team, which will pro-vide 2 teams until 11 pm Monday through Friday.

“The night shift has been cost-effective for us because we do a

lot of cases at night, and the call teams were paid time-and-a-half,” says Cavalcante.

Resort area has seasonal call needs Tahoe Forest Health System, Truckee, California, is a 25-bed, 4-OR critical access hospital with an unusually busy schedule be-cause it is in a resort area.

The hospital receives a lot of pa-tients with ski injuries in the win-ter and patients with other types of injuries in the summer. Because of these additional patients, the after-hours schedule during peak seasons is especially busy, which is fatiguing for the staff, says Linda Harman, BSN, RN, CNOR, direc-tor of surgical services.

OR staff include 12 RNs and 2 STs. Elective cases are scheduled from 7:30 am to 5:30 pm.

Any cases running over or add-ons were performed by the staff on call. As a result, staff were working long hours and had to return the next morning for their usual shift.

To compound the call problem, 4 part-time RN staff members plus the OR manager are RNFAs who had to provide 24/7 RNFA cover-age. This left them with limited availability to take regular call.

Now, during winter and sum-mer, 2 staff members are desig-nated to be the “on-call team” from 5 pm to 7 am Monday

through Friday. The team is paid for 40 hours but usually works about 20 hours.

“This was not done to save money but to address the fact that staff were fatigued,” notes Har-man.

Call-back (time-and-a-half) and stand-by (one-third time) pay have decreased with the call team, but Harman says it is difficult to measure the savings because of the difficulty in determining what the cost of call-back pay would have been if they did not have the call team.

No call for per-diem nursesAt Providence St Peter Hospital, an 11-OR community hospital in Olympia, Washington, the RNs voted to exclude per-diem nurses from call, says Lorna Eberle, BSN, RN, CNOR, director of periopera-tive services.

“We had nurses who wanted to cut back on their hours. They said they would go per diem if they didn’t have to take call,” says Eberle. The RNs are unionized and voted to make that happen.

A number of nurses who are close to retirement will probably stay on now as per-diem staff be-cause they won’t have to take call, she says. No other staff are ex-empt from call.

Holiday call scheduling has been turned over to the staff.

“We let them decide how to cover holiday call, whether in 4-hour or 8-hour shifts, or what-ever they decide. They do a fabu-lous job,” she says. ❖

—Judith M. Mathias, MA, RN

“

“Our staff turnover

is minimal.

CE credits now available to OR Manager subscribers!

http://www.ormanager.com/how-to-access-ces/#.UUM-wtjfxebV

A heavy call schedule at one community hospital was driving the perioperative

staff away and raising concerns about patient safety because of staff fatigue.

With a staff turnover rate of 40% in 2007, the perioperative management team knew changes were needed.

Since then, a new staffing model has almost eliminated call for most OR staff. Staff turnover fell to less than 1% in 2011. Staff and physician satisfaction are up, patient safety has improved, and personnel costs are down.

The call situation reflects how attitudes on work-life balance have changed.

“When I came to the OR 36 years ago, it was understood that call would be part of my sched-ule,” says Don Altgilbers, RN, RNFA, CNOR, patient care su-pervisor, OR/CVOR at Blessing Hospital in Quincy, Illinois.

“I would work 8 hours, be on call for 16 hours, and then return at 7 am to work 8 more hours. However, people in the workforce today aren’t willing to obligate that much time to work. They will give you 8 or 12 hours, and then they want to live their lives.”

A Level II trauma center, Bless-ing has 9 ORs and open-heart rooms. Its closest competitors for Level II trauma care are more than 100 miles away in Spring-field, Illinois, and St Louis.

Why were staff leaving?To help address the turnover problem, a consultant was brought in to review the depart-ment’s organizational structure and seek options to stabilize per-sonnel. As part of the project, the staff were surveyed about why they were leaving. Two major complaints:

•Theywere tiredofworking14days straight because of week-end call.

•Theyweretiredofworkingpasttheir shift plus being called in during the night and having to return to work at 7 am. “Staff dissatisfaction was

mostly driven by overtime and no control of that overtime,” says Lori Fecht, RN, RNFA, CNOR. The OR was also exceeding its personnel budget.

After an analysis, a 2-phase plan to revamp call was intro-duced:

Phase 1: First call was elimi-nated on Monday through Friday.

Phase 2: Weekend call was eliminated by developing 2 week-end teams.

Now the regular staff take only backup call from 7 pm to 11 pm during the week.

“We wanted to make sure we had an extra crew available from 7 pm to 11 pm because that is when a lot of our emergencies come in,” says Fecht, who was director of perioperative services when the model was adopted.

Flip shift for callA flip-shift plan was added to eliminate first call during the week, Altgilbers explains. The flip shift alternates staffing by 2 teams, with 1 nurse and 1 surgical technologist (ST) per team.

During one week, one team

works 7 am to 3:30 pm, and the other team is on first call from 7 pm to 7 am. The next week, they flip times.

The flip-shift staff are paid for 40 hours. On the week they take call, they work between 35% and 55% of the on-call time.

The flip shift allows for regular staffing of the OR from 7 am to 7 pm with 8- and 12-hour shifts. If cases are performed after 7 pm, the flip-shift team comes in and takes over. The OR staff then take backup call from 7 pm to 11 pm.

“After 11 pm, if a second team is needed, we start a calling tree and find someone,” he says.

Weekend callAn initial plan to revise weekend call adopted in 2009 was modified in 2011, Altgilbers notes.

Under the initial plan, 1 team with an RN and ST was responsi-ble for call from 7 am Saturday to 7 am Monday and worked Saturday and Sunday from 7 am to 7 pm.

The OR staff took backup call, except for Saturday and Sunday from 7 pm to 11 pm when they were on first call.

“We did this for a year, and found it was too much for one weekend team,” he says.

In January 2011, 2 weekend teams were put in place with a plan similar to the flip shift. One team works from 7 am to 7 pm and takes backup call from 7 pm to 7 am. The other team is on first call from 7 am to 7 am. The next weekend, the teams flip times.

The weekend teams are paid for 36 hours, which is considered full time, and they have 4 week-ends off a year.

Weekend team members must have 2 to 3 years of OR experience.

“We have OR staff waiting in line to be on the weekend teams,” says Altgilbers. “It works great for


New on-call plan helps to stabilize the staff and budget

Human resources

“

“They want

to live their lives.


CDC cites an urgent need to stop carbapenem-resistant superbugs

parents with young children and employees who are going back to school.”

