surgical scheduling: a lean approach to process improvement
TRANSCRIPT
B
Surgical Scheduling: A LeanApproach to Process ImprovementROSS WILLIAM SIMON, BA; ELENA G. CANACARI, RN, CNOR
ABSTRACT
A large teaching hospital in the northeast United States had an inefficient, paper-
based process for scheduling orthopedic surgery that caused delays and contrib-
uted to site/side discrepancies. The hospital’s leaders formed a team with the
goals of developing a safe, effective, patient-centered, timely, efficient, and
accurate orthopedic scheduling process; smoothing the schedule so that block
time was allocated more evenly; and ensuring correct site/side. Under the
resulting process, real-time patient information is entered into a database during
the patient’s preoperative visit in the surgeon’s office. The team found the new
process reduced the occurrence of site/side discrepancies to zero, reduced in-
stances of changing the sequence of orthopedic procedures by 70%, and increased
patient satisfaction. AORN J 99 (January 2014) 147-159. � AORN, Inc, 2014.
http://dx.doi.org/10.1016/j.aorn.2013.10.008
Key words: scheduling, orthopedic surgery, Lean.
efore February 2010, Beth Israel Deaconess
Medical Center in Boston, Massachusetts,
had an inefficient, paper-based process for
scheduling orthopedic surgery. This process caused
several issues:
n There was a three- to five-day lag time between
patients knowing they need to be booked for
surgery and being called by the office, and ur-
gent bookings were put on a wait list, creating
periods of uncertainty for patients;
n cases were backlogged;
n interdepartmental communication was poor;
n booking information was inaccurate and
booking times were scheduled in more than
one room with the same surgeon; and
n last-minute changes in procedure sequence led
to waste and workarounds.
http://dx.doi.org/10.1016/j.aorn.2013.10.008
� AORN, Inc, 2014
In addition to this, the facility was experienc-
ing a 4% occurrence of site/side discrepancies
in the preoperative clinic and 2% occurrence
in the OR as well as frequent patient cancella-
tions. These problems were significant enough
that hospital and perioperative leaders decided
that creating a formal team to address them was
justified. Members of the team who developed
the new orthopedic scheduling process, what
parts of the process they represented, and any
other roles they played on the team are shown in
Table 1. As a result, while we were developing
an automated booking system for ORs, the team
also worked to improve the orthopedic surgical
scheduling process, reduce patient cancellations,
and reduce or eliminate site/side discrepancies.
The project took place from February 2010 to
March 2011.
January 2014 Vol 99 No 1 � AORN Journal j 147
TABLE 1. Members of the Team and Their Roles
Job title Represented Other roles on the team
Chief administrative officer, orthopedics Administration Team co-leaderAdministration manager, orthopedics Procedure schedulingAdministrative assistant, surgical
schedulingProcedure scheduling
Anesthesiologist Preoperative and intraoperative processAssociate chief nurse, perioperative
servicesCentral processing department, preop-erative clinic, and OR process
Team co-leader, acted as a knowledgeresource, assisted with strategy,sponsored the project, broke downbarriers to progress
Central processing departmentsupervisor
Surgical kit preparation and case pick
Clinical advisor, orthopedics OR setup and intraoperative processesClinical manager, scheduling operations OR procedure schedulingSenior management engineer Team facilitator, helped with problem
solving and statistical analysisOrthopedic surgeons (2) Clinic, office, and intraoperative processOR scheduler OR procedure schedulingOR systems administrator Process data extraction Helped with statistical analysis
January 2014 Vol 99 No 1 SIMONdCANACARI
Using structured Lean problem-solving tech-
niques, the team developed and launched a safe,
effective, patient-centered, timely, efficient, and
accurate orthopedic surgical scheduling process.
In the analysis phase, the team mapped out the
process, starting with the patient’s call to schedule
an appointment with the surgeon through preop-
erative activities onsite, and identified existing
problems and opportunities for improvement. Then
the team organized the myriad problems into log-
ical groupings and prioritized these according to
impact, which provided a strategy for moving
forward with solutions. The team reviewed and
created solutions for all of the identified problems,
using an activity scorecard and a timeline for cor-
rective action implementation to drive progress. The
new process has solved several of the identified
problems, such as eliminating site/side discrep-
ancies and lag time between knowing the patient
needs to be booked and then contacting the patient,
reducing day before and day of cancellations, and
reducing the frequency of procedure sequences
being changed. The following article describes the
process used to develop the plan to address this
148 j AORN Journal
improvement opportunity, conduct the work, and
the accomplishments.
