the monthly publication for or decision makers...the place that performs the highest vol-ume of that...

March 2004 Vol 20, No 3

The monthly publication for OR decision makers

In this issueSpeaker offers tools for managing politics . . . . . . . . . .5

Change assistant pay, GAO advises . . . . . . . . . . . . . .7

Penelope, the robot, could scrub in . . . . . . . . . . . . .9

STERILE REPROCESSING.Gaining efficiency with instrument tracking . . . . . . .17

PERFORMANCEIMPROVEMENT.Practical guide forimproving performance . . .23

AMBULATORY SURGERYCENTERS.What�s ASC�s obligation for escorts? . . . . . . . . . . . . . .29

AMBULATORY SURGERYCENTERS.JCAHO tailors safety goalsfor ambulatory care . . . . . . .33

WORKPLACE . . . . . . . . . . .37

HEALTH POLICY & POLITICS . . . . . . . . . . . . . . .38

AT A GLANCE . . . . . . . . . . .40

ASC section on page 29.

Listening to your employees andletting them know you are listen-ing are common threads among

hospitals in Fortune magazine�s 100Best Companies to Work for 2004.

Faced with a growing nursing short-age, there�s evidence hospitals areworking harder to attract and keeptheir staffs�seven hospitals made thelist this year, up from two in 1998.

Companies are selected according towhat employees themselves have tosay about their workplaces. In all,46,526 randomly selected employeesfrom 304 companies filled out employeeopinion surveys. Nearly half also gavewritten comments about their work-places. Companies filled out question-naires detailing their people policies,

practices, and philosophies. OR Manager talked with nurse lead-

ers at three of the seven hospitals onthis year�s list.

Belief in employee inputBronson Healthcare Group of Kala-

mazoo, Mich, was the top-rated hospi-tal, coming in at number 21. It was oneof just 16 new companies to make thelist this year.

Bronson looks after its employeeswith concierge services like shoppingand errand running. Employee sugges-tions not only are encouraged, butaction is taken.

Bronson�s RN turnover rate is 6.9%,compared with the national average of

Listening to staff key for hospitalson Fortune’s list of top employers

Continued on page 10

Recruitment & retention

Hospital construction set a recordin 2002. Though there was aslight setback in 2003, �histori-

cally, it is at an exceptional level,� saysRichard Branch, an economist withMcGraw-Hill Construction, Lexington,Mass.

Major drivers are the shift to outpa-tient care, now 60% to 80% of manyhospitals� volumes, burgeoning tech-nology, and an aging population.

Building is also driven by competi-tion as hospital systems in fast-grow-ing areas, particularly in the Southwestand West, battle for market share. InPhoenix, for example, two new hospi-tals are opening right across the roadfrom each other. Denver �s booming

suburbs are opening new hospitals.In 2002, the number of community

hospitals grew by 19 to 4,927, the firstincrease since at least 1975, theAmerican Hospital Association reports.

�Spurred by the attractive demo-graphics of high-growth suburbanareas, changing consumer tastes, andthe prospect of big business from babyboomers in the coming years, healthcare systems across the country areawakening from a construction slum-ber attributed in part to the stiflingeffect of the Balanced Budget Act of1997,� the Jan 12 Modern Healthcarereported.

With these forces in play, surgical

Patient-friendly, high-tech facilitiesa trend in OR construction projects


OR design & construction

2

Full Page AdCODE4/c(Pickup)

2

Please see the ad for INTEGRATED MEDICAL SYSTEMSin the OR Manager print version.

If a friend or relative needed surgeryand asked us to recommend a hospi-tal, we�d probably suggest going to

the place that performs the highest vol-ume of that type of case.

The conventional wisdom says thatthe more of a procedure a hospital does,the better the outcomes are.

New research suggests it�s not thatsimple.