Satisfaction shoots upIn 2006 and 2007, independent surveys showed staff satisfaction at around 58%. In 2010, staff satis-faction rose to 86%.

Though physicians weren’t sur-veyed, they were interviewed and gave feedback over a hotline set up for them to voice concerns.

Now when staff are surveyed about what they are happy with, they say it is the flip shift and weekend crews.

“Eliminating first call has ad-dressed the fatigue factor, which improves patient safety,” says Altgilbers.

It has also helped to stabilize

the salary budget. Before the flip shift was introduced, overtime was causing OR salaries to be more than 11% over budget.

Accurate scheduling key“Once staffing stabilized, we knew we had to look at the sur-gical schedule and make sure the times were right for sched-uled cases. We couldn’t have the schedule run over all the time and be successful with one team after 7 pm,” says Fecht.

Much work and data analysis were done to improve scheduling accuracy and block time alloca-tions through meetings with phy-sicians, team leaders, directors, and supervisors. As a result, run-over cases have dropped dramati-cally, Fecht says.

A more staff-friendly call plan and a more predictable surgical schedule have created a perioper-ative department that is not only a better place to work for physi-cians and staff but also a safer en-vironment for patients. ❖


Do you have a staffing story to tell?

Have you reduced call or made other changes that have led to a safer practice environment? Share your success in OR Manager. Contact Elizabeth Wood, editor, at [email protected] for a pos-sible interview.

In the first half of 2012, 4.6% of US hospitals and nearly 18% of nursing homes had at least 1

case of carbapenem-resistant En-terobacteriaceae (CRE), deadly antibiotic-resistant bacteria, the Centers for Disease Control and Prevention (CDC) reports.

Some common forms are Es-cherichia coli, Klebsiella species, and Enterobacter species.

Carbapenems are a class of an-timicrobials used to treat resistant organisms.

CRE kills up to half of patients who become infected, is easily spread, and can transfer antibiotic resistance to similar bacteria.

The CDC says CRE has spread throughout the US but is relatively uncommon in most areas. Nearly all patients with CRE were in a health care setting or were recently treated there.

Actions to takeThe CDC is urging health care providers to help stop the spread of CRE by:

•knowing if your facility haspatients with CRE, staying aware of CRE infection rates, and finding out when a patient with CRE transfers into your facility

•following infection control rec-ommendations with every pa-tient and using contact precau-tions for patients with CRE

•dedicating rooms, staff, andequipment to patients with CRE

•prescribingantibioticswisely•removing temporary devices

like urinary catheters and venti-lators as soon as possible.

The CDC is offering a CRE Tool-kit with guidance for control of these resistant organisms. The toolkit continues to be updated as new information becomes avail-able. ❖

—CDC. Morbidity & Mortality Weekly Report. Vol 62. March 5,

2013. www.cdc.gov/mmwr/pdf/wk/mm62e0305.pdf

—CDC. Vital Signs. www.cdc.gov/vitalsigns/HAI/CRE/index.html

Shorter shelf life safer for blood?

Red blood cells stored longer than 3 weeks begin to lose their capacity to deliver oxy-

gen to tissue. These changes are not readily reversible after trans-fusion, finds a study.

A shelf life of 6 weeks is con-sidered standard. But older blood is more likely to have less flexible cell membranes, which can com-promise oxygen delivery.

“There is more and more in-formation telling us that the shelf life of blood may not be 6 weeks,” says the lead author, Steven M. Frank, MD, of Johns Hopkins.

“If I were having surgery to-morrow, I’d want the freshest blood they could find.”

Two large randomized con-trolled studies are underway to determine whether a 6-week shelf life is too long, the authors say. ❖

—Frank S M, Abazyan B, Ono M, et al. Anesth Analg. Published

online February 28, 2013. www.anesthesia-analgesia.org

Team members simply intro-ducing themselves to one another at the start of a case

made a difference in the rate of infectious events in a pilot study. The rate was 1.9% when the intro-ductions were documented and 21.1% when they were not. (The

infectious event rate included sur-gical site infec-tions, urinary tract infections, and pneumonia.)

Overall, in the study at Saint Francis Hospital and Medical Center, Hartford, Connecticut, team training plus use of a surgical safety checklist reduced adverse events from 24% in control patients to 16% in cases with team training only and to 8% in cases with checklists plus team training.

The authors say this is the first study to examine how team train-ing can help teams using a check-list with validation through the American College of Surgeons National Surgical Quality Im-provement Program (ACS NSQIP) database.

A report of the study, which used the AORN Comprehensive Surgical Checklist, is in the Jour-nal of the American College of Surgeons.

Study groupsData on patients from the NSQIP database was used as controls and compared with:•agroupof 246proceduresper-

formed by teams who had com-munications training

•a group of 73 procedures per-formed by teams who had com-munications training and used a checklist. Both physicians and staff received the training.Complications included surgi-

cal site infections (SSIs), venous

thrombosis, pulmonary embolus, and urinary tract infections.

The pilot study stemmed from a fellowship project by Scott Ell-ner, DO, MPH, FACS, a general trauma surgeon and vice chair-man of surgery at Saint Francis and a fellow with the American Hospital Association and the Na-tional Patient Safety Foundation.

After IRB approval was granted, the group held a kick-off in September 2010 to explain the project to those involved, including perioperative nurses, surgeons, anesthesiologists, certi-fied registered nurse anesthetists (CRNAs), surgical technologists, and nursing assistants, notes Cyn-thia Ross-Richardson, MS, BSN, RN, CNOR, the NSQIP coordina-tor at Saint Francis.

At the meeting, the group com-pleted a safety attitudes ques-tionnaire (SAQ) to determine the baseline patient safety culture in the OR. The SAQ is a validated survey developed at the Univer-sity of Texas.

Team trainingThe SAQ responses were used in forming the communication team-training sessions. The study team analyzed the SAQ answers, and Nancy Krafcik-Rousseau, PhD, a communication special-ist at Saint Francis, used them to form the communication team training sessions.

These 3 hour-long sessions in-cluded topics such as differences between introverts and extroverts, effective dialogue among OR per-sonnel, and how to use a check-list. Sessions were offered on all shifts, including weekends.

Introducing the checklistThe checklist was introduced in didactic sessions “because we wanted to build upon the impor-tance of each specific measure-ment and part of that checklist,” says Ross-Richardson. Staff also brought up their concerns.

Dr Ellner was a key to checklist implementation, she says, because the staff considered him a role model.