BACKGROUND
Our facility is a large academic medical center
located in the northeast United States. It is a level
1 trauma center with three operating suites and a
total of 38 ORs, in which we care for all types of
adult patients, except for those needing lung and
heart transplants, for a total of 27,000 procedures
per year.
In addition to internal scheduling difficulties and
inefficiencies, our facility was experiencing a 5.1%
cancellation rate before the process improvements.
In fact, patient-related causes are the most frequent
reasons for cancellation of orthopedic procedures.
In our review of patient reasons for cancellations
within 48 hours of surgery, we learned that most
often patients cancel because they change their
mind about having surgery. Sometimes they cannot
get a ride. Team members perceived that patients
equated surgical appointments with other types of
appointments (eg, the dentist) and were unaware of
the effects of cancelling. Cancellations can have an
SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org
effect on other patients, for example, and cancel-
ling within 48 hours affects the functional opera-
tion of the OR, because surgeons’ instrument kits
that were prepared and delivered to the OR have to
be brought back to the central processing depart-
ment, unpacked, and stored, which creates work
that does not add value. In the event of cancella-
tions, OR schedulers also must juggle the schedule
to accommodate the procedure order, leading to
more nonevalue-added work and, sometimes, a
reduction in OR usage.
The team collected data from our perioperative
information management system. Key metrics we
monitored included
n the total number of site/side discrepancies,
n the lag time between a surgeon knowing the
patient needs to be booked for surgery and the
orthopedic administrative assistant contacting
the patient,
n total procedure cancellations and the percentage
that are cancelled the day before surgery, and
n instances of changing the sequence of proce-
dures less than 48 hours before surgery.
In improving the orthopedic surgical scheduling
process, we also wanted to improve patient safety.
Before starting this project, site/side discrepancies
in the preoperative clinic occurred in 4% of pro-
cedures and in 2% of procedures in the ORdunlike
the new system, the old system did not require
surgeons to enter side and site in real time when
scheduling a surgery. One regulatory consideration
that drove us to address site/side discrepancies was
the Universal ProtocolTM for Preventing Wrong
Site/Wrong Procedure,1 which is accessible as part
of the National Patient Safety Goals.2 Additionally,
the American College of Surgeons issued a state-
ment that contains the following: “The American
College of Surgeons (ACS) recognizes patient sa-
fety as being an item of the highest priority and
strongly urges individual hospitals and health or-
ganizations to develop guidelines to ensure cor-
rect patient, correct site and correct procedure
surgery.”3(p26) In addition to this, AORN created
the AORN Comprehensive Surgical Checklist,
which incorporates the World Health Organiza-
tion’s checklist and The Joint Commission’s safety
requirements for the Universal Protocol in a sin-
gle document.4
GOALS
Before the team was selected, we established three
main goals for performing a quality improvement
project:
n develop a safe, effective, patient-centered, time-
ly, efficient, and accurate orthopedic scheduling
process (ie, requirements that mirror elements
of “The Six Domains of Healthcare Quality”5);
n smooth the schedule so that block time alloca-
tion is more even across the days of the week,
maximizing efficiency and utilization; and
n improve patient safety by ensuring correct site/
side.
We also incorporated the Lean process into our
plans from the beginning. To make trends visible,
we made extensive use of charting, graphing, and
Pareto analysis (ie, a special form of vertical bar
graph displaying the relative importance of all the
problems or conditions with the most important
on the left) to prioritize the problem-solving ap-
proach. Our patient cancellation data are displayed
in Figure 1.
ABOUT LEAN
The term “Lean” was coined to describe Toyota’s
business during the late 1980s.6 In Lean process-
es, a cross-functional team uses simple, structured
problem-solving tools, often referred to as “Lean
tools” or “the seven quality tools,”7 to move
smoothly from problem identification to solution
development and finally to ensuring that the im-
plemented improvements will not fall out of use and
allow the original problems to resurface. Successful
Lean health care projects start with a clear defini-
tion of the project, often called a project charter (see
Supplementary Figure 1 at http://www.aornjournal
.org).
