Much of the effort to ensure

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1 The monthly publication for OR decision makers February 2013 Vol 29, No 2 Inside OR Manager PATIENT SAFETY Surgical never events pegged at 4,000 a year...5 PERFORMANCE IMPROVEMENT A plan for avoiding readmissions after surgery...13 PATIENT SAFETY Adopting a no interruption zone for patient safety...20 OR BUSINESS MANAGEMENT How should we charge for preadmission testing?...23 ECRI INSTITUTE PERSPECTIVES Top 10 health technology hazards for 2013 are named...16 ASC award winners share quality improvements Patient safety Safer surgery: Is your scheduling process as accurate is it could be? Ten elements of safer surgery. Second in a series. Much of the effort to ensure correct-site surgery focuses on preoperative verification. But scheduling is where it all begins. Capturing complete and accurate information when the case is booked is key to preventing errors down the line. Safer Surgery Scheduling flaws are a common barrier in preventing wrong surgery, according to reports from 2 states where reporting of these events is mandatory. OR economics Destination surgery : Metrics drive patients to centers with better care Perioperative managers and staffs are collecting data on a growing list of metrics on surgical quality antibiotic prophylaxis, venous thromboembolism prevention, normothermia, and more. Related editorial, p 3 Now these and other metrics are coming into play as big companies like Walmart, Lowe s, and Pepsico seek the best value for their insured employees, especially those needing complex surgery. In Minnesota, b r e a k d o w n s i n initial scheduling, such as missing or incorrect information, were one root cause for events reported in In a survey of Pennsylvania facilities, access to accurate information before the patient s arrival in the preoperative holding area was one barrier to adopting evidencebased recommendations to prevent wrong-site surgery, reports the Pennsylvania Patient Safety Authority. (The recommendations Continued on page 6 Companies are o f f e r i n g t o p a y travel and waive deductibles and copays for selected patients who choose to go to leading centers ECONOMICS for procedures such as cardiac, orthopedic, and spine surgery. Some are national names like the Mayo Clinic and the Cleveland Clinic. They may also be regional centers with proven outcomes, like Mercy in Spring- Continued on page 11

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3 Editorial PUBLISHER, AI HEALTHCARE GROUP Carol Brault MANAGING EDITOR Pat Patterson EDITOR Elizabeth Wood CLINICAL EDITOR Judith M. Mathias, MA, RN EDUCATION COORDINATOR Judy Dahle, MS, MSG, RN CONTRIBUTING WRITER Paula DeJohn SENIOR VP/GROUP PUBLISHER Jennifer Schwartz TRADE SHOW DIRECTOR Beth Strelitz ART DIRECTOR David Whitcher SENIOR PRODUCTION MANAGER Joann M. Fato ADVERTISING National Advertising Manager Ashley W. Kerwin Account Executive, OR Manager Fax: REPRINTS Wright s Media sales@wrightsmedia.com Vol. 29, No. 2, February 2013 OR Manager (ISSN ) is published monthly by Access Intelligence, LLC. Periodicals postage paid at Rockville, MD and additional post offices. POSTMASTER: Send address changes to OR Manager, 4 Choke Cherry Road, 2nd Floor, Rockville, MD Super subscription (includes electronic issue and weekly electronic bulletin) rates: $179 (plus $10 shipping for domestic and Canadian; $20 shipping for foreign). Single issues: $29. For subscription inquiries or change of address, contact Client Services, clientservices@accessintel.com. Tel: , Fax: Copyright 2013 by Access Intelligence, LLC. All rights reserved. No part of this publication may be reproduced without written permission. OR Manager is indexed in the Cumulative Index to Nursing and Allied Health Literature and MEDLINE/PubMed. SISTER Sites dorlandhealth.com patientadvocatetraining.com contexomedia.com Access Intelligence, LLC Chief Executive Officer Don Pazour Executive Vice President & Chief Financial Officer Ed Pinedo Exec. Vice President, Human Resources & Administration Macy L. Fecto Divisional President, Access Intelligence Heather Farley Senior Vice President, Chief Information Officer Robert Paciorek Senior VP, Corporate Audience Development Sylvia Sierra Vice President, Production and Manufacturing Michael Kraus Vice President, Financial Planning and Internal Audit Steve Barber Vice President/Corporate Controller Gerald Stasko 4 Choke Cherry Road, Second Floor Rockville, MD Do you know who your competitors for surgical volume are going to be? It may not be the hospital or surgery center down the street or even across town. Your competitor could be in the next state or even across the country, at least for some types of surgery. Big employers, fed up with health care costs, are becoming sophisticated users of quality data. They re tapping into databases to identify the leading centers for cardiac surgery, total joint replacement, spinal surgery, and other types of major surgery. Walmart recently negotiated agreements with 6 medical centers with high quality ratings to treat surgical patients for a fixed price. (See article, p 1.) An all-in-one price marks a radical departure for the conventional fee-for-service medical industry, the Los Angeles Times reported (November 17, 2012). It s not just about price it s also about making sure patients need surgery in the first place. What s driving decisions? A neurosurgeon who was involved in negotiating with Walmart on a new contract for spinal surgery told us what he finds big employers are looking for. Alan Scarrow, MD, JD, FAANS, FACS, president of the Mercy Clinic, Springfield, Missouri, named 3 factors: Ethics: Companies want a hospital that provides treatment that will yield a positive outcome not procedures that are done because they can be done. These hospitals make sure patients get a thorough review by a panel of specialists so they are diagnosed correctly and given a treatment plan that they agree It's a radical departure. is in the best interest of the patient. Quality: Employers seek evidence of quality and outcomes showing what they can expect for the dollars they invest in employees care. Price: In negotiations, no one has said, We want the lowest price, Dr Scarrow notes. They want the best value for their employees, and that is tied to the first two points ethics and quality. A few years ago, he says, employers weren t as likely to connect cost to quality and utilization rates for surgery. Now they re better informed. They figure widely varying surgery rates don t mean Medicare patients in Brunswick, New Jersey, for example, need spinal surgery twice as much as patients in Philadelphia. Differences like these, repeated across the country, have been documented by the Dartmouth Atlas for more than 20 years ( org). Employers figure the variation is most likely because surgery follows local practice patterns rather than the evidence. It s a major shift. We used to say health care is local. Now companies find care doesn t need to be constrained by the local market. And they have tools to identify providers that provide greater value. Pat Patterson February 2013 OR Manager Vol 29, No 2 3

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5 Patient safety Surgical never events pegged at 4,000 a year Surgeons in the US leave a surgical item such as a sponge or a towel in a patient 39 times a week, perform a wrong procedure 20 times a week, and operate on the wrong body site 20 times a week, a new study estimates. The analysis is thought to be the first to gauge the national rate of never events incidents that should never occur in surgery. This study highlights that we are nowhere near where we should be, and there s a lot of work to be done, says the lead author, Marty Makary, MD, MPH, of the Johns Hopkins University School of Medicine. Using the National Practitioner Data Bank (NPDB), the researchers identified 9,744 paid malpractice judgments and out-of-court settlements over 20 years related to retained surgical items and wrongsite, wrong-procedure, and wrongpatient surgery. In these incidents: 6.6% of patients died Advisory Board Mark E. Bruley, EIT, CCE Vice president of accident & forensic investigation, ECRI, Plymouth Meeting, Pennsylvania Stephanie S. Davis, MSHA, RN, CNOR Assistant vice president of surgical services, Hospital Corporation of America, Nashville, Tennessee Reuben J. DeKastle, BN, MSHA, RN, CNOR Administrative director, patient care services, Weiser Memorial Hospital, Weiser, Idaho 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, Providence St Peter Hospital, Olympia, Washington We are not where we need to be. 32.9% had permanent injuries 59.2% had temporary injuries. Malpractice payments totaled $1.3 billion. The most common event was a retained item, followed by wrongprocedure, wrong-site, and wrongpatient surgery. Using published rates of surgical adverse events resulting in a malpractice claim, the researchers estimate 4,044 surgical never events happen in the US each year. Never events happened most often in patients between the Linda R. Greene, MPS, RN, CIC Director of infection prevention, Rochester General Hospital System, Rochester, New York Jerry W. Henderson, MBA, RN, CNOR, CASC Assistant vice president, perioperative services, Sinai Hospital, Baltimore, Maryland Lisa Morrissey, MBA, RN Nursing director, Main OR, Massachusetts General Hospital, Boston, Massachusetts John Rosing, MHA, FACHE Vice president and principal, Patton Healthcare Consulting, Milwaukee, Wisconsin Kathryn Snyder, BSN, MM, RN, CGRN Nurse manager, endoscopy/bronchoscopy/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 ages of 40 and 49. The researchers found that 12% of physicians had claims for more than 1 never event, suggesting there may be factors related to individual practitioners. Dr Makary says the NPDB is the best source of information about never-event claims because these are not the sort of claims that result in frivolous lawsuits or in settlements to avoid jury trials. There s good reason to believe these were all legitimate claims, he says, noting that a claim of a retained sponge can be proven by an x-ray. Public reporting advocated By law, hospitals are required to report never events that result in a settlement or judgment to the NPDB. If anything, he says, his team s estimates of these events are low because not all items left behind after surgery are discovered. Typically, they are found only when a patient develops a complication after surgery, and an effort is made to find out why. Most surgical facilities, of course, have procedures to prevent never events, including surgical checklists and counts for surgical items, though they aren t foolproof. In addition, Dr Makary advocates public reporting of never events, a move he says would enable consumers to make more informed choices about where to have surgery. Though hospitals are supposed to share never-event information voluntarily with the Joint Commission, that doesn t always happen, he notes. Reference Mehtsun W T, Ibrahim A M, Diener- West M, et al. Surgical never events in the United States. Surgery. December 17, Published online ahead of print. February 2013 OR Manager Vol 29, No 2 5