“You have to have a champion working on the front lines every day. He is passionate about deal-ing with conflict and making sure the patient is safe. Without him, I don’t think the project would have been as successful,” she says.

The check-in phase of the AORN checklist is initiated in the preoperative area. The remain-ing 3 phases are completed in the OR. The checklist, on a laminated card, starts with the time-out, which is initiated and led by the anesthesia provider.

Study observersDuring the study cases, trained observers assessed whether the checklist was used, tracked the number of times the circulating nurse exited during the case, and documented any safety-compro-mising events.

Three medical students, includ-ing Lindsay Bliss, MD, who had a strong interest in quality and safety, were trained to be observ-ers.

“Dr Bliss was passionate about the project and went well above


Team training, checklist equal better outcomes in pilot

Patient safety

“

“Introductions

made a difference.


and beyond what we were expect-ing,” notes Ross-Richardson.

“An observer would bring the checklist to the nurse in the pre-operative area and follow the pa-tient and checklist throughout the preop, intraop, and postoperative periods to sign-off in the PACU.

“We had a lot of commitment from them,” she adds. “One case lasted 9 hours, and the observer was there for all of it.”

Safety eventsEvents were grouped according to the nature of the deficiency, such as communication, equip-ment availability or malfunction, disruptive behavior, patient flow and process, and sterility.

Observations were tallied and analyzed, and the data was matched with the NSQIP data.

Though 150 cases with check-list use were necessary to maxi-mize the likelihood of statistical significance, the sample size was 73 because of limited availability of trained observers.

Still, the numbers collected did demonstrate some statistical significance, says Laura Sanzari, BSN, RN, APACHE outcomes co-ordinator for Saint Francis.

Checklist and outcomes Three components of the checklist were linked to significant changes in morbidity, though other events also showed a decrease. There were more deep SSIs when:•confirmationofpatient identity

was lacking•therewas a failure to address

the procedure and procedure site during the check-in section of the checklist.Also, cases where it was not

documented that the team mem-bers had introduced themselves to one another were more likely to have infectious events than those

where the introduction was docu-mented (21.1% vs 1.9%).

The fewer times the circulating nurse exited, the lower the mor-bidity rate. Exits varied from 0 to 25 per case.

What accounts for the results?Sanzari says she thinks the find-ings relate to the plan of care and disseminating the plan to the team prior to the procedure. The plan of care was part of team training.

“Having the plan of care, which includes the procedure, name, site, supplies, and equipment, af-fects the number of times the cir-culating nurse leaves the room,” she says. “Traffic in and out of a room causes air disturbances, which could lead to surgical site infections.”

Why would introductions make a difference?

One theory, she says, is that introductions instill a sense of accountability and help to en-sure that everyone’s voice can be heard.

Using a checklist also had an effect on OR time. Without a checklist, cases lasted an average of 155 minutes; with a checklist, that dropped to 145 minutes.

“It all relates to discerning the plan of care—knowing ahead of time what’s needed, checking the equipment, and making sure it works,” Sanzari reiterates.

Team training is key “Conducting this study has opened the door for others to re-alize there are ways to improve patient care in a simple, not very costly way,” says Ross-Richard-son. The tools are available, and most are free—the key is team training.

If a hospital has instructors who can provide team training, it can design a program using the SAQ. The SAQ provides a base-line measure of clinicians’ con-cerns. Team training can address those concerns, starting an OR on the path to safer surgery.

Saint Francis is continuing the team training when new issues arise and when new staff come on board.

The researchers say they will use the data to support universal adoption of the checklist at their medical center. They also plan to pursue a multicenter study to increase the statistical power of their research. ❖


ReferencesAORN Comprehensive Surgi-

cal Checklist www.aorn.org/Clinical_Practice/ToolKits/Correct_Site_Surgery_Tool_Kit/Comprehensive_checklist.aspx#axzz2IpccM7bN

Bliss L A, Ross-Richardson C B, Sanzari L J, et al. Thirty-day out-comes support implementation of a surgical safety checklist. J Am Coll Surg. 2012;215:766-776.

Dunn E, Mills P, Neily J, et al. Medical team training: applying crew resource management in the Veterans Health Administra-tion. Jt Comm J Qual Patient Saf. 2007;33:317-325.

Safety Attitudes and Safety Climate Questionnaire. https://med.uth.edu/chqs/surveys/safety-attitudes-and-safety-climate-questionnaire/

Patient safety

“

“Trained

observers tracked events.

Preparing patients for sur-gery at Cullman Regional Medical Center in Cullman,

Alabama, used to take about 200 phone calls a day. Here’s a typical scenario: The OR is ready for the next pa-tient. The OR calls the same-day surgery unit and asks if the patient is ready. Same-day surgery says the patient hasn’t arrived. Both depart-

ments call reg-istration to see if the patient i s there ye t . They’re told the patient hasn’t arrived. The OR keeps calling to check. When the

patient arrives, registration calls the OR to let them know and calls same-day surgery to pick up the patient. The OR immediately calls same-day surgery to see if the anesthesiologist can see the patient. Same-day sur-gery says it still needs a few minutes to prepare the patient. A short time later, same-day surgery calls the OR looking for the anesthesiologist, who has to be located. After the anesthe-siologist sees the patient, same-day surgery calls the OR and says the patient is to have spinal anesthesia. The OR calls the holding area to tell the staff to set up for a spinal.

Today, most of those phone calls have gone away, thanks to an electronic patient tracking sys-tem developed in house.

The hospital’s IT department did the programming for the 5-department system, which cost just under $10,000, including 5 LG flat screens and Apple Mac minis to run them. The tracking system, which received a Hos-pital & Health Networks Most Wired Innovator Award for 2012, stands alone and is not tied to Cullman’s electronic medical record.

Lean idea The idea for the tracking system sprang from a Lean Six Sigma course. One final assignment was to identify a project to implement.

For this assignment, Dewight Davis, RN, CNOR, executive di-rector of surgical services; Shelia Barksdale, RN, the OR supervi-sor; and 2 IT professionals, Debby Mason and Amel Drake, hap-pened to be at the same table.

As Davis and Barksdale shared their idea for the tracking system, the hospital’s CEO, Jim Weidner, stopped at their table. He liked the idea and gave his full sup-port for the project. Work on the system started in November 2009, and the system went live in Janu-ary 2010.

Though many tracking systems are on the market, there weren’t many at that time, and “certainly not for the price we were able to complete this project for,” Davis says.