A new study in the Jan 14 JAMA ledby Eric Peterson, MD, of Duke found, atleast for coronary artery bypass graft(CABG), there was only a modest associ-ation between hospital procedure vol-ume and outcomes. The authors exam-ined results for more than 260,000CABGs performed in 2000 and 2001.

They noted many low-volume hospi-tals had low mortality rates, and somehigh-volume centers had higher ratesthan expected.

Role of surgeon’s volume What may be more important is the

surgeon�s volume, another new reportsuggests.

Patients of high-volume surgeons hadlower death rates for cardiac surgery andcertain cancer operations than patients ofsurgeons who did those procedures lessoften, researchers led by DartmouthMedical School�s John D. Birkmeyer,MD, found. The report was in the Nov27, 2003, New England Journal of Medicine.

The study findings suggest high-vol-ume surgeons� patients had lower deathrates even when operated on in low-vol-ume hospitals�while patients of low-volume surgeons had higher death ratesregardless of where they had theirsurgery.

The study considered high-volumesurgeons those who did a yearly averageof more than:� 162 CABGs� 40 carotid endarterectomies� 17 lung resections� 4 pancreatic resections.

Do report cards help? The new findings have raised ques-

tions about using hospital volume as aquality measure, as does the LeapfrogGroup (www.leapfroggroup.org), a coali-tion of large employers and public agen-cies. Leapfrog encourages patients tochoose hospitals with the best outcomes

and a high volume of procedures�atleast 450 a year for CABG. If the Leap-frog number was the standard, 77% ofthe centers included in the JAMA studywould have to close.

In response, Leapfrog says it�s alreadymoving beyond hospital volume to userisk-adjusted mortality rates, at least forsome procedures.

But who has access to hospital mor-tality data? Not many. Just four states,California, New Jersey, New York, andPennsylvania, regularly publish risk-adjusted mortality rates for CABG, andthat�s not easy to get at.

And hospital-quality data on theInternet is spotty. A Leapfrog partner,HealthGrades (www.healthgrades.com),just touted its Distinguished HospitalAwards for Clinical Excellence. Theawards identify hospitals with the lowestmortality and complication rates forseven specialties, including cardiac care.

But the list is limited�the 164 win-ners were selected from only 869 hospi-tals that had the data needed for analy-sis�a fraction of the nation�s 4,000-somehospitals.

So what do you tell a friend or rela-tive? For now, the best data source iseasy to access�their own surgeon.Suggest they ask their surgeon howmany of that procedure the surgeon doeseach year, knowing that�s the numberthat probably makes the biggest differ-ence. ❖

�Pat Patterson

CorrectionIn the January article on patient track-

ing systems, Kelly Ratajczak of Fairview-University Medical Center in Minnea-polis should not have been identified asan RN.

3March 2004

Upcoming

OR Manager Vol 20, No 3

March 2004 Vol 20, No 3OR Manager is a monthly publication forpersonnel in decision-making positions inthe operating room.

Elinor S. Schrader: PublisherPatricia Patterson: EditorJudith M. Mathias, RN, MA:

Clinical editorBillie Fernsebner, RN, MSN:

Consulting editorJanet K. Schultz, RN, MSN:

Consulting editorKathy Shaneberger, RN, MSN, CNOR:

Consulting editor

OR Manager (USPS 743-010), (ISSN8756-8047) is published monthly by ORManager, Inc, 1807 Second St, Suite 61,Santa Fe, NM 87505-3499. Periodicalspostage paid at Santa Fe, NM and addi-tional post offices. POSTMASTER: Sendaddress changes to OR Manager, PO Box5303, Santa Fe, NM 87502-5303.

OR Manager is indexed in the CumulativeIndex to Nursing and Allied HealthLiterature and MEDLINE/PubMed.

Copyright © 2004 OR Manager, Inc. All rightsreserved. No part of this publication may bereproduced without written permission.