6 Patient safety Safer surgery Continued from page 1 are at The earlier you can align all of the information about the patient, the less the chance of error, says the Authority s clinical director, John Clarke, MD, who is also professor of surgery at Drexel University in Philadelphia. If you wait until a nurse is rushing around in the preoperative holding area, the chance of error is greater. Strategies for accuracy In the Pennsylvania survey, 47 facilities named 80 strategies they used to meet the goal of having 100% of documents complete, correct, and in agreement on initial verification when the patient arrives in the preop holding area. The most common strategies: verification and reconciliation of information prior to the day of surgery by the OR schedulers and/or preadmission nurses use of preoperative verification checklists embedding verification in an electronic scheduling form making phone calls to patients the day before surgery. Phoning patients the day before surgery, while not the most common method, seemed to be effective because it entails active verification, Dr Clarke notes. Unlike with an automated call, a nurse who calls patients is able to probe and elicit responses to confirm information. Foster close communication Close communication with surgeons offices is an essential link in a safe scheduling process. Dr Clarke notes key points that can aid this process: Errors were quite alarming. Agree with the surgeons offices that a minimum set of information will be required to schedule surgery, such as the patient s identity, procedure, and surgical site. Agree that when possible, patient information, the consent, and the history and physical (H&P) will be obtained by the surgeon in the office when the decision for surgery is made. Have experienced OR schedulers who are firm yet respectful in communicating with offices. Audit the process for receiving information from the surgeons offices to make sure the process is working as expected. For example, track 5 to 10 cases monthly. See if you re doing what you think you are doing, Dr Clarke suggests. If not, ask, What are the barriers? " Tips and a checklist template for surgeons offices for preventing wrong surgery plus a monitoring tool are available on the Authority s website (www. patientsafetyauthority.org). Booking errors alarming An in-depth analysis of surgical booking for more than 4,500 patients in an 8-OR ambulatory surgery center (ASC) turned up errors that were quite alarming, says the administrator, Thomas Halton, BSN, RN, CNOR. He is Ten components for safer surgery The 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 World Health Organization Surgical Safety Checklist 8. Daily huddle 9. Error reporting 10. Just culture the assistant director of nursing for the Stony Brook Medicine ASC, affiliated with Stony Brook University in New York. The project s aim, he says, was to affirm the hypothesis that the preprocedural verification process currently in place was effective in identifying potential wrong-site/ wrong-side errors. The project examined variables from the booking sheets, H&Ps, surgical schedules, consent forms, and staff interventions for all cases over 7 months. In all, 241 (5.3%) discrepancies were noted on the booking sheets. Of the total, 62 were wrong-site or -side documentation errors on preop paperwork and booking sheets from the physicians offices. 6 OR Manager Vol 29, No 2 February 2013

7 Patient safety For surgeons offices: What you can do to prevent wrong-site surgery When scheduling an operation, include the correct patient name and procedure. Include the side or site if pertinent. Do not use abbreviations. Write out all numbers. When obtaining the consent, include the correct procedure. Include the side or site if pertinent. Do not use abbreviations. Write out all numbers. Make sure the patient has signed the consent before the patient next presents to the surgical facility. The history and physical should give the preoperative diagnosis, including the side or site if pertinent. It should also state the planned procedure, including the side or site if pertinent, without abbreviations. Pertinent supporting information uniquely found in the office records should be included in the history and physical, or copies should be attached. If relevant, laboratory results, imaging studies, and/or pathology results should be included in the preoperative documentation. When information leaves the surgeon s office, check to make sure the name of the procedure on the scheduling slip, consent, and history and physical all match. All discrepancies should be reconciled as soon as possible. Copyright Pennsylvania Patient Safety Authority. Additional information and tools at Orthopedics, ophthalmology, and plastic surgery had the highest percentages of discrepancies, but no service or surgeon had error-free booking information. Preverification effective The analysis confirmed that the preprocedure process was effective in preventing errors from reaching the OR. Halton says the facility has not had any wrongsite or -side errors, which he attributes to the preprocedural check. The steps include: confirmation of correct patient information in the booking process verification in the preop clinic the nurse s preop phone call to the patient the day before surgery final verification with the patient on the day of surgery by all disciplines (preop nurse, anesthesia provider, OR circulating nurse, and surgeon) before entry to the OR. A time-out is then performed in the OR before the first surgical instrument is passed. Halton presented the data to all surgical services and the patient safety and OR committees as well as the hospital QA committee. We received a lot of support from the hospital after the data was presented, he says. Interventions underway Stony Brook is working on interventions to prevent booking errors. An electronic booking process with required fields is in the trial phase. Once this is in place, offices will enter their own booking information, avoiding transcription errors by the facility. Offices will have the ability to send the booking. We can review it and send it back for attestation, Halton says. Another fail-safe: A huddle is held at 1 pm each day to review and verify the next day s schedule. It s a team approach, Halton says. On hand with him are the surgical schedulers, the OR head nurse, the preop nurse, the sterile processing supervisor, materials manager, anesthesia director, and OR service clinicians. In one telling example of how errors are caught, a patient himself a physician came in for orthopedic surgery. The schedule and consent said the right side. The patient had signed the consent for the right side on the day of surgery. But during preoperative verification, the preop nurse asked the patient to confirm the site/side. No, it s my left, the patient said. That puts it in perspective the nurse did her job, says Halton. Single path to scheduling A single path to surgical scheduling helps avoid booking inaccuracies for Advocate Health Care, a Chicago-based system with 10 hospitals. For a case to be added to the schedule, the surgeon s office must submit a written form with a minimum set of data elements Continued on page 8 February 2013 OR Manager Vol 29, No 2 7

8 Patient safety Continued from page 7 completed. The form is faxed to the scheduling office, where it enters an electronic file and is routed to the appropriate places. Previously, surgeons scheduled in multiple ways by phone, fax, or dropping by the scheduling office. Once we looked at the whole process, we decided it was best to have a written document, says Cindy Mahal-van Brenk, MS, RN, CNOR, executive service line leader for surgery at Advocate Lutheran General Hospital in Park Ridge, Illinois. The most crucial part of the implementation was working with the surgeons offices, she says. It took a lot of face time. We held breakfasts, went to their offices, and had sidebar meetings if they had questions. We asked for feedback on what could be better about the form. Explaining the rationale for the change helped. We talked with them about good catches and what went wrong based on the process we had, she says. They pointed out that everyone loses if a case has to be canceled or a sentinel event occurs because of a flaw in scheduling. Requiring a written document has made a difference, she notes. Almost daily, a doctor might say, That wasn t how I scheduled this. We can say, Let s look at the fax form. Then the doctor will say, Oh, I guess I did. Advocate Lutheran General also holds a daily huddle with representatives from anesthesia, nursing, preadmission testing, and sterile processing to review and confirm the schedule and key information for the next day s cases. Verbal orders are no longer accepted. Physician signature required Only signed orders not verbal orders are accepted to schedule surgery at Cayuna Regional Medical Center, a critical access hospital in Crosby, Minnesota. The policy change is part of a 6-month quality improvement project to streamline and improve scheduling accuracy. The hospital faced several challenges with scheduling: Required preop tests were sometimes missed. Unapproved abbreviations were used at times. Multiple forms for a single patient, each with partial information, were circulated through the facility. To document errors that had occurred, the director of surgical services, Deb Moengen, RN, CPAN, compiled folders of scheduling forms with errors and gave them to the medical director. Examples were missing signatures and unapproved abbreviations. After reviewing the folders, the chief of the medical staff decided verbal orders would no longer be accepted, Moengen says. A multidisciplinary work group has introduced other changes: a new scheduling form with required information a policy to standardize abbreviations. As a handy reference for abbreviations, the hospital installed software purchased from www. medabbrevs.com on desktops. The new scheduling form will be incorporated into the electronic medical record software. Eventually, physicians offices will be able to schedule procedures electronically, though there is a challenge of working with different types of electronic records. Moengen s advice on improving the scheduling process: Engage physicians from the beginning. Involve the IT department if your facility is moving to an electronic system. Collect data on errors to document the need for change. Most of all, have patience, Moengen says. You think it s a form, but it s not. It s the whole process. Pat Patterson References Clarke J. What keeps facilities from implementing best practices to prevent wrong-site surgery? Barriers and strategies for overcoming them. Pennsylvania Patient Safety Advisory. 2012;9(Suppl 1): Minnesota Alliance for Patient Safety. Surgery Scheduling and Verification Pilot Project. Project tools. org/index.php?option=com_co ntent&task=view&id=88&item id=0 Minnesota Department of Health. Adverse Health Events in Minnesota. 8th annual public report, January state.mn.us/patientsafety/ ae/2012ahereport.pdf 8 OR Manager Vol 29, No 2 February 2013

9 Patient safety An electronic path for streamlining scheduling An electronic form surgeons offices use to place scheduling orders has streamlined the preoperative process and sharply reduced case cancellations for a Chicago-area hospital. Cancellations are down from about 12% to less than 1% of cases since the scheduling form was introduced in early The offices took to the electronic form quickly, and more than 95% are using it. Now we get all of the information we need. There are hard stops, and the form can t be submitted for scheduling unless it has everything filled in, says Katrina Spears, BSM, MAOL, manager for business and informatics, surgical services, at Advocate Good Samaritan Hospital in Downers Grove, Illinois. The Level 1 trauma center with 15 ORs began looking for solutions to scheduling after a Lean project found waste in the process. In one example, faxed scheduling forms were being rejected on average of 960 times a month. Forms had missing information, were illegible, or had an antibiotic selection that needed to be clarified. Straightening out the orders required phone calls and additional work for hospital and office staffs, notes Lina Munoz, BSN, RN, CPAN, manager of the Presurgical Testing Department. The form has hard stops. Electronic scheduling process In the new system, offices enter the booking on the online form by CPT or ICD-9 code, which Spears says provides additional benefits. The software automatically checks for medical necessity for Medicare patients. Before, we had to check for medical necessity, she says. This way, the offices can check when they schedule. It has reduced Medicare denials. Having the code also aids precertification of patients insurance coverage. Other improvements: For CPT codes that entail laterality, a drop-down menu was added so offices can check the procedure side/site. On the hospital side, the CPT codes are mapped to procedure names. CPT codes are tied to procedures included in the Surgical Care Improvement Project (SCIP). An alert is triggered when one of those cases is scheduled so the correct antibiotic can be selected. When applicable, a drop-down menu requires the office to enter the type of sequential compression device (SCD) the surgeon prefers for venous thromboembolism prophylaxis. Edits tracked Once the electronic form is received, the surgical scheduler enters the information in the OR scheduling system. If offices modify a scheduled procedure later, the edits are entered online and automatically color coded so OR schedulers can see the changes made. All iterations are stored, which has eliminated confusion previously caused by edits to paper forms, Spears notes. Patients can use the same software used for the electronic scheduling form to preregister online through a secure web portal. They also have the option to submit their health histories. The histories are available to the surgeons offices as well as the hospital. The hospital plans to use the software to trigger alerts as part of a new program for spinal surgery patients who will be screened for methicillin-resistant and/or methicillin-sensitive Staphylococcus aureus. Electronic form is MD order The electronic scheduling form serves as a physician order, which enables the hospital to start the presurgical process, including scheduling any testing, as soon as the order is received. The form is printed and placed in the patient s record under orders. The scheduling form has a box the office can check to acknowledge that the surgeon is aware of the anesthesia protocol and authorizes the hospital to move ahead. Testing is selected based on the patient s history according to anesthesia department guidelines. The nurse does not need to sign the order and have the physician counter-sign later, Munoz says. It s electronic and automated. That is also true for preop medications that are part of standing order sets. The electronic form also resolves a snag that occurred when patients were allergic to penicillin (PCN). Before, it took back-andforth communication with the offices to have the surgeon approve an alternative. Now, if the patient is allergic to penicillin, the surgeon can click on Alternative Antibiotic Prophylaxis and select one of these choices: Continued on page 10 February 2013 OR Manager Vol 29, No 2 9