Calls cut in half“Like most ORs, we were inun-dated with communication by telephone,” says Davis. Cullman has 9 ORs including 1 cysto/urol-ogy room.

The tracking system, which consists of 5 electronic white-boards, has cut the calls in half.

The electronic whiteboards are located in registration, same-day surgery, the OR, the postanesthe-

sia care unit (PACU), and the fam-ily waiting area. The whiteboard in same-day surgery has a touch-screen overlay, which is where the data manipulation occurs.

The electronic whiteboards in the patient care areas show when a patient has signed into registra-tion, alerting same-day surgery staff to go after the patient. They also have the patient’s expected arrival time in the preop holding area so anesthesia providers and OR teams can plan accordingly.

Once the anesthesiologist sees the patient, the whiteboard is up-dated with the type of anesthesia to be administered so the staff in the preop holding area can start setting up for a spinal or epidural if needed.

“The patient’s location is now posted on the whiteboards for all the teams to see,” says Davis. “The phone calls now are more clinical rather than a barrage of questions about the patient’s loca-tion.”

Keeping families informedWhen a patient arrives in registra-tion, the patient’s family is pre-sented with a personal identifica-tion number (PIN), a variation of the medical record number. Once the patient is moved to the OR, the tracking board in the family waiting area shows the PIN.

The family can track the PIN as it moves across 4 columns: In OR, Surgery Started, In Recovery, Out of Recovery (illustration).

Before the whiteboard was in-stalled in the waiting area, fami-lies watched television.

Now, Davis says they gaze at the whiteboard and wait for their family member’s number to move to the next column.

The right side of the board has an area for advertisements and announcements, such as wellness


Phone calls go away with a low-cost tracking system

OR performance

OR

Per

form

ance

‘05‘06

‘07‘08

‘09

“

“Calls now are more clinical.


information. Some physicians have inquired about posting ad spots, which the hospital is con-sidering.

Future applicationsFuture uses for the tracking sys-tem are to collect data for bench-marking and for analyzing pa-tients’ times from admission to the anesthesia assessment to entry into the OR.

“This can help us determine if we are having patients admitted too early, which is a huge dissat-isfier,” says Davis.

Though the OR has always been able to track times using the

nursing documentation system, other numbers have not been available, such as time from regis-tration to admission to same-day surgery and time from admission to anesthesia assessment.

“We’re able to track efficiencies now that we didn’t have a good tracking methodology for in the past,” says Davis.

Presently, the IT department compiles the information from the tracking system and produces re-ports using an Access database. A software upgrade is being consid-ered to make reporting easier.

“It was truly exciting to be on the team developing this system,”

says Davis. “More than one morn-ing, the IT team came to work with bags under their eyes from working most of the night on the program,” he says. “But no one ever complained. Instead, they said, ‘See what you think.’ It was our baby we were developing.” ❖


ReferenceWeinstock M. 2012 most wired.

Hospitals & Health Networks. 2012;86(7):24-35. www.hhnmag.com/hhnmag/fea-tures/HHNMostWired2012/MostWired2012.shtml

OR performance

Screen shots of the patient-tracking system at Cullman Regional Medical Center. The tracking system was developed in-house.

OR Business Performance is a new series intended to help OR managers and directors improve the success of their business.

Imagine that you were recently hired as director of periopera-tive services at a 450-bed hospi-

tal with 18 operating rooms. Now, 6 months into your tenure, it’s time for your first performance review.

When you walk into the con-ference room, you are surprised to see not only the CNO but also the CEO, the COO, and the CFO.

The CEO kicks off the review by saying there are is-sues in the OR that the hospital needs to address imme-diately. The CFO explains that for

the hospital to remain in business, there must be a 20% increase in annual case volume and a 10% decrease in overall operating ex-penses. Your heart skips a beat. The CNO emphasizes that quality must improve to comply with new federal payment policies. Finally, the COO adds that increasing sur-geon satisfaction is critical to the hospital’s long-term strategy.

All eyes turn to you. “How can you help us achieve these goals?” the CEO asks.

An unusual scenario?Is this scenario unusual? Increas-ingly, the answer is no. The OR has always been critical to the fi-nancial success of a hospital. In better-performing facilities, sur-gical services accounts for more than two-thirds of gross revenue and up to 60% of the operating margin. Economic pressures have made OR volume growth and cost control more important than ever. New payment models are turning

patient satisfaction and outcomes into important revenue drivers. Improving the business perfor-mance of perioperative services is now a critical competency of OR management.

How can you simultaneously grow volume, cut costs, improve outcomes, and enhance surgeon satisfaction?

First, don’t panic. Resist the urge to slash spending and dic-tate staff changes. Instead, you should gradually transform the OR’s organization, culture, and operations.

Identify opportunitiesStart by taking a clear look at department performance. Work with the finance department and the planning office to answer key questions:

1. Where is the OR making or losing money? Ask the decision support team to provide a breakdown of OR

profit and loss by specialty and by surgeon. (The team should be able to generate these numbers using charge and expense data within the invoice system.) This profitability analysis will help you identify service lines that are driving the department’s financial results.

2. How can the OR grow revenue?Analyze your state’s publicly available discharge data to calcu-late your hospital’s market share by service line. Profitable ser-vice lines with room for market growth are the best opportunities for boosting revenue. For exam-ple, in the bubble chart, the best revenue growth opportunities are in neurosurgery and invasive car-diology. Spine surgery and ortho-pedic surgery also have potential for profitable growth.

3. What are the costs per procedure? Analyze invoices and reports


Better business performance is a critical competency

OR Business Performance

SpineSurgery

OrthopedicSurgery Gynecology

Market Share, %

GeneralSurgery

BariatricSurgery

CardiovascularSurgery

VascularSurgery

ThoracicSurgery

Open HeartSurgery

InvasiveCardiology

Electrophysiology

UrologicSurgery

35,000

30,000

25,000

20,000

15,000

10,000

5,000

035 40 45 50 55 60 65 70 75

Neurosurgery

ENT

Ave

rag

e C

on

trib

uti

on

Mar

gin

, $

The upper left quadrant shows higher-profit services with room for growth. The horizontal axis represents service line market share. (Use public data to calculate your hospital’s share of area discharges.) The vertical axis represents service line contribution margin (net service line revenue minus contractual al-lowances and expenses). Bubble size represents annual discharges. Dashed lines denote median market share and contribution margin. Source: Surgical Directions.ECONOMICS


to identify supply, labor, and equipment costs per encounter. Then roll up encounter-level data to obtain the average cost per procedure type. For exam-ple, the data might show that the average cost of performing a rotator cuff repair in your OR is $2,500. How does that cost com-pare to the Medicare payment? ORs need to get costs below Medicare reimbursement levels to survive.