AORN Journal j 149
Figure 1. Patient-related causes were the most frequent reasons for cancellation of orthopedic procedures,although there were numerous reasons a patient might cancel within 48 hours of surgery.
January 2014 Vol 99 No 1 SIMONdCANACARI
The project charter should be drafted by those
who have key knowledge of the problemdor op-
portunity for improvementdand the supervisors
of the likely team members. We chose to use
the term opportunity for improvement in place
of problem for philosophical reasons. The word
problem is perceived negatively, and Lean is
rooted in the spirit of continuous improvement,
where problems are embraced as opportunities
for improvement rather than seen in a negative
context. Lean leaders view problems as great op-
portunities for improvement. Essential elements of
the project charter include
n a description of the problem, providing the
background and justification for working on the
project;
n clear, measurable goals;
n a projected project completion date;
n a suggested approach;
n metrics that quantitatively define the problem or
opportunity;
150 j AORN Journal
n team composition, including a leader, a facili-
tator, and a sponsor or sponsors who serve as
resources if the team runs into a roadblock; and
n a list of the major steps in the process, usually
six or fewer.8
The Lean process provides a set of management
principles that defines a way to manage projects.
For example, improvement projects should not be
conducted by only a select few champions in an
organization; successful Lean improvement pro-
jects include those who do the work. The under-
lying belief of the Lean process is that the people
who do the work know it best, and they should
be given the authority to improve their work pro-
cesses.9 The process knowledge and experience
of those who do the work is far more valuable
in both problem-solving and successfully imple-
menting solutions than having members who have
only peripheral contact with the work. Addition-
ally, we found that members of the team do not
need to have a deep knowledge of Lean principles
Figure 2. In this excerpt from the swim lane process map used during a project to improve orthopedic surgeryscheduling, the boxes represent steps in the processes and the hexagons represent problems identified whencreating the process map. Process steps are included in a horizontal row dedicated for a particular departmentor function.
SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org
to be successful; they can be highly productive
contributors to the project without spending hours
in Lean training classes. The best way to learn
about Lean is to participate in a well-facilitated
improvement project during which the team moves
through identifying problems or opportunities for
improvement, generating solutions, and maintain-
ing the improvement phases.
METHODS
At the first team meeting, the team facilitator, Ross
Simon, senior management engineer, delivered an
overview of Lean principles. Throughout the proj-
ect, the facilitator offered problem-solving tools to
help the team move swiftly and efficiently through
the process.
We overcame barriers by engaging stakeholders.
Physicians served as champions to help design and
pilot test the online surgical booking system. The
pilot test work started with a group of orthopedic
surgeons who embraced the technology. We also
brought in others, including administrators who
worked for the surgeons. The team drove the pro-
cess and did the work. For the first three months,
the team met weekly for one hour to review the
status of action items and decide what we needed
to do next. After this initial period, we met every
other week or monthly to ensure that the new pro-
cess was working well. Our last formal meeting was
held a year after the first meeting. Team meetings
were primarily strategic; other than the few activ-
ities that we had to do together, such as brain-
storming, we did the work outside of our regular
meetings. By doing everything that we could out-
side of meetings, we maximized the usefulness of
meeting time by using it strategically, identifying
the status of activities, and collectively deciding
on the next step.
AORN Journal j 151
Figure 3. Excerpt from a cause and effect diagram used during a project to improve orthopedic surgeryscheduling. A cause and effect diagram can be used to help a quality improvement team consider any additionalproblems and root causes that might not be identified with an annotated swim lane process map.