Subscription rates: $86 per year. Super sub-scriptions (electronic) $129 per year.Canadian, $98. Foreign, $115. Single issues$10. Address subscription requests to POBox 5303, Santa Fe, NM 87502-5303. Tele:800/442-9918 or 505/982-0510. Web site:www.ormanager.com

Editorial Office: PO Box 5303, Santa Fe, NM87502-5303. Tele: 800/442-9918. Fax: 505/983-0790. E-mail: [email protected]

Advertising Manager: Anthony J. Jannetti,Inc, East Holly Ave/Box 56, Pitman, NJ08071. Telephone: 856/256-2300; Fax:856/589-7463. John R. Schmus, nationaladvertising manager. [email protected]


Editorial

“

“Hospital-quality data

on the Internet is spotty.

Obesity: A weighty matterAdvice on accommodating the in-

creasing volume of heavier patients.

Keeping your patients warm Suggestions for improving the

process of this important measure forpreventing surgical infection.

Regional anesthesia gainingground

What you need to know about thisgrowing movement.

4

Please see the ad for CTC CARDINAL HEALTHin the OR Manager print version.

Managers face it every day�dis-putes over adding a case to theOR schedule, rivalry over new

capital equipment, conflict among thestaff. It all comes under the label �poli-tics,� and it can have managers reachingfor the Maalox.

One dictionary definition of politics is�competition between competing inter-est groups for power and leadership.�

But knowing the definition and find-ing practical solutions are two differentmatters.

Organization development consultantWilliam F. Moskal, EdD, will speak aboutmanaging workplace politics at the ORBusiness Management conference May12 to 14 in Albuquerque, NM.

He keynotes the conference with a talkentitled Working Through Politics in theHealth Care Setting. He will also lead a

two-part breakout session on NegotiationSkills for Business Managers.

Moskal describes his presentations asbeing long on practicality and short ontheory as he draws on 30 years of experi-ence in team building and organizationdevelopment.

A recent project was a multi-team

effort at Baptist Hospital of Miami inFlorida to improve the percentage ofpatients discharged by noon.

Moskal teaches managers, staffs, andphysicians how to get to the table quick-ly when there is a conflict�includingovercoming the excuse of �I don�t havetime��and to find a common groundfor neutralizing disputes.

Moskal estimates he spends 90% ofhis time with health care organizationsand has led seminars for the AmericanCollege of Healthcare Executives for 20years. He was corporate organizationdevelopment specialist for Detroit�sHenry Ford Health System and is nowwith IRI Consultants to Management,Detroit (www.irisolutions.com)

Moskal built a foundation for conflictresolution during Detroit�s desegregationefforts in the 1970s.

Seminars and breakoutsThe conference begins on Wednesday,

May 12, with three all-day seminars andcontinues Thursday and Friday. The con-ference includes a track on OR designand construction.

The preconference seminars are:� Working Through an OR Construc-

tion Project� Developing a Successful Bariatric

Surgery Program� Supply Chain Optimization in the OR.Among breakout topics are:� Supply Chain Management� Creating an Environment Where

Anesthesia Groups Want to Practice� Designing Effective Operating Room

Space� Efficiency vs Politics: Staffing, OR

Allocation, Day of Surgery Decisions,and Strategic Decision Making (twoparts)

� Five Characteristics of A SuccessfulPerioperative Services Department(two parts)

� Wireless Technology for InventoryControl

� Tracking Systems for OR Manage-ment

� Capturing Useful Data Through anAutomated Supply System

� Benchmarking for Improving Proces-ses. ❖

The conference brochure can be found atwww. ormanager.com. Or phone 800/442-9918.