10 Patient safety Continued from page 9 Cefazolin 1 or 2 gm (physician aware of PCN allergy) Cefoxitin 1 or 2 gm (physician aware of PCN allergy). Offices can attach a link to the surgeon s medication order for the procedure. For orthopedic cases, the office can attach an equipment list. Launching electronic scheduling Spears, Munoz, and the vendor met with the offices before the electronic form was developed and asked for feedback. These face-to-face meetings and regular communication are why Spears thinks electronic scheduling was adopted so readily. Use of the electronic form is not mandatory, but once the offices are trained, they never go back, Spears says. The form saves offices time because forms no longer have to be returned for missing or illegible information. The electronic form also saves time for the hospital staff. She estimates the equivalent of 1 FTE has been saved because nurses no longer have to track rejected forms or check for medical necessity. As an added efficiency, when health care reform is implemented in 2014, the software will help the hospital identify self-pay patients who will need to be informed about the availability of insurance coverage. The web-based scheduling form uses software by Health- Nautica, Oakbrook Terrace, Illinois, which provides computerized provider order entry systems. A software developer from the company helped the hospital modify the form to fit its scheduling needs. Pat Patterson Readmissions less likely with good nursing environment Medicare patients treated in hospitals with a good work environment for nurses had up to 10% lower odds of readmission than did those treated in hospitals with a poor work environment, according to data from 412 hospitals in California, Pennsylvania, and New Jersey. Improving nurses work environment and reducing nurses workload are organizationwide reforms that could result in fewer readmissions for Medicare beneficiaries with common medical conditions, said lead author Matthew D. McHugh, PhD, JD, MPH, CRNP, of the University of Pennsylvania School of Nursing. Data from more than 200,000 nurses showed that in hospitals with good work environments, the likelihood of readmission within 30 days among Medicare patients was lower among patients with heart failure, heart attack, and pneumonia. Preventable readmissions cost hospitals more than $15 billion annually, and hospitals are being penalized for excessive readmissions. The researchers suggested hiring more staff nurses, noting that the costs could be offset by increased productivity, less turnover and need for retraining, better patient outcomes, and fewer readmissions and postdischarge services. Reference McHugh M, Ma C. Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Med Care. 2013;51: More surgeons are joining ranks of hospital-employed physicians More than half of practicing US physicians are either employed by hospitals or belong to a large group practice that has a contract with a hospital. Surgeons increasingly are joining the mix. The number of surgeons employed full time by hospitals increased 32% between 2006 and 2011, according to Anthony G. Charles, MD, MPH, and colleagues at the University of North Carolina in Chapel Hill. Hospitals employing physicians stand to gain market share by increasing admissions, diagnostic testing, and outpatient services. Direct employment means hospitals can: beef up the number of on-call physicians, especially in emergency departments and rural clinics get the specialists they need for a state regulation, such as trauma center designation guarantee use of their facility by the physicians they employ. The trend toward hospital employment is most apparent among younger general surgeons and female surgeons, the researchers found. Between 2000 and 2009, the number of general surgeons graduating from medical school who were employed rose from 64.5% to 86%. Among female surgeons, 61% were employed in 2001 vs 75.5% by Physicians and hospitals alike need to align more closely to meet financial and professional expectations, the researchers wrote. Reference Charles A G, Ortiz-Pujols S, Ricketts T, et al. The employed surgeon. Arch Surg. 2012: doi: /jamasurg OR Manager Vol 29, No 2 February 2013

11 OR economics Destination surgery Continued from page 1 field, Missouri, which has entered into a new contract with Walmart for spinal surgery. These centers agree to an allinclusive price that covers the patient s surgery and immediate recovery. Tipping point I think we re at a tipping point where huge numbers of employers are going to be doing this kind of thing, Thomas Emerick of Emerick Consulting, Fayetteville, Arkansas, told OR Manager. He helps large companies develop such plans, which go by names such as surgery benefit networks, Centers of Excellence, or skinny networks, indicating they are more selective than PPOs. The focus, Emerick says, is on getting high-quality, cost-effective care for a small segment of employees about 10% who consume 80% of a company s health plan resources. These outlier patients have multiple comorbidities and need specialized surgery. Though companies can save with these arrangements, the discount is not really the point. Discounts are irrelevant, he says. It s about making sure the patient has the right diagnosis and treatment plan. Does a patient really need a spinal fusion, for example? Emerick says 10% to 20% of these patients are misdiagnosed in their local setting, and another 40% have a treatment plan that is erroneous or suboptimal. In contrast, the selected referral centers practice true evidencebased medicine, he says. There is accountability for the surgeons. I think we re at a tipping point. Taking note of variation Companies have taken notice of research showing wide variation in elective surgery rates across the country, as documented by the Dartmouth Atlas project. Medicare patients in Casper, Wyoming, for example, are 7 times more likely to have spinal surgery than patients in Honolulu. And women over 65 in Grand Forks, North Dakota, are more than 7 times more likely to have a mastectomy for early-stage breast cancer than are women in San Francisco. This implies that whether a patient has surgery depends in large part on practice patterns in that area, not necessarily on the evidence. Seeking better value Surgery consumes about 30% of a company s overall health plan costs, and companies are realizing there s an opportunity to get better value, says Chip Burgett, executive vice president for Bridge- Health, a Denver-based firm that develops surgery benefit plans. BridgeHealth seeks out centers that perform in the top quartile nationally and then negotiates a bundled case rate that can save a company 25% to 30% compared with the PPO rate, depending on the market, he says. The firm currently has a network of 45 referral centers. What s in it for patients? The arrangements are voluntary. But patients are offered an incentive, such as expense-paid travel for themselves and a companion plus waiver of the deductible and copay. With today s higher deductibles, they could save $3,000 to $10,000 out of pocket. The referral center agrees to provide concierge-type service. After surgery, patients stay 1 week to 10 days to allow for physical therapy, wound care, and a postop clinic visit. Arrangements are made for follow-up care in the local community, if needed. Negotiating with Walmart In 2 years of negotiations that led up to Mercy s contract with Walmart for spinal surgery, the company took a detailed look at Mercy s quality data, how it evaluates surgical candidates, the price, and the service Mercy could offer as a destination center for surgery. The contract took effect in January David Cane, Mercy s regional vice president, says one thing Walmart noticed is that Mercy tends not to do as much spinal surgery for back pain as others do, probably less than half. Though price figured in, they recognized there is a lot of value in not having surgery when it isn t needed. Mercy already used a multidisciplinary approach in evaluating patients, explains the president of the Mercy Clinic-Springfield Division, Alan Scarrow, MD, JD, FAANS, FACS, a neurosurgeon. Health care is divided into fiefdoms by specialty. Here, we re trying to break down fiefdoms, Dr Scarrow notes. Continued on page 12 February 2013 OR Manager Vol 29, No 2 11

12 OR economics Direct contract with one company promises savings on spine implants A direct contract with one company for spinal implants promises to be a cost saver for Mercy in Springfield, Missouri. Mercy performs about 1,600 spinal procedures a year, though not all use implants. Implant costs are the drivers in spinal surgery, says Mercy s Alan Scarrow, MD, JD, FAANS, FACS. A neurosurgeon, he is also president of the Mercy Clinic-Springfield Division. Though Mercy was using 7 or 8 implant vendors, Dr Scarrow says there is little evidence that one implant system is better than another. Choices are driven largely by physician preference, including relationships developed with the sales force. He says Mercy had information indicating that about 42% of the price for spinal implants goes for sales, general, and administrative costs, including distributors and sales personnel. Going direct By going direct to the manufacturer, Mercy reasoned it could eliminate those costs and get a better price. We sat down with all of the spine surgeons and said, Here s the problem: We have to be profitable at Medicare rates and below. The only way we can do that is to get implant costs under control, Dr Scarrow says. Mercy s supply-chain arm, ROi (Resource Optimization and Innovation), began looking for a manufacturer with good product breadth for spinal products, including lumbar and cervical hardware, interbody fusion devices, minimally invasive surgery supplies, and so forth. Requests for proposal were sent to the 16 largest spinal implant companies, with 9 returning proposals. All of Mercy s 8 spine surgeons reviewed the proposals, including the prices, and gave their opinion on the product quality. Then they took a vote. The choice was Zimmer. The contract took effect December 1, Now we have no more reps in the OR on a routine basis, Dr Scarrow says. ROi employs a person who provides technical support. When a surgeon has a special need for an item Zimmer does not provide, the request is reviewed by a committee of physicians and administrators who can grant or deny the request. Dr Scarrow says he thinks companies are realizing hospitals have to control their costs for expensive devices. Every hospital is going to be under this kind of pressure, he says. There is no way costs are going to be able to stay where they are, given the economic pressures. Continued from page 11 For the Walmart agreement, he says, Mercy agreed patients would see a pain management specialist, a physiatrist, and 2 surgeons, preferably an orthopedic surgeon and a neurosurgeon, about whether patients could benefit from surgery and what treatment would be most appropriate. Making sure their employees get the right treatment is a major part of what these large employers are looking for, he adds. They re saying, We want to provide health care for our employees, but we want to provide the treatment that is going to affect their outcomes not a treatment that is done because it can be done. Tackling spinal implant costs At the same time but unrelated to the Walmart agreement, Mercy took a new approach to controlling spinal implant costs a direct contract with one manufacturer, Zimmer, bypassing distributors and sales reps. All 8 spine surgeons agreed to use that single company except for certain special needs (sidebar). Destination center for surgery Mercy had to prepare to be a destination center by planning logistics and support for patients who travel from a distance. As one aspect of that, a navigator is assigned to meet patients at the airport and help them get to the hotel, clinic, and hospital and to make sure patients always have a way to communicate with staff assigned to their care. Additional training has been provided for staff who interact with these patients. Mercy is working on setting up similar programs for cardiac care, cancer, pediatrics, and other specialties. Continued on page OR Manager Vol 29, No 2 February 2013