January 2014 Vol 99 No 1 SIMONdCANACARI
Process Mapping
As appropriate on most process-related Lean im-
provement projects, our first team activity was to
meticulously list the process steps and note prob-
lems and opportunities for improvement associated
with each step. During process mapping, the focus
is on discovering the current processes of an or-
ganization, establishing the root cause problems
with those processes, and looking for solutions.10
It was important that the team agree on the cur-
rent process and issues so that we could develop
robust solutions together. We found that people
often disagreed or misunderstood the processes
that we had in place, so mapping out the process
provided an opportunity for us to appreciate each
team member’s role and to annotate process steps
to identify problems and opportunities for im-
provement. The team used a swim lane process
map to document our processes (Figure 2). Swim
lane diagrams were proposed by Geary Rummler
and Alan Brache in their 1990 book Improving
Performance.11 This method of diagramming fa-
cilitates plotting and tracing processes quickly
152 j AORN Journal
and easily and, in particular, displays the inter-
connections between processes, departments, and
teams.12 As is typical of most complex processes,
our swim lane process map included 84 process
steps, 48 problems, and 13 opportunities for
improvement.
Next, we used a cause and effect diagram
(Figure 3) to help us consider any additional pro-
blems and root causes we might not have identified
with the annotated swim lane process map. Com-
monly called a fishbone diagram, cause and effect
diagrams illustrate the factors affecting a process
by sorting out and relating the causes of a problem.13
Every effect is likely to have several major cate-
gories of causes. The major causes in these dia-
grams often are summarized into four categories:
people, machines, methods, and materials.14 Lean
practitioners later added “environment” to include
the workplace. To complete this diagram, team
members placed all of the problems and opportu-
nities for improvement that we identified in the
swim lane process map next to the appropriate rib
on the cause and effect diagram. Then we asked
Figure 4. In this affinity diagram, the team split identified problems into seven groups. The types of solutionsused to address each problem precede the problem on the diagram.
AORN Journal j 153
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Figure 5. An impact analysis grid can help identifywhich solutions will have the highest impact and theleast difficulty to implement. Solutions to problems inthe upper-left corner of the grid, for example, areboth high impact and low difficulty.
January 2014 Vol 99 No 1 SIMONdCANACARI
ourselves what we were missing that fell into the
categories of methods, materials, manpower, ma-
chinery, and the environment. In using Lean meth-
odology, it is important to lay out all of the problems
before jumping to solutions. As usually happens
with this type of process, we added additional
causesdspecifically, we noted additional causes
that contribute to inefficiency, inaccuracy, and lack
of timeliness in the orthopedic surgical scheduling
process. Our completed cause and effect diagram
contained more than 50 problems.
The number of problems we identified seemed
daunting. To get a grasp on all of the issues, the team
used an affinity diagram to organize the problems
into logical groupings15,16 (Figure 4). We split the
problems into seven logical groupings (ie, patient
information, patient access, administration, sched-
uling, physicians, roadblocks, equipment). Placing
seemingly disparate problems into logical groups
reduces the number of problems into manageable
groups, eliminates redundancies if problems are
identified more than once earlier in the process,
and helps ensure that the solutions developed later
will address the broad scope of related problems.
As the team developed and implemented solutions
to the problems, we annotated each to indicate work
that had been completed or was under way. As an
example of how we grouped problems, the fol-
lowing fell into the category of patient information:
n the number of patient identifiers that are
required,
n incorrect patient contact information,
n ineligible insurance,
n incorrectly spelled names, and
n missing orders for preadmission testing.
Prioritizing and Developing Solutions
To develop a strategy for solving the problems, the
team prioritized the categories according to how
difficult they would be to solve and how much they
would help us to meet our goals when they were
solved. The team agreed to create an impact anal-
ysis chart based on Leankaizen methods,17 shown
in Figure 5, for this purpose.
154 j AORN Journal
To start, the team developed solutions to prob-
lems that fell into the upper left corner of the grid
(ie, high impact, low difficulty), such as the lag
time created when scheduling forms completed
by surgeons were batched and brought from the
clinic in one building to another building of the
medical center where orthopedic administration is
located. By completing this process, we achieved
early and meaningful wins, such as reducing the
number of last-minute changes by surgeons, which
helped maintain order in the central processing de-
partment. These early wins helped the team main-
tain a high level of energy and morale, which is
important because complex projects like this one
may require several months to complete.
Defining Tasks and CommunicatingProgress
The team used an activity scorecard to define and
communicate all of our tasks (Figure 6). The score-
card includes a short title for the task, the issue being
addressed, the next activity to address the issue,
the task’s priority relative to all of the other tasks,
Figure 6. An excerpt from an activity scorecard used during a project to improve orthopedic surgery scheduling.Columns in the scorecard are (from left to right) the task number, short title of the task, the issue beingaddressed, the next activity, the task priority versus other tasks, who is responsible for completing the work,the target completion date, and the current status.
SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org
the name of the individual or individuals who are
responsible for completing the task, the target com-
pletion date, and the current status. During team
meetings, whenever the team identified an action
that needed to be taken, it was entered onto the
activity scorecard so everyone could see it. The
scorecard, used instead of traditional meeting mi-
nutes, was updated and redistributed after each
meeting. This helped us drive progress, keep
members focused during team meetings, and add
a sense of accountability to those who took on the
tasks.
In addition to the activity scorecard, we also
used a graphical depiction of a simple implemen-
tation plan (Figure 7) as a timeline for key action
items. This plan provided an overall view of the
most important tasks. The team used it to help
reinforce accountability by highlighting the time-
liness of responses to planned work.
RESULTS
The differences between our original, paper-based
orthopedic surgical scheduling process and the new
online process were significant (Table 2). The new
process gave our facility several benefits. The lag
time between the surgeon knowing a patient needs
to be booked for surgery and the orthopedic
administrative assistant contacting the patient was
decreased from three days to less than one day.
Improving process flow by eliminating batching
(eg, our process where booking forms were col-
lected over a period of days and then brought as
a batch to the administrative assistant, who then
contacted the patient) is an underpinning of Lean
philosophy. Lean terminology includes “one-piece
flow” or “single-piece flow,” which means that
in a perfect flow environment, the product (or pa-
tient) would move in batches of one, because this
minimizes delays.18 Now, because the surgeon
completes booking online after seeing a patient, the
booking is immediately visible to the orthopedic
administrative assistant, and lag time is minimized.
If patients decide to have surgery late in the after-
noon one day, they will be called the next day to
validate preoperative clinic and surgery dates and
times.
To address no-show and last-minute cancel-
lations, the team adopted a practice used in the
outpatient clinic at the medical center: we started
including a notice in the surgical confirmation letter
to patients stating that a $250 fee will be charged
for cancellations within less than 48 hours before the
scheduled appointment time. We have not charged
any patients the $250 fee to date, but we have
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Figure 7. A graphical depiction of a simple implementation plan can be used as a timeline for key action itemsduring a process improvement project.
TABLE 2. Orthopedic Surgical Scheduling Process Flow
Topic Before After
Timing of the surgeonscheduling surgery
The surgeon scheduled his or her surgeries on 5different paper booking forms.
The surgeon schedules surgery online in real time.
Surgical schedulingprocess
Scheduling forms were batched and brought fromthe clinic in one building to another building on themedical center campus, where orthopedicadministration is located.
The surgical schedule is visible online in real time tothe orthopedic scheduler.
Contacting the patientafter his or her visitwith the surgeon
Patients were contacted by the orthopedic admin-istrative assistant to schedule the day of surgery 3to 5 days after the patient’s visit with the surgeon.
Patients are contacted by the orthopedic admin-istrative assistant within 1 day of the patient’svisit with the surgeon to schedule surgery.
Surgical consents andpatient information
Regular faxes of consent and patient informationoften were lost or unavailable.
Consent and paperwork are electronically faxedand available throughout the patient’s perioper-ative experience.
Special equipment There was no standard format for listing specialequipment needed for surgery.
The listing and selection of special equipment isclear and concise in the online booking system.
Site/side discrepancies There was a 4% occurrence of site/sidediscrepancies.
Because booking is in real time with the patient inattendance with the surgeon, there are no site/side discrepancies.
156 j AORN Journal
January 2014 Vol 99 No 1 SIMONdCANACARI
Figure 9. The number of instances of physicians changing the sequence of procedures within 48 hours of sur-gery was reduced between January and June 2010 as a result of the improved orthopedic scheduling process.
Figure 8. Patient cancellations within 48 hours of surgery were reduced between June 2009 and October 2010as a result of the improved orthopedic scheduling process.
SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org
reduced the patient cancellation rate by 35%, from
5.1% to 3.3% (Figure 8).