Speaker offers tools for managing politics

5OR Manager Vol 20, No 3March 2004

Gail Avigne, RN, BA, CNORNurse managerShands Hospital at the University of Florida, Gainesville

Mark E. Bruley, EITVice president of accident & forensicinvestigation, ECRIPlymouth Meeting, Pa

Judith Canfield, RNC, MNA, MBAAssociate administrator of surgical servicesUniversity of Washington MedicalCenter, Seattle, Wash

Michele Chotkowski, RN, MSHADirector, perioperative servicesCentral DuPage Hospital/CentralDuPage HealthWinfield, Ill

DeNene G. Cofield, RN, BSN, CNORDirector of surgical servicesMedical Center EastBirmingham, Ala

Larry Creech, RN, MBA, CDTVice president, perioperative servicesClarian Health SystemIndianapolis, Ind

Cheryl Dendy, RNAdministrative director, AmbulatorySatellites, St John Hospital and MedicalCenter, Detroit

Franklin Dexter, MD, PhDAssociate professorDepartment of AnesthesiaUniversity of Iowa, Iowa City

Aileen Killen, RN, PhD, CNORDirector of nursing, perioperative servicesMemorial Sloan-Kettering Cancer CenterNew York City

Robert V. Rege, MDProfessor and chairmanDepartment of SurgeryUT Southwestern Medical CenterDallas, Tex

Marimargaret Reichert, RN, MAAdministrator, Surgical Care CenterSouthwest General Health CenterMiddleburg Heights, Ohio

Kathy E. Shaneberger, RN, MSN, CNORDirector, perioperative services andortho/neuro service lineMercy General Health PartnersMuskegon, Mich

Shelly Schwedhelm, RN, BSNDirector, perioperative servicesNebraska Health System, Omaha

Sallie Walker, RN, BA, CGRNBaptist Physicians Surgery CenterLexington, Ky

Allen WarrenBusiness manager, surgical servicesMission St Joseph�s HospitalAsheville, NC

Anny Yeung, RN, MPA, CNOR, CNAAAssistant vice president for perioperative services & associate hospital directorSUNY Downstate Medical CenterNew York City

Advisory Board

William F. Moskal, EdD

6

Please see the ad for LAWSON SOFTWAREin the OR Manager print version.

How Medicare pays for assistants-at-surgery is getting more atten-tion in Washington, DC.

The General Accounting Office(GAO) recommended in January thatCongress roll all Medicare payments forassistants into hospital inpatient pay-ments and no longer make assistant pay-ments under the physicians� fee sched-ule.

The GAO says the current paymentsystem for assistants is �flawed,� andthere are no standards or consensus onassistant qualifications to guide Medicarepayment decisions.

Congress asked for the report in 2001to assess the potential impact of autho-rizing payments to certified RN firstassistants (CRNFAs) under Medicare�sphysicians� fee schedule.

Meanwhile, in the new Medicarereform bill signed in December, Congresscalled on another advisory body, theMedicare Payment Advisory Commis-sion (MedPAC), to study whetherMedicare should pay for CRNFA ser-vices. That report is due by Jan 1, 2005.

Hospitals provide mostassistants

Though there is not good data, theGAO believes hospital employees pro-vide more than 60% of assisting for pro-cedures the American College ofSurgeons (ACS) identifies as �almostalways� needing an assistant. Theremainder is provided by various typesof professionals whose services are paidunder the physicians� fee schedule inMedicare Part B. These include physi-cians, physician assistants, nurse practi-tioners, and clinical nurse specialists.CRNFAs have been lobbying to beadded to Part B payment.

Payments for assisting by nonphysi-cians have gone up sharply�by 200%since 1997 when the Balanced BudgetAct expanded billing to advanced prac-tice nurses and said PAs did not have tobe employed by surgeons to bill forassisting. In the meantime, payments forMDs who assist have declined by 23%.

Assisting is just a small part of theMedicare budget, with Part B paymentsfor assisting amounting to less than 2%of total payments to surgeons.

Hospitals do not receive additionalpayment for providing assistants.Teaching hospitals receive extra pay-ments for training residents, who may

assist, though more are having to hirenonphysicians in the wake of the new 80-hour weekly work limit for residents.