4. How efficient is the OR? Improvements in efficiency will not only reduce costs but also increase revenue. Use the OR’s clinical information systems to pull data on utilization, cancel-lations, start times, and turnover times. In most systems, this data can be reported from the sched-uling module. Once you have the numbers, see the chart for com-parisons.

A critical question: Does your current OR utilization represent wasted capacity?

For now, just do simple analy-ses to answer basic questions. A rough outline of your OR’s cost and profitability structure will help identify opportunities for improvement.

Keep in mind that none of these improvements can be ac-complished alone. You need co-operation and leadership from key OR stakeholders.

Marshal supportHow do you get stakeholders to work together on OR perfor-mance improvement? Leading hospitals have achieved strong collaboration by creating a Surgi-cal Services Executive Committee (SSEC).

The SSEC, a multidisciplinary board of directors, includes repre-sentatives from surgery, anesthe-sia, nursing, hospital administra-tion, and ancillary departments.

The group aims to optimize the OR’s operational, financial, and strategic performance.

An SSEC is an effective ap-proach because as a committee of the hospital rather than the medi-cal staff, it is able to focus on the overall performance of the OR. And because it includes clinicians, business managers, and hospital leaders, the SSEC addresses prob-lems from every angle:•Costcontrol.ORcostsaredeter-

mined by complex factors, in-cluding block schedule models, staffing, inventory systems, and surgeon supply preferences. A cost-control effort requires mul-tidisciplinary cooperation.

•Efficiency improvement. Ef-ficiency metrics are strongly affected by preoperative pro-cesses . Anesthesiologists ,

nurses, and surgeons must work together to minimize can-cellations and improve on-time start rates.

•Revenue enhancement.Grow-ing surgical volume requires a strategic focus. The adminis-tration needs to lead a collab-orative effort to build the OR around surgeon service. The strength of this governance

model is that the committee has the authority to enforce its deci-sions. Successful SSECs are able to overcome obstacles to make the ORs more efficient, more in tune with surgeons, more aligned with the market, and more profitable. (For more on OR governance, see the January 2013 OR Manager.)

Assemble the teamDeveloping an SSEC is a step-by-step process. To get support from hospital executives, explain how an SSEC is key to achieving the OR’s goals.

Include active physicians who are respected for their clinical skills. Most surgeons and anesthe-siologists will welcome the chance to improve their work environ-ment.

OR Business Performance

“

“Do simple

cost analyses.

OR performance benchmarksPerformance metric Benchmark

Block time utilization 75% - 85%

Same-day cancellations < 1%

On-time starts > 90%

Turnover time (outpatient) ≤ 20 min

Turnover time (inpatient) ≤ 30 min

Capacity (annual cases/OR) 1,075

Source: Surgical Directions client database.



CMS proposes modifying ASC rule requiring staff radiology servicesPrepare a dashboard

Prepare for the first meeting by developing an OR performance dashboard report. Use the data you gathered and include efficiency breakdowns by surgeon. A com-prehensive dashboard will help focus the SSEC on the core needs of the department. It will eventually be instrumental in educating OR staff on critical performance goals.

Coming upThe next column will describe how to work with the SSEC to plan and implement change. The first priority will be to tackle a problem that bogs down many ORs—low utilization. Learn how to work with SSEC leaders to de-sign a block scheduling system that will increase volume and improve the cost structure while boosting surgeon satisfaction. ❖

This column is written by the peri-operative services experts at Surgical Directions (www.surgicaldirections.com) to offer advice on how to grow OR revenue, control costs, and in-crease department profitability.

ReferenceNew Reality. New Choices. Ninth

Annual National Business Group on Health/Watson Wyatt Survey 2004. National Business Group on Health and Watson Wyatt World-wide. www.watsonwyatt.com/us/pubs/insider/2004_04.asp

Continued from page 21

Many ambulatory surgery centers (ASCs) have little need for a staff radiolo-

gist because only a few procedures require on-site imaging. Yet, ASCs are subject to a rule similar to those that require hospitals to keep radiologists on staff.

That will no longer be true if a proposed change takes effect later this year.

On February 4, 2013, the Cen-ters for Medicare and Medicaid Services (CMS) issued a proposed rule that would recognize the lim-ited use of radiology at ASCs. The requirement to hire or contract with a certified radiologist would be limited to cases in which radiol-ogy is needed, most commonly for orthopedic and pain management procedures.

Specifically, CMS proposes to change Sec 416.49(b)(1) of the Conditions for Coverage (CFCs) to require that ASCs limit radiol-ogy services to those integral to the procedures it performs and to change Sec 416.49(b)(2) to per-mit a physician who is qualified according to state law and ASC policy to supervise radiology ser-vices.

Reason for changeCMS says the rule change grew out of President Obama’s execu-tive order to help reduce health care costs by repealing unneces-sary regulations.

CMS estimates the rule revi-sion will save ASCs approximately $41 million annually. Of the 5,300 Medicare-certified ASCs as of De-cember 2011, 48%, or 2,544, will be affected by the rule change, CMS predicts.

A welcome changeComments on the proposed rule, CMS-3267-P, are being accepted until April 8, 2013, and some orga-nizations are already applauding.

William Prentice, chief ex-ecutive officer of the Ambula-tory Surgery Center Association (ASCA), says ASCA supports final adoption, though it will suggest some wording changes. He notes that radiology at ASCs most often is used during sur-gery to guide the surgeon’s movements, and this does not require the services of a radi-ologist. ASCA members report that it is difficult to find radiolo-gists willing to join their medi-cal staff.

CMS began requiring radiolo-gists at ASCs in 2008. Since then, ASCs have been required to find and credential radiologists to supervise interpretation of im-ages. However, ASCs are also limited by regulation to using only images that are part of a procedure, yet they must pay a radiologist to be present during those procedures to interpret the images along with the surgeon. Meanwhile, to be qualified to perform any procedure, a sur-geon must be able to interpret radiology images integral to that procedure.

The expense and inconvenience of bringing in a radiologist, CMS says, is unnecessary and burden-some. “Supervision of radiologic services should be appropriate to the types of procedures conducted by the ASC,” the proposed rule states. ❖

—Paula DeJohn

“

“The rule

is considered unnecessary.