In addition to scheduling advantages, the new
online booking system also helped with site/side
discrepancies and dropped our occurrence of this
error to zero. The online booking system is set up
such that the surgeon cannot bypass specification
of site/side in the booking workflow, and the sys-
tem forces physicians to think about the side of
a surgery in real time, while he or she orders the
booking and while the patient is in the office. In our
previous system, the surgeon had to remember the
AORN Journal j 157
January 2014 Vol 99 No 1 SIMONdCANACARI
side at the end of the clinical day when he or she
filled out paperwork for several patients. Before the
implementation of the new process, we had an av-
erage of four procedures per week during which a
site/side discrepancy was caught in preadmission
testing and two per week caught in the preoperative
area; after the new process was implemented, both
went to zero.
As is the case when patients cancel surgery
within 48 hours of its scheduled start, supplies, time,
and manpower are wasted when surgeons change
the sequence of procedures less than 48 hours before
surgery. The new process made the problem more
visible to surgeons, so the team reduced the in-
stances of changing the sequence of orthopedic
procedures by 70%, from 20 occurrences per
month to six occurrences per month (Figure 9).
As an added benefit of the online scheduling
system, patient satisfaction increased with the re-
duced delays. When we began the project, patient
satisfaction, as measured by the Press Ganey metric
of “likelihood to recommend,” was very good at
67.6%. At the completion of our project a year after
starting it, we increased the score by nearly 20%,
to an average of 84%.
CONCLUSION
Changing the culture of an organization to support
a Lean approach to process improvement is not
easy. Lecturing personnel on Lean principles will
provide a foundation for Lean; however, personnel
will not be convinced of its value or become
proficient in the use of Lean tools and techniques
without participating in well-facilitated process
improvement teams that work on real, challenging
problems and implement sustainable solutions.
Work accomplished by the orthopedic surgical
scheduling team has moved the medical center
forward in this direction. Our facility has seen an
increased spirit of collaborative partnerships and
understanding of roles, a new mindset that views
problems as opportunities, creative new solutions
to old problems, an eliminated silo mentality, best
158 j AORN Journal
practices shared between teams, a more team- and
goal-oriented culture, and stakeholders who are
empowered to solve problems.
Practical examples of our accomplishments
include that our project team developed an effi-
cient, accurate, and timely orthopedic scheduling
process; reduced day-before and day-of cancella-
tions, reduced procedure sequence changes, in-
creased patient satisfaction, and eliminated the
disorganized schedule, which had caused us to
be unable to get orthopedic procedures onto the
schedule for four consecutive months. The online
system also reduced schedule changes made by
surgeons within 48 hours because it allows sur-
geons to review the surgery schedule proactively
online in real time.
The new process allowed us to allocate a dedi-
cated block for urgent/emergent plastic orthopedic
hand trauma and pilot test a preoperative clinic
faxing/scanning project, and the new process im-
proved the relationship between scheduling and
orthopedics personnel to promote collaboration. We
focused on orthopedic surgery scheduling with this
project, and online scheduling has had such a posi-
tive effect on performance in orthopedics that work
is under way to implement the process in other ser-
vices at the medical center. The importance of
improving patient safety with respect to site/side
discrepancies created an urgency that facilitated
moving this project forward. Regardless of the many
advantages the new project has provided, without
that sense of urgency, it has been a challenge to
spread this process to other services in the medical
center.
SUPPLEMENTARY DATA
The supplementary figure associated with this
article can be found in the online version at http://
dx.doi.org/10.1016/j.aorn.2013.10.008.
Editor’s note: The Universal Protocol for
Preventing Wrong Site, Wrong Procedure,
Wrong Person Surgery is a trademark of The
Joint Commission, Oakbrook Terrace, IL.
SURGICAL SCHEDULING: A LEAN APPROACH www.aornjournal.org
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Ross William Simon, BA, is a senior manage-
ment engineer at Beth Israel Deaconess Medical
Center, Boston, MA. Mr Simon has no declared
affiliation that could be perceived as posing a
potential conflict of interest in the publication of
this article.
Elena G. Canacari, RN, CNOR, is associate
chief nurse of perioperative services at Beth
Israel Deaconess Medical Center, Boston, MA.
Ms Canacari has no declared affiliation that
could be perceived as posing a potential conflict
of interest in the publication of this article.
AORN Journal j 159