Flaws in current paymentThe GAO found the current method

of paying for assistant services is flawedfor three reasons: � Medicare may be paying too much

for some surgical care because it doesnot deduct from the hospital paymentwhen an assistant�s services are paidunder the physicians� fee schedule.(This point is hard to understandbecause hospitals are not paid extrafor assisting.)

� Paying individuals to assist ratherthan including the payment in hospi-tal reimbursement does not give thehospital or surgeon an incentive touse assistants only when medicallynecessary.

� There is no consensus on qualifica-tions for assistants to use to distin-guish between those who are eligiblefor payment under Part B and thosewho are not. Hospitals use a gamut of profession-

als to assist�medical residents, foreignmedical graduates, RNs (whether certi-fied as first assistants or not), surgicaltechnologists (certified or not), physicianassistants, licensed practical nurses,orthopedic assistants, and so on.

There are no consensus requirementsfor assisting. Medicare has no regula-tions on assistant qualifications. No statelicenses all of the professionals whoassist. Only Texas has a specific assistant-at-surgery license, but it does not requirea license to assist. Certification programsfor assistants have various requirements.

Nor is there much evidence on thequality of care assistants provide. TheGAO could find only six articles in themedical literature as of February 2003,and none compared the quality of careprovided by one type of nonphysicianwith another.

Because consensus is lacking, theGAO says expanding the number of pro-fessionals eligible for payment as assis-tants under Part B would not ensure thatMedicare pays only those with theappropriate background.

The GAO sees some advantages forbundling assistant payments into hospi-tal reimbursement:� Hospitals would have the incentive to

use assistants only when necessary

and to use appropriately qualifiedassistants.

� Most hospitals already have a creden-tialing process for employees becauseof requirements by the JointCommission on Accreditation ofHealthcare Organizations. If Congress follows the GAO�s advice,

hospitals still would be on their own, asthey are now, to decide who is qualifiedto assist and to set up a credentialingprogram for granting clinical privilegesto assistants. With no national regula-tions or standards, hospitals have todetermine for themselves what qualifica-tions they believe are appropriate fortheir own patient population, range ofservices, and surgeon preferences.

The GAO, an arm of Congress, con-ducts analyses for lawmakers on publicpolicy issues. ❖

The GAO report is at www.gao.gov


Change assistant pay, GAO advisesFirst assistingresources

Seeking to set up a credentialingprogram for first assistants? Here areresources:American Academy ofPhysician Assistants Issue brief: Surgical physician assis-tants. www.aapa.org/gandp/surgical. htmlAmerican College ofSurgeonsStatements on principles:Qualifications of the first assistant inthe operating room.www.facs.org/fellows_info/statementsAssociation of periOperativeRegistered NursesRevised AORN statement on RN firstassistants. 2003 Standards, Recom-mended Practices, and Guidelines.Denver: AORN, 2003. www.aorn.org

Hughes S. An RN first assistant�sguide to private practice. AORN J.April 2003; 77: 748-761.Association of SurgicalTechnologistsRecommended Standards of Practice.www.ast.org

8

Please see the ad for ADVANCED STERILIZATION PRODUCTSin the OR Manager print version.


In the future, if you�re short on staff,you might be able to call on Penelope,the surgical robot, to scrub.Penelope is the first robot in the OR

that is a coworker, says her inventor,Michael R. Treat, MD, associate profes-sor of clinical surgery in the College ofPhysicians and Surgeons of ColumbiaUniversity in New York City andattending surgeon at New YorkPresbyterian Hospital.

Named for Ulysses�s wife in themythic Odyssey by Homer, Penelopewill watch over the surgeon�s instru-ments and have them ready to use.

Penelope, still in testing, has a�brain� focused on surgical instru-ments, says Dr Treat. She looks at theinstruments, counts them, knows wherethey are, and hands them to the sur-geon.

A prediction algorithm allows therobot to anticipate what the surgeonneeds.