What’s in the OR Manager Toolbox?Look in the OR Manager Tool-box for forms, policies, and other help.

New to the Toolbox:

•Safetychecklistsforambula-torysurgerycenters

•Surgicalschedulingfaxform

Find the Toolbox at www.ormanager.com.


Faster procedures benefit patients and bottom line

Shortening the time it takes for an outpatient procedure may increase volume, OR

utilization, and hence revenue—but that is not the point, say the nation’s top performers in a re-cent survey of procedure times.

Rather, the purpose is to en-hance patient safety and satisfac-tion. For example, less time in the waiting room means less fear and frustration. A shorter procedure time means less time under anes-thesia, which in turn means less time in recovery and a better un-derstanding of postdischarge in-structions.

The Accreditation Association for Ambulatory Health Care In-stitute for Quality Improvement (AAAHC Institute) tracks selected procedure times in a semiannual survey. Overall, ambulatory sur-gery centers (ASCs) have been shortening the length of patient visits, but there will always be room for improvement, according to AAAHC Institute Senior Direc-tor Naomi Kuznets, PhD.

“ASCs always strive to do bet-ter,” she says. “These results show improvement for certain organi-

zations, which is always laudable. I don’t think there is ever a stop-ping point for these studies.”

The AAAHC Institute uses procedure times as benchmarks for quality, Kuznets explains, “be-cause they reflect processes not dictated by clinical guidelines and are, for the most part, within the control of the organization.”

The latest results, due out shortly before press time, cover the period from July 1, 2012, to December 31, 2012.

The previous study, conducted between January 1, 2012, and June 30, 2012, covered colonoscopy, knee arthroscopy, pain manage-ment by low-back injections, and cataract surgery. High-scoring ASCs in the first 2 categories agree

that advance planning, teamwork, and sincere concern for patient wel-fare were the keys to excellence.

Quick, but carefulIn the January through June colonoscopy survey, 61 ASCs sub-mitted data on 2,086 cases. The median preprocedure time was 62 minutes, with a range of 12 to 97 minutes. The procedure itself took from 9 to 27 minutes, with a median of 18 minutes. The in-terval to discharge ranged from 13 to 62 minutes, with a median of 36 minutes. Total facility time for participants ranged from 57 to 166 minutes, with a median of 121 minutes.

At the Ambulatory Endos-copy Center of Central Florida (AECCF) in Longwood, the aver-age discharge time was 12.6 min-utes (rounded to 13), making the center a top performer in that cat-egory. The AECCF is a freestand-ing, physician-owned center with 2 procedure rooms. The center’s 4 gastroenterologists perform about 300 colonoscopies per month.

“

“Benchmarking

shows gains.

Ambulatory Surgery Advisory BoardLee Anne Blackwell, BSN, EMBA,

RN, CNOR Vice president, clinical services, Practice Partners in Healthcare, Inc, Birmingham, Alabama

Nancy Burden, MS, RN, CAPA, CPAN Director, Ambulatory Surgery, BayCare Health System, Clearwater, Florida

Lisa Cooper, BSN, BA, RN, CNOR President, Surgery Center, Samaritan Medical Center, San Jose, California

Rebecca Craig, BA, RN, CNOR, CASC CEO, Harmony Surgery Center, Fort Collins, Colorado and MCR Surgery Center, Loveland, Colorado

Stephanie Ellis, RN, CPC Ellis Medical Consulting, Inc Brentwood, Tennessee

Rikki Knight, BS, MHA, RN Clinical director, Lakeview Surgery Center, West Des Moines, Iowa

LeeAnn Puckett Materials manager, Evansville Surgery Center, Evansville, Indiana

Donna DeFazio Quinn, BSN, MBA, RN, CPAN, CAPA Director, Orthopaedic Surgery Center Concord, New Hampshire











Endoscopy manager Angela Corallo, RN, attributes the rapid recovery time in part to sedation management by the certified reg-istered nurse anesthetist (CRNA), who decreases the sedation before the end of the procedure but still maintains an adequate level of comfort for the patient.

One of the first tasks in deter-mining the discharge time, she re-calls, was defining it. The AAAHC Institute defines discharge crite-ria for colonoscopy as the period from when the physician removes the scope to the time the patient is medically ready to leave. “That is not the actual time they leave,” she notes.

No patient is released before 30 minutes have elapsed post-procedure. Patients must be alert

and oriented, they must have dis-cussed the results with the physi-cian, and their driver must have arrived.

The center identified 2 ways to shorten that period: keep medica-tion levels to the minimum neces-sary for patient comfort, and start planning for a smooth recovery well before the patient arrives in recovery. The third factor, which makes it all possible, is a team that is able to communicate and coordinate actions.

“Our major emphasis is on keeping the patients safe and comfortable. All of the following processes revolve around these concepts,” Corallo says.

Step by stepThe road to a rapid discharge be-gins with a well-organized admis-sion.

The receptionist is the first staff member to interact with the arriv-ing colonoscopy patient, and her role is crucial.

“She is the start of the patient’s experience with us, and she could make that experience unpleasant if she does not handle the patient properly,” Corallo says.

Upon arrival, patients often are hungry, irritable, in need of a bathroom, embarrassed, or ner-vous about the procedure. At the AECCF, a nurse is available to provide immediate assistance and explain what will happen. The AECCF prides itself on having adequate staff, with long experi-ence and low turnover.

The admitting nurse takes vital signs and then reviews medica-tions, consents, and medical his-tory for accuracy. After the pa-tient changes into a gown and is


AmbulatorySurgery Centers

AAAHC Institute benchmark study 2012Preop phase Procedure Discharge phase Total

Range Median Range Median Range Median Range Median

(minutes)

Colonoscopy

Jan-June 12 to 97 62 9 to 27 18 13 to 62 36 57 to 166 121

July-Dec 17 to 129 59 9 to 29 16 15 to 75 40 63 to 183 116

Knee arthroscopy

Jan-June 24 to 115 90 17 to 42 27 48 to 113 71119 to

246 192

July-Dec 60 to 135 88 13 to 81 28 35 to 141 75135 to

341 193

The chart shows comparative results for colonoscopy and knee arthroscopy between the first and second halves of 2012. AAAHC Institute conducts benchmarking studies twice a year to track procedure times.

Source: Accreditation Association for Ambulatory Health Care Institute for Quality Improvement.



on a stretcher, the nurse starts an IV line with fluids to relieve de-hydration; this, too, helps speed recovery.