13 Performance improvement A plan for avoiding readmissions after surgery A Medicaid patient is admitted to the hospital for repair of an enterocutaneous fistula. He s considered a high risk for readmission after surgery because he doesn t have a working refrigerator or telephone. That means he won t be able to keep fresh food on hand or call his physician if he has problems. More OR Performance likely, he ll go to the emergency room and become a readmission. To avoid that result, a transition planning nurse makes arrangements before his surgery so he can have the refrigerator repaired and install a phone. The patient recovers well, and a potential readmission is headed off. That s the direction I d want to head, says John F. Sweeney, MD, FACS, chief, division of general and gastrointestinal surgery at Emory University School of Medicine in Atlanta. He is senior author of a study finding that postoperative complications are the single most significant independent risk factor of readmissions after general surgery. The report was published in the Journal of the American College of Surgeons (sidebar). Dr Sweeney is fostering a pilot program at Emory to lower surgical complication and readmission rates, with an emphasis on early transition-of-care planning. Focus on readmissions Readmission rates are a focus for hospitals. On October 1, 2012, the Centers for Medicare and Medicaid Services (CMS) began penalizing hospitals for excess 30-day readmissions for 3 conditions: acute myocardial infarction, heart failure, and pneumonia. There are Postop complications drive readmissions Postoperative complications are the leading risk factor for readmission after general surgery, in a finding by researchers from Emory University School of Medicine, Atlanta. Patients with complications were 4 times more likely to be readmitted than those without. The most common reasons for readmission were: GI problems/complications (28%) surgical site infections (22%) failure to thrive/malnutrition (10%). In all, 11% of patients were readmitted within 30 days of discharge in the analysis of more than 1,400 patients from Emory University Hospital. The study provides a framework for developing a simple readmission-prevention plan that includes early transition-of-care planning. Kassin M T, Owen R M, Perez S D, et al. J Am Coll Surg. September 2012;215: The plan is to assist with transitions. plans to follow suit for surgical patients. The penalties are mandated by the Affordable Care Act and spelled out in regulations from CMS. The program will expand to more conditions starting in fiscal year A surgical procedure itself places patients at risk for readmission, beyond any medical problems, Dr Sweeney notes. It s also possible to intervene early because surgery generally is a scheduled event. Having a plan to assist patients with care transitions should prevent readmissions. A triple word score Hospitals can t look at the problem of readmissions without thinking about length of stay and complications. They are all intertwined, Dr Sweeney told OR Manager. Programs that make even a modest difference in all of these areas will lead to significant movement in costs and the value of care patients receive, he says. It s like a triple word score in Scrabble, he says. When you have a 10% reduction in readmissions, plus a 10% reduction in length of stay, plus a 10% reduction in complications, it adds up to significant savings. Getting ahead of discharges In Emory s pilot transition-of-care program, a nurse practitioner interviews high-risk patients, assesses their risk for readmission, and develops a plan that allows patients to be discharged and followed as outpatients. The program includes complication prevention bundles and standardized care, which Dr Sweeney says can support the Continued on page 14 February 2013 OR Manager Vol 29, No 2 13

14 Performance improvement Adhering to SCIP doesn t lower postop UTIs Most urinary tract infections (UTIs) after surgery happened in patients considered exempt from the SCIP Inf-9 measure that promotes removing urinary catheters within 48 hours of surgery, finds a study from Emory University Atlanta. (SCIP refers to the Surgical Care Improvement Project.) In the study, John F. Sweeney, MD, and colleagues examined the relationship between adhering to the SCIP measure and the postop UTI rate. For 2,459 patients analyzed, they found that though SCIP compliance increased over time, this was not linked with improved monthly UTI rates. Of 69 UTIs found, 61 were cases that were compliant with SCIP, but 49 were exempt from the measure, and catheters were not taken out within 48 hours after surgery. Patients can be exempted if a physician documents a need and justification for leaving the catheter in place. For 100 random controls, compliance was similar, but the exemption rate was lower. The odds of a postop UTI were 8 times higher in patients deemed exempt from SCIP. In view of the result, the researchers advise modifying the SCIP guidelines so there are fewer exemptions, and more catheters are removed earlier. Indwelling urinary catheters account for 80% of UTIs. Owen R M, Perez S D, Bornstein W A, et al. Arch Surgery. 2012;147: Continued from page 13 costs to hire a nurse practitioner and the additional personnel needed for the program. Emory is developing plans to pilot this program. The goal will be to track these outcomes to see if patient management protocols and transition management actually do improve readmissions rates and whether the improved quality supports the program financially. Identifying risks Patients who develop a complication in the hospital have an increased risk of readmission, but the risk is 2 to 3 times higher if the complication develops after they go home, says Dr Sweeney, who is also director of the Department of Surgery s clinical quality and patient safety program. The problem is that when a patient starts to have trouble, he makes a call, and is told to go to the emergency room. When he shows up in the emergency room, he s admitted, and there s your readmission, Dr Sweeney notes. Preadmission screening helps not only to identify medical-surgical readmission risks but also potential problems for patients who don t have the resources and family support they will need when discharged. Having a nurse practitioner screen patients, make sure the transition plan is implemented, and interact with the patient after discharge could make a difference, he says. Zeroing in on UTIs Like the decision to operate on a patient, Dr Sweeney points out, a physician s decision to send a patient home is a very expensive decision that carries a fair amount of risk. He and his research group are examining what information a physician needs to make the right decision about discharging a patient. They started by identifying factors associated with readmission. In the study, they found that the leading surgical complications associated with the risk of readmission were wound infections, pulmonary complications, and urinary tract infections (UTIs). UTIs, though infrequent, were associated with the highest readmission risk 8 times higher than for a patient without a UTI. When we compared ourselves nationally, we found we re doing better than average with the occurrence of UTIs. Looking closer, we saw a chance of reducing the number even further with a simple protocol for taking catheters out as soon as possible on a regular basis, he says. Decreasing UTIs by 25% may not be a huge number, but one UTI costs about $12,000 and increases length of stay by 2.5 days. The protocol, which includes removing catheters based on Centers for Disease Control and Prevention criteria, is being piloted on 1 surgical unit and eventually will be rolled out to all units. UTI rates persist with SCIP He notes that UTI rates persisted even though the hospital was fully compliant with the Surgical Care Improvement Project (SCIP) measure to remove the Foley 14 OR Manager Vol 29, No 2 February 2013

15 Performance improvement catheter within 48 hours after surgery. That was because the SCIP measure says a catheter can be left in beyond 48 hours if the physician documents why the catheter should not be removed. An analysis of patient records found some of the documented reasons for leaving the catheter in weren t valid (sidebar). We found we are just really good at documenting why we re leaving the catheter in, and the biggest risk for our urinary tract infections is the amount of time the catheter is in place, he says. Our protocol now is that catheters are removed within 48 hours [after surgery] unless patients have had a urologic procedure or low rectal surgery. We re going to be aggressive and track our results. I m convinced that something as simple as what we re talking about will move the dial and will make a difference, he says. With a little effort and ingenuity, Dr Sweeney says he is optimistic that a lot of readmissions can be prevented. Judith M. Mathias, MA, RN References Centers for Disease Control and Prevention. Catheter-associated urinary tract infections (CAUTI). Resources and toolkit. gov/hai/ca_uti/uti.html Kassin M T, Owen R M, Perez S D, et al. Risk factors for 30-day hospital readmission among general surgery patients. J Am Coll Surg. September 2012;215: Surgical care improvement project: Percent of surgical patients with urinary catheter removed on postoperative day 1 or postoperative day 2 with the day of surgery being day zero. px?id=27416&search=surgical+c are+improvement+project Destination surgery Continued from page 12 A national market for surgery Increasingly, the quality data your hospital gathers and generates through claims is being used by employers, insurers, and benefits consultants. And that data is beginning to drive where patients go for specialized surgery and that could be outside the local market. There has been the premise that health care will continue to be delivered locally, says Shane Wolverton of The Delta Group, Greenville, South Carolina. Now, he says, in certain areas and for some elective procedures, surgical programs are going to be competing on a regional or even national basis. The firm developed the Care- Chex quality rating system that BridgeHealth and others use to select top-performing centers. The database uses sophisticated software to create a composite quality score and rating that uses risk-adjusted outcomes as well as process and patient satisfaction measures to identify the centers with the best results. Employers are going to be putting plans in place that actually pull patients out of the markets they reside in and steer them toward providers they believe deliver the same or better quality at a better rate, Wolverton says. He offers this advice for OR managers and directors: Understand how your surgery program is being assessed and learn what methods are being used. (See how your hospital ranks in CareChex and learn about the methodology at www. thedeltagroup.com.) Take advantage of these databases internally to analyze and improve your own performance. Many hospitals subscribe to databases that enable them to conduct this type of analysis. Good news: Your hospital doesn t need a national reputation to shine. Hospitals that pop up as leaders in CareChex aren t necessarily those with brand identity. Employers may find they can get high-value care from regional and even local providers. For example, the top quality performer nationally for coronary artery bypass is TriStar Centennial Medical Center in Nashville, Tennessee. For joint replacements, it is the Hospital for Special Surgery in New York City, and for spinal surgery, it is Sinai Hospital of Baltimore in Maryland. Employers, employees, and individuals can search these databases to see where the stars are. There will be winners and losers, Emerick says. The hospitals that are outstanding can become destinations. Those that aren t may not get as many patients. Pat Patterson References Dartmouth Atlas of Health Care. Improving patient decision making in Health Care. November 29, pages/decision_making_series Evans M. Wal-Mart s surgical strike. Modern Healthcare. 2012;42(43): October 22, Terhune C. Companies go surgery shopping. Los Angeles Times, November 17, www. latimes.com February 2013 OR Manager Vol 29, No 2 15