Penelope�s role in the OR will be toscrub for small cases to free humanscrub personnel for more complexcases, Dr Treat says.

Penelope’s componentsPenelope�s control software gives

her routines for speech recognition to�listen� to the surgeon as well as�vision� to see the instruments, motioncontrol to move her arm, and speechgeneration to give her a voice.

With a lightweight robotic arm andelectromagnetic hand, Penelope unpacksinstruments from a vertical back traycomposed of stand-up cases, arrangesthem on the forward Mayo tray, andhands them to the surgeon. The hand canpick up instruments weighting up to 8ounces. It can pick up sponges with theaddition of a magnetic chip.

Penelope keeps instruments mostlikely to be needed on the Mayo tray.She monitors the progress of the opera-tion and makes predictions aboutwhich instruments will be needed next.The Mayo tray has space for 12 instru-ments, and the vertical back tray holds42 types of instruments, arranged insequence on pegs.

Penelope is voice-activated. Whenthe surgeon asks for an instrument, therobot extends her arm to a pre-set pointand waits a few seconds before releas-ing it.

�The handoff point right now is

fixed in space, which probably is notthe best way to do it, but it is an accept-able starting point,� Dr Treat notes.

Penelope views the scene through adevice like a web cam with softwarethat can tell the robot where the instru-ment is. For example, when the surgeonis done with an instrument, he or sheputs the instrument down. Scanningthe field, the robot sees the instrument,determines how far to reach, picks upthe instrument, and brings it back.

A robot that can learn At the start of a case, the circulating

nurse uses a personal digital assistant(PDA) to interface with Penelope. Thecirculator might say, �We are going todo a hernia, and it is Dr Treat�s hernia.�Penelope knows what instruments topick for a hernia case and knows DrTreat�s preferences, and she lays thoseinstruments out. The circulator drapesthe robot and covers the arm and handwith a sleeve-type drape.

Penelope has one arm at present butmay be given another later. She current-ly does not have the gripper hand thatwould be needed for laparoroscopiccases but might later on.

�The cool thing about Penelope isthat she can learn,� Dr Treat says.

Penelope�s prediction engine�artifi-cial intelligence software�listens to thesurgeon�s last few requests and predictswhat instruments will be needed next.

To develop the software, Dr Treat

hypothesized that, even though no twosurgical cases are exactly alike, caseshad enough structure to make reason-able guesses. To provide the hypothesis,he recorded cases in the OR for sixmonths. He then compiled a databaseof a couple of thousand instrumentrequests and wrote artificial intelligenceprediction algorithms.

The rate of predicting the rightinstruments improves with time. AfterPenelope works with someone for a-while, he says, it really would seem asif she could read the surgeon�s mind.

If the surgeon asks Penelope for aninstrument she doesn�t have, she coulduse her voice to ask the circulator orcommunicate with the circulator throughthe PDA.

What about emergencies?Would Penelope be able to handle

an emergency, or would a human haveto scrub in? Dr Treat says he doesn�tknow yet, but he believes she couldhandle an emergency in the future. Inthe next level of software development,he plans to give her �a sense of what todo when stuff hits the fan.�

Because of the robot�s design, thesurgeon can reach over and take whathe or she wants quickly.

Penelope will have an uninterrupt-ible battery power supply like a com-puter in case the electricity goes off so

Penelope, the robot, could scrub in

Penelope, the surgical robot, hands an instrument to her inventor, Michael Treat, MD.


12%, and its vacancy rate is 7.3%.Bronson has 350 beds and 8 inpatientand 9 outpatient ORs.

Commitment to employees is strongfrom the board of directors on down.

�We really do believe in employeeinput. We have found that the peoplebest qualified to tell us how to do thingsare the people who are actually doingthose things,� says Susan Ulshafer,senior vice president of human resourcesand organizational development.

Noting that �employees don�t leaveorganizations; they leave managers andleaders,� she says Bronson emphasizesleadership development, ensuring itsleaders have skills and abilities neces-sary to retain a quality workforce.