The contract anesthesiologist then evaluates the patient, fol-lowed by the CRNA, who will administer and monitor the seda-tion. Next, the physician meets with the patient to review con-cerns and expectations. After the patient is fully sedated, there is a time-out to verify the pro-cedure and patient’s identity, and then the procedure begins. Shortly before it ends, the dose is decreased, allowing recovery to begin sooner. The physician routinely removes air from the colon at the end of the procedure, which also helps decrease recov-ery time.

The CRNA and a float nurse accompany the patient to the re-covery room. The CRNA remains until the patient is stable.

There, the advantage of a quicker recovery is evident: the patient spends less time sedated, has less chance of nausea, and is more alert when the physician comes in to discuss the results.

“What happens upon admis-sion affects everything that hap-pens afterward,” Corallo says. Pa-tients who know what to expect and are comfortable will have a better recovery.

At the front endAt Mountain Laurel Surgery Cen-ter in Honesdale, Pennsylvania, the average precolonoscopy time was 12 minutes, making the cen-ter a top performer in that cat-egory. In the just-released second study, Mountain Laurel was again named a top performer.

The freestanding, physician-

owned center has 3 gastroenter-ologists and 2 procedure rooms where about 60 colonoscopies per week are performed.

Director of nursing Patricia Williams, RN, says close coordi-nation with the physicians makes the short wait times possible. Within 30 days of a scheduled colonoscopy, the physician’s of-fice staff interviews the patient. ASC nurses contact the patient 2 or 3 days before the procedure to review all medications and con-ditions and to determine if there have been any changes.

By the time the patient arrives at the ASC, the information is on hand, and only a quick review is necessary. The physician then reviews the consent form with the patient. The anesthesiologist or CRNA interviews the patient before moving the patient to the procedure room.

The rapid, efficient processing not only saves time but also mini-mizes anxiety, Williams explains. “We try to work with our patients when they come in for the proce-dure,” she says. “Because of that, most of the anxiety has dissipated. They know what to expect.”

She notes that younger pa-tients, usually present for diag-nostic colonoscopies, tend to be the most anxious on arrival but

respond well to the attention they receive.

“They say it’s the way we pres-ent ourselves that helps them calm down,” Williams says. “One of the younger patients recently told me, ‘It’s so nice to come here, compared to someplace else.’ ”

Propofol safetyBoth AECCF and Mountain Lau-rel administer propofol during colonoscopies, but AECCF com-bines it with midazolam (Versed) and fentanyl. Ondansetron (Zof-ran) is also available in case of nausea.

Because propofol has been known to produce sudden ad-verse side-effects, the Institute for Safe Medication Practices (ISMP) and other experts strongly recom-mend having trained anesthesia personnel—that is, an anesthesi-ologist or CRNA—administer the drug, even if the drug is intended for sedation only.

“After all,” the ISMP’s Novem-ber 3, 2005, Medication Safety Alert notes, “how much supervi-sion can the physician provide if he or she is focused on the proce-dure itself?”

Both ASCs follow that guide-line. CRNAs are present during procedures to administer the drugs and monitor the patient’s respiratory function. Anesthesi-ologists are available on site.

Propofol is the sedative of choice for colonoscopies because it is fast acting with a short-term ef-fect, which is ideal for a brief pro-cedure. “Patients wake up sooner with no side-effects and are more alert,” Williams explains.

Because of current shortages,


“

“Plan for a smooth

recovery.











some ASCs, such as AECCF, aug-ment propofol with other drugs. According to the American So-ciety of Health-System Pharma-cists’ Current Drug Shortages Bul-letin of February 5, 2013, 2 major suppliers, Hospira and American Pharmaceutical Partners, have propofol on back order. Hospira cites manufacturing delays, and APP is unable to meet growing demand.

Efficient arthroscopy Knee arthroscopy calls for pa-tient stays of up to 4 hours, but the principle is the same: careful planning and medication man-agement can make the patient’s visit shorter and easier.

Staff nurse Shannon Waring, RN, oversees benchmarking stud-ies at Los Alamitos (California) Surgery Center. Even before the AAAHC study, she was in the habit of monitoring procedure times.

In the first 2012 study, Los Alamitos ranked number 3 in av-erage preprocedure time, at 45 minutes. “That’s where we ex-celled,” Waring says.

For the January through June knee study, 33 organizations re-ported data on 796 cases. The preprocedure time range was 24 to 115 minutes, with a me-dian of 90 minutes. The median procedure time was 27 minutes, with a range of 17 to 42 min-utes. Discharge times averaged 48 to 113 minutes, with a me-dian time of 71 minutes. Total time spent in the facility ranged from 119 to 246 minutes, with a median of 192.

Los Alamitos, an indepen-

dent ASC with 3 ORs owned by a group of physicians, performs about 1,600 knee arthroscopies annually.

The surgeons and ASC staff work closely to coordinate patient scheduling and preparation, ac-cording to Waring.

“We have frequent meetings, with OR technologists, RNs, and sometimes anesthesiologists,” she says. “We work closely with our surgeons.”

The ASC is strict about OR start times. “If you are scheduled at 7:30 am, we start surgery at 7:30 am.” RNs and surgical tech-nologists arrive an hour before start time to make sure instru-ment trays are ready. The nurses are cross-trained so they can move from preop to the OR to the postanesthesia care unit as necessary.

Paperwork is completed the day before surgery in a phone call to the patient. When patients arrive, they sign the paperwork, and then an RN leads them to the dressing room.

“People don’t really wait in our waiting room,” Waring notes. “We bring the patients right back.”

The RN checks vital signs, starts the IV, adds antibiotics, and checks the consent form.

Then the anesthesiologist comes in and reviews the patient’s his-tory. Following surgery, the same nurse and anesthesiologist accompany the patient to the re-covery area.

Recovery time for knee arthros-copy with general anesthesia is 1 hour. After the patient awakens, the surgeon meets with him or her to clarify discharge instruc-tions.

Planning and teamworkWaring says the key to keeping preprocedure time short is to have all of the required documentation completed the day before. The surgeon’s office collects the infor-mation and sends the completed forms to the ASC.

“We have a good working rela-tionship with our surgeons,” she notes.

ASC employees meet regu-larly with their counterparts in the physicians’ offices to compare notes and head off potential prob-lems.

But these clinicians do not just talk among themselves; they also make it a point to communicate with patients. That, Waring says, is another secret to their success.