16 ECRI Institute Perspectives Top 10 health technology hazards for 2013 are named OR Manager, Inc., and ECRI Institute have joined in a collaboration to bring OR Manager readers quarterly supplements on topics such as medical technology management and procurement, risk management, and patient safety. ECRI Institute is an independent nonprofit that researches the best approaches to improving patient care. Each year, advances in health technologies provide new ways to improve patient care. But some also create new opportunities for harm. Thus, hospitals must regularly examine their hazard-control priorities in order to remain focused on the most pressing risks. ECRI Institute s newly released Top 10 Health Technology Hazards is a comprehensive report published annually to raise awareness of the potential dangers associated with the use of medical devices and systems. When prioritizing your 2013 patient safety efforts, this is a good place to start. Now in its sixth year of publication, the annual Top 10 list highlights the technology safety topics that ECRI Institute believes warrant particular attention for the coming year. Some are hazards that ECRI Institute sees occurring with regularity, such as alarm The top 10 hazards at a glance Here is a snapshot of this year s list. 1. Alarm hazards 2. Medication administration errors using infusion pumps 3. Unnecessary radiation exposures and radiation burns during diagnostic radiology procedures 4. Patient/data mismatches in EHRs and other health IT (HIT) systems 5. Interoperability failures with medical devices and health IT systems 6. Air embolism hazards 7. Inattention to the needs of pediatric patients when using adult techniques 8. Inadequate reprocessing of endoscopic devices and surgical instruments 9. Caregiver distractions from smartphones and other mobile devices 10. Surgical fires hazards. Some are problems that the Institute believes will become more prevalent, given the way the technology landscape is evolving. And some are well-known topics that periodically warrant renewed attention because of their potential to cause harm. The list is not comprehensive, nor will all of the hazards listed here be applicable at all healthcare facilities. The healthcare environment and the products device manufacturers are developing are becoming more complex, says James Keller, ECRI Institute s vice president of health technology evaluation and safety. There are just a lot more things that can go wrong than when devices were simpler. It s important to adopt interoperable technology, but be more mindful of the risks. Following is an excerpt from the 2013 list, originally published in ECRI Institute s Health Devices journal (Nov. 2012). 1. Alarm hazards Medical device alarms perform an essential patient safety function. Physiologic monitors, ventilators, infusion pumps, dialysis units, and a host of other medical devices sound alarms or issue alerts to warn caregivers of potential problems with the patient. The sheer number of alarms, however, has itself become problematic. Frequent alarms for events that aren t clinically significant or for avoidable conditions can result in caregivers becoming overwhelmed trying to respond to the alarms or becoming desensitized, leading to missed alarms or delayed or inappropriate responses. For example, caregivers may turn down the volume of alarms to an inaudible level, or they may improperly adjust alarm limits outside the safe and appropriate range in an attempt to reduce the number of alarms OR Manager Vol 29, No 2 February 2013

17 ECRI Institute Perspectives While the problem is complex, and it may not be possible to fully eliminate the risks, healthcare facilities nevertheless can continuously improve the manner in which alarms are managed. Initiatives can target reducing the number of clinically insignificant alarms, for example, or achieving more reliable and timely responses to alarm conditions. 2. Medication administration errors using infusion pumps Medication mishaps are among the most common errors in health care and thus warrant particular attention in any facility s patient safety efforts. One area where technology managers can play a vital role is in ensuring the safe administration of medications using infusion pumps. Infusion errors can have severe consequences: Patients can be highly sensitive to the amount of medication or fluid they receive from infusion pumps, and some medications are life-threatening if administered in the wrong amounts or to the wrong patient. For years, ECRI Institute has recommended the careful implementation of smart pumps. Smart pumps can, for example, reduce gross misprogramming errors and provide a safer method of bolus administration. However, even these technologies are not foolproof. The next step in infusion safety and one that will require considerable involvement from clinical engineers, IT staff, and other technology managers will involve integrating infusion pumps with electronic ordering, administration, and documentation systems. Successful integration, which is a multistep, multiyear process, can help reduce a significant portion of the errors that can occur even with smart pumps. 3. Unnecessary exposures and radiation burns from diagnostic radiology procedures Image quality in diagnostic radiology procedures typically improves as the radiation dose increases. As a result, there is a natural tendency to use higher doses. However, higher doses are associated with greater risks to the patient. Acute reactions to excessive radiation exposure, such as radiation burns or hair loss, occur only in extreme cases but still too frequently and such incidents can usually be prevented. The more common concern is that exposure to radiation increases the patient s risk of eventually developing cancer, a risk that can t be eliminated but that nevertheless should be controlled. ECRI Institute recommends that healthcare facilities look more broadly at the factors that can contribute to unnecessary exposures with any diagnostic imaging modality. Questions to consider include: Could imaging techniques that don t rely on ionizing radiation be used to obtain the needed information? Have acceptable images already been acquired recently, making a repeated exposure unnecessary? Are technologists using doses that are as low as reasonably achievable to acquire the desired information? Are skin dose levels being tracked throughout the course of fluoroscopic procedures? 4. Patient/data mismatches in EHRs and other health IT systems The skill of the caregivers, the capabilities of the technology, the evidence supporting the procedure all can be rendered meaningless if the procedure being performed on Mr. Smith was initiated because of test results that actually belong in the electronic health record (EHR) of Ms. Jones. Mistakes leading to one patient s data ending up in another patient s record are not a new phenomenon. But with health IT systems, the capabilities that make the systems so powerful their ability to collect data from and transmit data to a variety of devices and systems, for example can serve to multiply the effects of such errors. Successful data transfer between a medical device and an EHR or other information system requires (1) that data from the February 2013 OR Manager Vol 29, No

18 ECRI Institute Perspectives device be associated with the correct patient s record in the information system and also (2) that the device and patient record be correctly disassociated when the device is switched from one patient to another. Factors that affect whether data is associated with the correct patient include the functionality of the devices and systems involved as well as the workflow employed. 5. Interoperability failures with medical devices and health IT systems Establishing interfaces among devices and information systems can help improve patient safety by reducing errors associated with manual documentation, for example. However, interoperability allowing the appropriate exchange of data can be difficult to achieve, and patient harm can result if this is not done effectively. Safety efforts should target interoperability issues including: Health Devices research has shown that interfaces between medical devices, such as between ventilators and physiologic monitoring systems, may not work as intended, and may even allow dangerous conditions to exist. Hazards can also exist when systems are not able to exchange data with one another or when the exchange goes awry. One consequence of interoperability is that changes to one device or system can have unintended effects on other devices or systems. Avoiding such hazards requires effective change management, ensuring, for example, that software upgrades are performed in a controlled manner. 6. Air embolism hazards Intravascular air embolism is a potentially lethal complication of certain medical and surgical procedures. Clinicians are generally aware of the risks of air embolism during such procedures, and the circumstances that can lead to patient harm are rare. Nevertheless, ECRI Institute occasionally receives reports and conducts investigations of fatal incidents. Thus, periodic renewed attention within a patient safety program is warranted to ensure that caregivers are taking appropriate measures to minimize the risks. Broad initiatives to prevent air embolism events are complicated by the wide range of procedures and clinical specialties involved. For example, ECRI Institute has received reports and conducted investigations of embolism events associated with the use of automatic contrast media injectors for radiologic procedures, central venous access devices (CVADs) for intravascular catheterization, pressurized spray devices for applying fibrin sealants, and sphygmomanometer or noninvasive blood pressure cuff tubing being erroneously connected to IV lines. The Institute is also aware of or has investigated air embolism incidents related to the use of extracorporeal blood circuits for hemodialysis and heart-lung bypass procedures, air insufflators for gastrointestinal insufflation, and pressure infusers. 7. Inattention to the needs of pediatric patients when using adult technologies ECRI Institute noticed a theme developing when reviewing topics for inclusion on its Top 10 list: Many of the topics included a pediatric component. That is, a given hazard posed particular risks for pediatric patients (eg, infants, children), or a particular technology didn t adequately address the needs of this population, which could jeopardize the safety of these patients. Often the issue is that a technology designed for adult patients nevertheless needs to be used on children, in some cases because no alternatives exist. In the absence of devices tailored exclusively for the pediatric population, health care personnel must exercise particular care when using technologies designed for adults on children. Radiology practices provide just one example of how the care of pediatric patients can be 18 OR Manager Vol 29, No 2 February 2013