“We focus on the patient and the patient’s experience. We have a common goal.”

Regardless of the type of proce-dure, that philosophy applies. The top performers agree that plan-ning and effective communication make for speed but never haste.

It means making patients feel cared for, not rushed. As Waring observes, “Just because you’re ef-ficient doesn’t mean you have to compromise in the way you’re caring for someone.” ❖

—Paula DeJohn



“

“Patients

know what to expect.


Popular OR Manager Webinars Are Now Available!

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21442

OR Manager offers webinars twice a month on topics of vital interest to managers and directors of the operating room. Learn from the comfort and convenience of your home or office!

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■ Do You Really Know How Well Your ORs Are Being Cleaned? Hear about the latest research for establishing an evidence-based method for validating how well your ORs are being cleaned, presented by researcher Philip Carling, MD. He discusses how the OR can set forth policies, establish cleaning validation, and educate cleaning personnel.

■ The Perioperative Impact on Value-Based Purchasing (VBP) In this on-demand webinar, you will hear what’s new in VBP and learn about specific strategies that perioperative nurses can employ to improve quality and performance. You will also hear about what to anticipate in the future for VBP.

■ Improving the Collaboration of the Perioperative Team to Reduce SSIs Reducing surgical site infections is everyone’s responsibility. An infection prevention expert discusses how patients and health care providers can collaborate in preventing infections during the patient’s journey from the physician’s office through the surgical facility and back home again.

■ Best Practice Block Scheduling and Tips for Implementation Learn how to create a successful block program that meets both hospital utilization targets and surgeon needs. This includes an effective scheduling program, the creation and enforcement of strong block policies, and an effective governance structure.

Webinars are approved for Continuing Education Credits. Your purchase of these on-demand webinars comes with access to an online CE portal where you can take the webinar post-test, earn continuing education credit hours, and print your certificate.

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New learning portalAs each monthly issue is posted online, the post-test will be added to your account automatically for you to access and complete. This new online learning portal also is an easy way to store and manage your CE credits and certificates of completion.

If you need help logging into your account or accessing the learning portal, contact OR Man-ager at 1-888-707-5814 or [email protected]. ❖

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Take specific actions to reduce anesthesia administration risks in your OR with INsight.™ Whether you need to assess your anesthesiology department’s processes or are looking for a more customized solution, we are here to help you:

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MS13

116

AHRQ identifies top patient safety strategies

In an update of the 2011 Making Health Care Safer, the Agency for Healthcare Research and Quality

(AHRQ) has identified 22 patient safety strategies proven to be ef-fective. Of these, 10 are “strongly encouraged” for adoption based on strength and quality of evidence.

Notably, AHRQ recommends: •preopandanesthesiacheckliststo

prevent intra- and postop events•bundles that include checklists

to prevent central line-associ-ated bloodstream infections

•interventions to reduceurinarycatheter use

•interventions to improve pro-phylaxis for venous thromboem-bolism. ❖

To learn more, visit www.ahrq.gov/research/findings/evidence-based-re-ports/makinghcsafer.html.

Special RepoRt

Published June 2012 by

patient Safety: Taming Noise and Distractions in the OR

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The table of contents includes:• Turnover rates stable, use of temp staff is down, annual survey finds

• Staffing for surgery centers is in a holding pattern

• Beyondbucks:Bestideasfor recognizing staff

• Assistingatsurgery:1in3ORs using assistants don’t require special qualifications

• HalfofORdirectorsplantoretire by the end of the current decade

• Survey:ASCeconomicconditions may be easing pages

• Teachinghospitalsaddingbusiness managers

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OR Manager Vol 27, No 1232

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At a Glance

OR Manager Vol 29, No 4 April 2013

Lower postop mortality with BSN-prepared nursesFewer deaths after general, vas-cular, and orthopedic surgery oc-curred in hospitals with a higher number of nurses with baccalau-reates, a study finds.

A 10-point increase in the per-centage of BSNs was associated with an average reduction of 2.12 deaths/1,000 patients and 7.47 deaths/1,000 patients when there were complications.

If all 134 hospitals in the study had increased the percentage of BSNs by 10 points during the study period, some 500 deaths might have been prevented, the authors estimate.

—Kutney-Lee A, Sloane D M, Aiken L H. Health Affairs.

2013;32:579-586.

Bariatric centers of excellence not linked to better outcomesRates of complications and reoper-ation for bariatric surgery patients were similar before and after 2006, when Medicare began restricting coverage of the procedure to cen-ters of excellence, finds a study.

Analysis included 2004 to 2009 discharge data for nearly 321,500 Medicare patients in 12 states.

Though outcomes improved during the study period, the change was already underway be-fore the Medicare decision and could partly be explained by the evolution toward lower-risk pro-cedures, the researchers say.

The findings suggest that CMS should reconsider the policy, the authors suggest.

—Dimick J B, Nicholas L H, Ryan A M, et al. JAMA. 2013;

309:792-799.

Robotic-assisted hysterectomies rise, offer little benefitRobotic-assisted hysterectomy in-creased from 0.5% to 9.5% of pro-cedures between 2007 and 2010, though the technique is more expensive and does not improve outcomes or reduce complica-tions, finds a study.

Though robotic-assisted hyster-ectomy patients were less likely to stay in the hospital longer than 2 days, the procedure cost nearly $2,200 more per case than did lap-aroscopic hysterectomy.

Overall complication rates were similar for the 2 procedures.

—Wright J D, Ananth C V, Lewin S N, et al. JAMA.

2013;309:689-698.

Epidural analgesia better than local for postop painEpidural analgesia controlled pain better than wound filtration with local anesthetic after colorec-tal surgery, a French study finds. Epidural analgesia patients also had faster functional recovery and shorter hospital stays.

The superior pain relief justi-fies the added cost and complex-ity of epidural analgesia, the au-thors say.

—Jouve P, Bazin J, Petit A, et al. Anesthesiology. 2013;118:622-630.

Hip implants fail more often in womenWomen had a 29% higher risk of implant failure than men in a study of more than 35,000 total hip arthroplasties, even after tak-ing other individual risk factors into account.

More women received 28-mm femoral heads and metal on highly cross-linked polyethyl-ene-bearing surfaces. Men had a higher proportion of 36-mm or larger heads and metal-on-metal-bearing surfaces.

—Inacio M C S, Ake C F, Paxton E W, et al. JAMA Intern Med. Published online ahead of print

February 18, 2013.

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