19 ECRI Institute Perspectives compromised when applying adult technologies. Practices that place children at risk include using dose settings designed for adults and overusing radiologic imaging techn o l o g i e s. O t h e r e x a m p l e s include computerized provider order-entry (CPOE) systems that don t include appropriate dosing options for children, EHRs that don t allow caregivers to view the full height and weight charts at the same time, and a lack of pediatric supplies in emergency departments. 8. Inadequate reprocessing of endoscopic devices and surgical instruments Several high-profile incidents described in previous Top 10 lists illustrate the consequences of failing to properly and consistently perform all steps in the endoscope reprocessing procedure, including some necessary manual tasks. For 2013, ECRI Institute continues to recommend that flexible endoscope reprocessing procedures receive scrutiny, but also encourages healthcare facilities to address the reprocessing function more broadly in their patient safety initiatives. This recommendation was influenced both by incident reports obtained and analyzed by ECRI Institute PSO, and by the results of a recent investigation that ECRI Institute conducted for a facility that was experiencing repeated reprocessing failures. The incidents reported and the one ECRI Institute investigated involved dirty instruments being presented for use in surgery or other medical procedures. These were instruments or devices that were not adequately decontaminated and cleaned before they underwent disinfection or sterilization, or that otherwise were not properly reprocessed. In some cases, the contamination was not detected until after the item had been used on a patient. 9. Caregiver distractions from smartphones and other mobile devices A lot has been written about the security considerations associated with the use of mobile devices like smartphones, tablet computers, and other handheld computing devices. But a topic that is just starting to get attention, and one that may be more likely to lead to substandard patient care or even physical harm to patients, is the potential for caregivers to become distracted by their devices. While the need for clinicians to multitask is nothing new interruptions from pagers and other communication devices have long been a part of the job smartphones and other mobile devices now make it easier for clinicians to be interrupted for non-work-related reasons. What s more, these devices make it easier for clinicians to create their own interruptions. With the mobile device in their hands, clinicians can easily succumb to the temptation to surf the web or conduct personal business during patient care. The potential to make mistakes or miss information are significant concerns, but not the only ones. Caregivers who are focusing on a device s screen, rather than looking at the patient, may miss clues about the patient s condition and cause patients to wonder whether they are getting appropriate attention. 10. Surgical fires Fires that ignite in, on, or around a patient during surgery occur in only a minuscule percentage of the millions of surgical cases performed each year. Nevertheless, this hazard remains on the Top 10 list because (1) surgical fires are high-impact events that can have devastating consequences, and (2) surgical fires continue to occur more frequently than many people realize despite the availability of effective guidance for fire prevention. ECRI Institute continues to receive at least one report of a surgical fire each week. The consequences of surgical fires clearly can be severe: Patients can be disfigured or killed, staff can be injured, and critical equipment can be damaged. Additionally, a surgical fire can result in reputational damage for the healthcare facility. The good news is that virtually all surgical fires can be avoided. For this to be possible, however, each member of the surgical team must clearly understand the role played by oxidizers, ignition sources, and fuels in the OR, and must communicate about the risks with other team members. Reprinted with permission f rom the November 2012 issue of ECRI Institute s Health Devices journal. Visit for additional details about each hazard and recommendations for addressing them. February 2013 OR Manager Vol 29, No 2 19

20 Patient safety Adopting a no interruption zone for patient safety The time-out is called, but conversations are going on, and the staff is still assembling equipment. No one seems to be listening. Then during the case, the anesthesiologist has trouble hearing over the loud music and chatter. The circulating nurse needs confirmation on a specimen but can t get the surgeon s attention. Distractions and interruptions happen in the OR as often as every 3 minutes, studies show. Do these distractions contribute to errors? Researchers recently conducted a controlled study to find out. In a lab, 18 surgical residents performed laparoscopic cholecystectomies on a simulator. Each resident performed procedures both with and without distractions and interruptions. Distractions and interruptions were introduced randomly without residents being aware of the study s purpose. In results: 8 of 18 (44%) of the participants made major errors when there were distractions and interruptions only 1 of 18 (6%) did so when there were none. A trigger word signals quiet. No-distraction strategies Some ORs are taking steps to tame distractions during critical periods of cases. One strategy is the sterile cockpit or the no distraction zone (NIZ), a term more applicable to health care. Aviation adopted the sterile cockpit years ago after an analysis of 78 accidents showed 72% were linked to distractions. On average, in aviation, there are 7 warning signs before an accident, but distractions can keep a crew from recognizing them, says Steve Harden, an airline captain with LifeWings, who has consulted with hospitals on patient safety for 12 years. The Federal Aviation Administration now has a rule saying that during critical phases of the flight, such as takeoff and landing, no conversations or paperwork not directly related to the flight operation are allowed. Pilots are suspended for violations. An NIZ for the OR As in aviation, an NIZ in the OR is a quiet time during critical phases of a procedure triggered by a word such as Delta. For example, an NIZ can be declared during the 3 phases of the World Health Organization (WHO) Surgical Safety Checklist: sign-in (briefing), time-out, and sign-out (debriefing). The trigger word can also be used anytime during a procedure when a team member sees something amiss or requires quiet. During an NIZ, the team: stops all conversation stops all unnecessary activity turns down any music addresses the situation in an engaged way. The bottom line is that the NIZ helps you build a wall between your team and distractioninduced errors, Harden says. NIZ: The prerequisites An NIZ can t be used in isolation, Harden stresses. To be effective, it must be part of a culture of patient safety and teamwork. A safety culture accepts that because all procedures are performed by humans, errors will occur, no matter what tools or countermeasures are used. A safety culture is characterized by professional support, mutual respect, cross-checks, and the willingness of all team members to speak up if something seems amiss. The record on speaking up isn t strong. Based on results of safety climate surveys analyzed by the Agency for Healthcare Research and Quality in 2011, we know that if any hierarchy is present in the interaction, over 50% of staff will not speak up, says Harden. Teamwork training, such as education in crew resource management (CRM) or TeamSTEPPS, an evidence-based teamwork system, helps to lay the groundwork. In the training, interdisciplinary groups of physicians, nurses, and other personnel learn principles of patient safety, communication, assertiveness, and other methods that create more cohesive units. A collegial, interactive team catches and neutralizes mistakes, holds one another accountable, and backs each other up, Harden notes. At Nebraska Medical Center, for example, before teamwork training, 69% of OR personnel say they would speak up, he says. That rose to 93% afterward. Design in the buy-in Safety strategies like the NIZ and surgical safety checklists are most likely to be accepted and used 20 OR Manager Vol 29, No 2 February 2013

21 Patient safety consistently if they are designed or modified by front-line clinicians who will actually use them. The WHO checklist is intended to be modified to fit each organization s needs. The key principle is that the people who use a checklist are the ones who design it, Harden says. A mistake I see a lot of places make in the way they design or revise their checklists is to have it done by administrators in surgical services. It s more successful if the checklist is modified by a multidisciplinary work group of nurses, techs, and physicians. For physicians who sit on the work group, he adds, You have to be crystal clear that they are representing their peers. The physicians agree that they will convey to their peers how the checklist is to be used. Introducing the NIZ Nearly all procedural areas in the 6-hospital Memorial Health System, based in Hollywood, Florida, have adopted the NIZ, triggered by the word Delta. When someone says Delta, it means, I have a problem. Stop, says Jenny Kadis, MS, RN, CPAN, the system s director of clinical effectiveness. A safety statement about using Delta is part of the surgical safety checklist. During the briefing at the beginning of a case, the surgeon reminds the team about Delta by saying something like: Speak up for safety. Look for red flags. Use Delta any time. If the surgeon forgets, anyone else on the team can remind the surgeon to make the safety statement. Delta is also called anytime during a case when a team member spots a problem. Some examples: A surgical technologist called a Delta when a piece of equipment wasn t working. An anesthesiologist called a Delta when there was a lot of music and chatter, and he needed to hear. A labor and delivery nurse called a Delta when a lap sponge was missing while she was counting on a c-section. First, she said, A sponge is missing. No one listened. She repeated the statement. Again, no one stopped. Then she said, Delta, and they all stopped closing and looked up, Kadis recalls. The sponge was found with the placenta in the specimen bucket. The right word It took a surprising amount of time to identify the right word for triggering the NIZ. Delta was suggested because of its tie to aviation. There was considerable discussion about what Delta might mean in different clinical areas. Eventually, consensus developed. Now Kadis says Delta is recognized throughout the Memorial system. Tips: No interruption zone (NIZ) Agree on a term for declaring an NIZ, such as Delta. Customize the surgical safety checklist to include Delta. Have the surgeon reinforce the use of Delta during the briefing. Conduct interdisciplinary teamwork training on use of the NIZ. Laying the groundwork Memorial began building the foundation for a safety culture in 2007 when it introduced CRM. That s the key to success, the willingness to fund training, Kadis says. We brought it in with full support of the executive team. Even in the wake of the nation s economic downturn, Memorial continues to fund a CRM director position. CRM training is mandatory for all personnel in procedural areas, including physicians, and the requirement is included in the medical staff bylaws. Aides, transporters, and unit secretaries also participate in training. Physicians must train within 6 months of joining the organization. One cardiologist had his procedural credentials suspended until he completed the training class. The chief medical officer is a driving force. During the rollout of the CRM training, he and Kadis targeted key physicians, visiting their offices, making phone calls, and following up to enlist champions. Assertiveness for staff Having the staff feel comfortable with speaking up is essential for safety, Kadis notes. Memorial s staff receive training in assertiveness. She s developed real-life scenarios so they can practice. Examples: A surgeon preparing to list 15 specimens at the end of a case says, Listen, because I m only going to say this once. How do you respond? A Delta is declared. A vendor who is in the OR is on the Continued on page 22 February 2013 OR Manager Vol 29, No 2 21

22 Patient safety Continued from page 21 phone and won t get off. How do you handle the situation? (At Memorial, any person present in the OR is considered a team member and is expected to adhere to policies.) Showing the value Physicians need to see there is something for them in participating, Kadis adds, saying, We ve worked hard to show value. One way to show value is to record concerns that arise during debriefings at the end of cases and to act on them. Circulating nurses fill out a debriefing form. The concerns are categorized, recorded in an Excel spreadsheet, and sent to the OR director, who assigns personnel to address them. That person is responsible for giving an update to the physician within 72 hours. They don t have to be solved by then, she notes. Resolutions are recorded and quantified. Managers report regularly at the Department of Surgery meeting, saying, for example: In the past 6 months, we ve made 1,100 updates to preference cards. We ve examined the lights in Room 10, and they re going to be replaced. We ve had the vendor provide additional staff training on the video system. They also share success stories: During a briefing, we found out a baby was allergic to a medication, and only the circulating nurse knew. Turnover time has improved because staff is more prepared for cases. Business has also improved. After the OR director was able to document 50 delays caused by insufficient instrument sets for Team training lays groundwork. lap choles, the administration approved the purchase of additional sets, enabling more cases to be performed. Kadis says she can t overemphasize the need for team training. People think CRM is just about building a time-out process, she says. But it s not only the time-out; it s speaking up; it s working as a team; it s talking openly. There s so much more than just building the tools. Tools are great. But if you just read a poster, and you re not talking to each other, you might as well not bother. Pat Patterson A copy of Memorial Health System s surgical safety checklist with the safety statement is in the OR Manager Toolbox at Steve Harden can be reached at sharden@saferpatients.com. A recording of his OR Manager webinar, Eliminating Distraction-Induced Errors, with further tips, can be purchased at References Code of Federal Regulations. Title 14. Part 121. Subpart T. Section Flight crewmember duties. 46 FR January 19, c=ecfr&rgn=div8&view=text&no de=14: &idno=14 Feuerbacher R L, Funk K H, Spight D H, et al. Realistic distractions and interruptions that impair simulated surgical performance by novice surgeons. Arch Surg. Published online July 16, doi: /archsurg Healey A N. Sevdalis N, Vincent C A. Measuring intraoperative interference from distraction and interruption observed in the operating theatre. Ergonomics. 2006:49: Weigmann D A, El Bardissi A W, Dearani J A, et al. An empirical investigation of surgical flow disruptions and their time relationship to surgical errors. Paper presented at: Proceedings of the Human Factors and Ergonomics 50th Annual Meeting, October 16-20, San Francisco, California. Zheng B, Martinec D V, Cassera M A. A quantitative study of disruption in the operating room during laparoscopic antireflux surgery. Surg Endosc. 2008;22: Save the date! OR Manager Conference September 23-25, 2013 The Premier Conference on Managing Today s OR Suite Join your colleagues for oneday seminars on September 23 and the two-day conference on September Gaylord National Resort National Harbor, Maryland Near Washington, DC 22 OR Manager Vol 29, No 2 February 2013

23 OR business management How should we charge for preadmission testing? A column on managing the OR revenue cycle. What are the rules for charging for preadmission testing and postop recovery? How should ORs handle charges for a patient who stays in the OR because a postanesthesia care bed is not available? In this column, Keith Siddel, JD, MBA, an expert on the revenue cycle, answers questions about charging and revenue capture. He is an attorney with HBL Concepts LLC, Creede, Colorado. QIs there a way we can charge for a patient s preoperative care, including preoperative testing? Siddel: Under Medicare rules, nondiagnostic services, including testing prior to surgery, furnished to Medicare patients in the 3 days preceding an inpatient admission are considered operating costs of inpatient hospital services. That is, the surgery-related services a patient receives during that period are bundled into the DRG payment for those services. For non-drg hospitals and units, the payment window is 1 day. These are psychiatric hospitals and units, inpatient rehabilitation hospitals and units, longterm care hospitals, children s hospitals, and cancer hospitals. The payment window does not apply to critical access hospitals. If the testing is routinely performed more than 3 days before the surgery and billed separately, that will attract attention from auditors. Two new things to be aware of: The Health and Human Services Office of Inspector General will be auditing for compliance with the 3-day window in The services are bundled. Medicare is discussing moving toward a 14-day window for bundled payment. This is consistent with the trend toward paying by an episode of care, that is, bundling payments for the physician, hospital, and posthospital care. That will cause headaches because you will have to figure out whether some of these services were provided elsewhere. Even though you don t get paid separately for preop services, you should still bill the payor for them. The reason is that you have to account for your costs. Medicare uses these charges in determining the costs of services. The costs in turn are used in setting the cost-to-charge ratio, which Medicare uses to determine payment amounts. If you don t charge, these services aren t factored into the costs used in setting Medicare payments. QWhat if a patient has unrelated outpatient services at our hospital, is discharged, and 2 days later is admitted with a myocardial infarction? Would that payment be bundled? Siddel: The Medicare rule is that services that are bundled should be clinically related. If the preadmission nondiagnostic services are unrelated to the inpatient hospital claims, that is, are clinically distinct or independent from the reason for the beneficiary s inpatient admission, these unrelated costs are covered by Medicare Part B, and the hospital or any wholly owned or wholly operated entity should include the technical portion of the services in its billing. The challenge is that almost no legacy computer system is equipped to figure out what is clinically related. Therefore, the payment is likely to be bundled, and you would have to appeal that. QAfter surgery, if a patient goes directly to the Phase 2 PACU (postanesthesia care unit), skipping Phase 1, our finance department says we don t get paid for that. Is that correct? Siddel: Yes, that s true. But you don t get paid separately for Phase 1 recovery anyway because that is bundled in the DRG payment for surgery. QIf you keep a patient in the PACU longer than expected because of the oxygen saturation level, can you be paid for that? Siddel: No, because the PACU stay is included in the DRG/APC payment. That is also true in the cath lab. For example, if a patient has a cardiac catheterization and stays in recovery for 7 or 8 hours, you will not be paid more for the recovery time, because Medicare says that is a normal recovery period and thus is included in the procedure payment. QHow should we handle the charges if a patient is held Continued on page 24 February 2013 OR Manager Vol 29, No 2 23

24 Continued from page 23 in the OR for a time after the procedure because the PACU is full? Siddel: It doesn t matter where the patient is. If the patient is receiving the recommended level of care, you can charge for that level of care. Thus, if the patient is receiving the care he or she would receive in the PACU, you would charge for that level of care. Auditors check to see what level of care is being provided. Learn more about HBL Concepts at Keith Siddel will respond to questions in the column. Send your questions to Pat Patterson, editor, at ppatterson@accessintel.com. Siddel can be reached at ksiddel@ hblconcepts.com. The Nurses Float passes down Colorado Boulevard in Pasadena, California, during the Rose Parade on New Year s Day. The float honored Sally Bixby, RN, the first nurse to serve as president of the Tournament of Roses, as well as nurses everywhere. The float was a 5-year effort led by a group of 5 perioperative nurse volunteers. Flowers were applied by hundreds of volunteers. Best-Selling Books f r o m O R M a n a g e r! OR Manager presents two popular books on improving OR performance and patient safety. PATIENT SAFETY IN THE OR Patient safety is a critical issue in the operating room. In this compilation of articles from OR Manager, you will fi nd the latest information on patient safety in the surgical suite, including regulatory requirements, surgical safety checklists, SCIP, preoperative briefi ngs and debriefi ngs, handoffs, and team communication. IMPROVING OR PERFORMANCE In this book, you ll fi nd ideas and information from recent OR Manager articles for addressing challenges like late starts, inaccurate case time estimates and block scheduling. You ll read about strategies like dashboards, benchmarking and Lean management to help your surgical suite keep ahead of changes in health care. EACH BOOK IS $79 PLUS SHIPPING AND HANDLING, BUT BUY BOTH AND YOU LL SAVE 10%! To learn more and to purchase, visit: OR Manager 4 Choke Cherry Road, 2nd Floor Rockville, MD Tel: Fax: clientservices@accessintel.com 21470

25 April 7-9, 2013 Marriott City Center Denver, Colorado This intensive, interactive workshop is an opportunity for OR business managers to increase their knowledge of OR processes, to develop critical skills to drive effective business practices for surgical services, and to network with colleagues. The workshop will be led by speakers experienced in managing the business of perioperative services, including an expert in the health care revenue cycle specific to perioperative services, and an OR clinician. Focus of Workshop The focus is on developing analytical/critical thinking skills as well as on understanding cost components and overall financial management of the OR. Attendees will have the opportunity to work on projects during small-group breakout sessions to problem-solve and develop strategic planning skills. Some of the topics to be covered are: OR charging methodology Vendor management Management of the revenue cycle Data management for decision making Operational efficiencies Value analysis process Role of the business manager TargeT audience Participants will include business managers involved in the business decisions that drive the OR s economic, quality, technical, and program development. Limited to 75 participants, the two-day workshop will open with a welcoming reception on Sunday evening and end Tuesday afternoon. Workshop FormaT The workshop will open with a welcoming reception and introduction of speakers on Sunday, April 7. This will provide an opportunity to register and meet other attendees. A full-day session is planned for Monday, April 8, and a half-day session for Tuesday, April 9. Registration information will be available soon. contact Judy Dahle, MS, MSG, RN Education Coordinator OR Manager Jdahle@accessintel.com Registration is now open:

26 ASC award winners share quality improvements Surgical infection rates are dropping to zero, mammography results now arrive in minutes rather than weeks, and patient satisfaction surveys actually reflect patients interpretations of their experiences. This new world has arrived in some innovative locations, and it is poised to spread. The Accreditation Association for Ambulatory Health Care (AAAHC) Institute for Quality Improvement annually issues awards for quality improvement, and among the criteria for selection is the way improvements can be adopted by other facilities. The 2012 Bernard A. Kershner Innovations in Quality Improvement Awards, named after AAAHC Institute s first chairman, went to the 355th Medical Group at Davis-Monthan Air Force Base in Tucson, Arizona, and Siouxland Surgery Center in Dakota Dunes, South Dakota. Among the honorable mention awards was one recognizing Madison (Wisconsin) Surgery Center. You need to build trust. A cleaning solution Dakota Dunes is a planned community of about 2,700 residents located at the extreme southeastern corner of South Dakota, bordering Nebraska and Iowa. Siouxland Surgery Center draws patients from all 3 states, performing about 8,000 surgical procedures per year, primarily hip and knee arthroplasty and lumbar spinal fusion. Formerly an ambulatory surgery center (ASC), it now also provides inpatient care. In January 2012, infection preventionist Jennifer Hadley, BSN, RN, CIC, was appointed director of quality services, the first time those responsibilities were consolidated in a single position. Reviewing outcome statistics, she noted that incidents of surgical site infection were higher than expected for lumbar fusion and hip and knee arthroplasty. We strive for zero, Hadley says. Her experience with infection prevention made her suspect organisms carried by surgical instruments because of the high volume and rapid instrument turnover. What convinced her was the information provided by several surgical technologists (STs). The STs had been aware of the infections. They came forward and said they had seen errors in sterilization, Hadley recalls. They knew there were some process improvements that could be made. Improving the process A review of steam sterilization standards from the Association for the Advancement of Medical Instrumentation (AAMI, www. aami.org) helped identify which processes needed improvement. Working with Hadley, the surgical staff made the following changes: reorganized the workflow so instruments would proceed in Continued on page 28 Ambulatory Surgery Advisory Board Lee 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 26 OR Manager Vol 29, No 2 February 2013

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28 Ambulatory Surgery Centers Continued from page 26 only 1 direction: from dirty to clean to sterile improved the cleaning process improved access to protective apparel. Our main focus was on the decontamination area, Hadley says. There, brushes are used to clean out chips of bone and fragments of tissue. The center purchased a new supply of brushes and cleaning tools. It installed magnifiers at each sink so sterile processing workers could examine cracks and crevices more closely. For the same reason, it installed brighter lighting. For the workers protection and to prevent cross contamination, Hadley ordered a complete supply of protective apparel. Now personnel wear gloves, gowns, face shields, and masks while handling soiled instruments. Increasing sterile processing staff She also doubled the size of the sterile processing staff to 6 from 3 full-time equivalents. Previously, 1 had been assigned to decontamination and 2 to sterilization; now, the breakdown is 3 and 3. Still, some items proved impossible to clean reliably. One was suction tips. Ambulatory We had reusable Surgery tips, but Advisory Board Cleaning processes were upgraded. the lumen inside was so tiny we couldn t Lee Anne find Blackwell, a brush BSN, small EMBA, enough RN, to clean CNOR it, Hadley recalls. So we Vice president, clinical services, Practice changed to disposable tips. Partners in Healthcare, Inc, Birmingham, the Alabama OR, clinicians now start In soaking instruments in a basin Nancy Burden, MS, RN, CAPA, CPAN containing enzymatic cleaner immediately Health System, after use. Clearwater, This new Floridastep prevents blood and protein from Director, Ambulatory Surgery, BayCare Lisa Cooper, BSN, BA, RN, CNOR drying on the instruments. President, Surgery Center, Samaritan Suppliers Medical Center, were San Jose, brought Californiaon board. One problem, Hadley recalls, was late delivery of implants and instruments, making it difficult to sterilize them in time for scheduled procedures. As Hadley tells it, Now we have a rule. The rep must deliver the implants and instruments by 4 pm the day before surgery, or the case is cancelled and the rep gets to explain why to the surgeon. We have not had any problems since then. The human factor The results have been worth the effort. During the first 3 quarters of 2012, lumbar spinal fusion infection rates decreased by 61.5%. For knee and hip implants, the number of infections was 0 in all 3 quarters. The critical factor, according to Hadley, is management support. Our administrative team was on board from the very beginning, she notes. But collaboration, rather than top-down directives, makes such changes possible. Rebecca Talk Craig, to the BA, RN, people CNOR, that CASC work there, CEO, Harmony she advises. Surgery Center, Talk Fort to the Collins, Colorado and MCR Surgery techs and OR nurses. If the techs Center, Loveland, Colorado had not brought this forward, it would Stephanie have Ellis, been RN, CPC much more difficult to find the source of infection. Ellis Medical Consulting, Inc Brentwood, Tennessee She has worked at other facilities, Rikki Knight, where BS, quality MHA, RN coordinators Clinical director, Lakeview Surgery were not approachable, and staff Center, West Des Moines, Iowa had little incentive to speak up. At Siouxland, she resolved to bring all participants to the table and to listen without judgment. The results speak for themselves. You need to build trust and have a cohesive team, she says. Mission accomplished Radiologists at Davis-Monthan Air Force Base have found a way to reduce anxiety and inconvenience for military personnel, dependents, and retirees coming to the base for mammograms. Lt Col John McArthur, MD, is chief of radiology at the 355th Medical Group. On his arrival in 2010, he was determined to shorten waiting times, which could exceed 30 days, for exam results. The mammography unit is small, performing about 12 exams per day, and was a low priority compared with other x-ray procedures. Still, he realized timely diagnoses could be critical, and patients endured considerable anxiety waiting for them. In addition, technical staff spent time and effort calling patients back for additional images at the request of radiologists. Mammography was seen as a screening exam and not so timesensitive as other x-rays, he says, but there s a lot of anxiety in the waiting period. Col McArthur is 1 of 2 radiologists on staff, and they agreed to make a change: to increase their own workload for the benefit of LeeAnn patient Puckett satisfaction and efficiency. Materials Now, manager, patients Evansville receive Surgery results Center, Evansville, Indiana immediately after their exams, Donna often DeFazio first-hand Quinn, in BSN, a consultation MBA, RN, with CPAN, the CAPA radiologist; follow-ups Director, Orthopaedic Surgery Center take place; and, if necessary, further procedures are scheduled. Concord, New Hampshire Patients leave satisfied, knowing their status. Technicians no longer Continued on page OR Manager Vol 29, No 2 February 2013

29 SALARY/CAREER SURVEYS SPECIAL REPORT Learn more about the roles and responsibilities of the perioperative nurses, OR directors, and OR managers who manage OR departments in hospitals and in ASCs in this new special report from OR Manager. Order yours online using promo code REPORT13 and you ll save $20! Regular Price: $199 Your Price: $179 Format: Downloadable PDF For OR careers, my choice was easy. UT Southwestern. For over 20 years, the OR Manager publication has asked OR directors and managers in hospitals and ambulatory surgery centers (ASCs) to share anonymously information about their salaries, benefits, and management responsibilities. 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 Beyond bucks: Best ideas for recognizing staff Assisting at surgery: 1 in 3 ORs using assistants don t require special qualifications Half of OR directors plan to retire by the end of the current decade Survey: ASC economic conditions may be easing pages Teaching hospitals adding business managers UT Southwestern Medical Center in Dallas is one of the world s leading academic medical centers, with 12 specialties earning national recognition from U.S. News & World Report for Our teams perform more than 18,000 surgical procedures a year using some of the world s most advanced medical equipment and navigation systems, including three da Vinci surgical systems, a Gamma Knife and a new hybrid OR. Sign-on Bonus & Relocation Available! OR Nurse Manager Requires TX RN license, BSN & 5 years OR nursing management experience. OR, Outpatient Surgery & PACU Staff Nurses Requires TX RN license & 2-3 years applicable RN experience. Apply online at: utsouthwestern.edu/careers For questions, contact Denise.Allen@UTSouthwestern.edu (No agencies please) Order your special report online using promo code REPORT13 and you ll save $20! We are the future of medicine, today. OR Manager 4 Choke Cherry Road, 2nd Floor Rockville, MD Tel: Fax: clientservices@accessintel.com Dallas, Texas The University of Texas Southwestern Medical Center is an Equal Opportunity Institution.

30 Ambulatory Surgery Centers Continued from page 28 spend time contacting patients for follow-up, and transcription expenses are down. No more rack and stack Under the previous system, following the mammogram, the technologist would set aside the film for later analysis. This is known as the rack and stack method. It might be 2 weeks before the radiologist would pick up the film. The radiologist would dictate a report and send it to a transcription service, with a 4- to 5-day turnaround time. The radiologist would review the transcription for accuracy and then have a technician send the patient a letter. In about 20% of cases, the patient would be called back for additional views, not necessarily because of cancer. The entire staff participated in a working group to consider ways to improve the process. Starting in July 2010, things changed. First, the appointment time was increased to 30 minutes from 20 minutes. Immediately after the exam, a radiologist reviews the image. If it is other than normal, he or she talks to the patient. The patient goes home with a letter explaining the result. Ambulatory Surgery Advisory Board Follow-up for patients Talk to the techs and nurses. At Davis-Monthan, if the patient needs Lee Anne an Blackwell, ultrasound BSN, EMBA, follow-up, RN, she CNOR is sent directly to the ultrasound unit. If a biopsy or MRI is Vice president, clinical services, Practice Partners in Healthcare, Inc, Birmingham, for, Alabama she is referred back to called her physician, as the base does Nancy Burden, MS, RN, CAPA, CPAN not perform those. Director, Ambulatory Surgery, BayCare In Health the System, process, Clearwater, the 355th Florida eliminated its transcription service, Lisa Cooper, BSN, BA, RN, CNOR saving about $45,000 per year. President, Surgery Center, Samaritan For other Medical x-rays, Center, San it has Jose, purchased California voice recognition software. Turnaround is immediate, but the radiologist must expend more time proofreading his own dictation. The radiologists are willing to accept the inconvenience, Col McArthur says, because it means less work for the administrative staff and a significant improvement in patient service. The model is not unique to Davis-Monthan, he says, but is currently rare. We re not the first, he notes. For an ASC or radiology group considering it, he has this advice: First get the buy-in of radiologists. That is critical because a radiologist must always be present to view images and meet with patients. Therefore, it may not be practical for a large facility with a high volume of mammograms. It is also important that appointment times be extended. Are patients satisfied? Madison Surgery Center received Rebecca Craig, honorable BA, RN, CNOR, mention CASC for an CEO, enhanced Harmony patient Surgery Center, satisfaction Fort Collins, Colorado and MCR Surgery questionnaire. Madison, a joint Center, Loveland, Colorado venture of the University of Wisconsin Stephanie Hospital Ellis, RN, CPC and Clinics, Meriter Hospital in Madison, and the Ellis Medical Consulting, Inc Brentwood, Tennessee University of Wisconsin Medical Foundation, Rikki Knight, BS, a MHA, physician RN group, Clinical director, Lakeview Surgery serves 12,500 patients annually. Center, West Des Moines, Iowa According to quality and risk manager Pam Smestad, RN, the questionnaire needed updating for 2 reasons: to be consistent with that used by the Medical Foundation and to obtain information from the patient s perspective. In early 2012, the center began using a new 15-question survey. It uses the foundation s survey as a model but also incorporates information from patient focus groups. After 3 quarters of use, the new survey form is revealing improved patient satisfaction. The center staff are taking results to heart and addressing respondents concerns. Each patient receives the written survey at discharge and is asked to mail it back within 60 days. The response rate is about 35%. Satisfaction rates, already better than 90%, have improved by several percentage points in most areas. A better way The AAAHC Institute invites its accredited organizations to apply for the awards annually. There were 40 applicants this year. An expert panel reviews each application based on 10 criteria, which include a clear description of the goals of the program, proper methodology, and measurable results. The review includes a site visit. Naomi Kuznets, PhD, senior director and general manager of the AAAHC Institute, says the annual winners illustrate how best LeeAnn practices Puckett can be translated into usable Materials examples manager, Evansville for the rest Surgery of the Center, Evansville, Indiana industry. Donna Of DeFazio this year s Quinn, winners, BSN, MBA, she RN, says, They CPAN, provide CAPA easy-to-follow, understandable examples that we Director, Orthopaedic Surgery Center Concord, New Hampshire believe a large number of organizations could use to develop their own quality improvement studies. Paula DeJohn 30 OR Manager Vol 29, No 2 February 2013

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