�In effect, our leaders are our reten-tion officers,� says Ulshafer. �And ouremployees are our best recruiters�21%of our new hires come through ouremployee referral program.�

Bronson holds CEO and CNO officehours when employees can come andgive their suggestions. During thesetimes, the offices are always full.

�What is nice,� notes Katie Harrelson,RN, Bronson�s vice president/chief nurseexecutive, �is that most often employees

come with very positive suggestions forsolutions to issues they really have iden-tified in their work environment.�

One example of an employee solu-tion is that the OR staff do their ownscheduling, comments Holly Wohlfert,RN, nursing manager of central pro-cessing and former OR manager.

On their own, the OR staff decidedto reward their peers for longevity bygiving them the option of not workingweekends or holidays after they havebeen there 20 years.

A hand in the process �It is not enough to tell employees

you are listening to them; employeeshave to be able to see that you use theirinput,� says Ulshafer.

Bronson has developed a sign shapedlike a hand to label projects that are aresult of staff input. The sign signifies,�You have a hand in the process.� Whenemployees see the sign on any communi-cation, they know it is the result of anemployee suggestion.

Bronson has made a big commitmentto furthering employee education. Anemployee focus group told the adminis-tration that employees wanted tuitionpaid up front, and that was done.Because of this, there has been a dramat-ic increase in the number of employeesgoing to school. Bronson�s managers goto great effort to arrange an employee�swork schedule around classes.

�If an employee needs to leave at 1pm for a class but can come back at 7pm, we will split their shift,� saysWohlfert.

Bronson administrators like todelight and surprise their employeesand share rewards.

For example, to reward employeesfor the Fortune honor, administratorsgave each of them a prepaid Visa cardto spend as they wanted.

Another program Ulshafer says hasbeen �wildly successful� is providingemployees with concierge services.

�We know how tough it is to achievethat work-life balance,� she says. Theservice will deliver and pick up drycleaning, take cars to be serviced, dopersonal shopping, and run errands.The only thing the service won�t do istransport kids or pets.

Compensation is keyCompensation is crucial to recruit-

ment and retention, says Kathy Sydow,RN, MSN, administrator of periopera-tive, anesthesia, and ambulatorysurgery divisions at Memorial Health inSavannah, Ga. Compensation is onepoint that made Memorial stand out inthe Fortune ratings. Hospital workersserving in Iraq receive full salary whileoverseas. And everyone gets a bonuscheck at the end of the year.

�People work for money. They arenot here just because they want to helpout,� says Sydow. �If employees feellike they are compensated at the ratethey should be, you have cleared yourfirst hurdle.

�Then your only other hurdle is tomake them feel like they can do a goodjob when they are here. Nurses willleave when they don�t feel like they areable to do a good job.�

The OR staff have a lot of fun, saysSydow. The OR manager has a goodsense of humor and always has a jokegoing on. Plus, she supports the nurs-ing staff and is not afraid to confrontsurgeons, she adds.

To enable staff to live where theywant, the OR has set up a call room fornurses and surgical technologists with abed and TV so they can stay over ifthey don�t live within 30 minutes of thehospital.

The OR stays well staffed through itsOR nurse residency program.

�Nurses very rarely come to the ORwith experience, so we train them,�

10 OR Manager Vol 20, No 3 March 2004


Continued from page 1

Health careorganizations on Fortune list21. Bronson Healthcare,

Kalamazoo, Michwww.bronsonhealth.com

26. Griffin Hospital, Derby, Connwww.griffinhealth.org

35. Mayo Clinic, Rochester, Minnwww.Mayoclinic.com

37. VHA, Irving, Texwww.vha.com

43. Baptist Health Care, Pensacola,Flawww.ebaptisthealthcare.org

51. Baptist Health South Florida,Coral Gables, Flawww.baptisthealth.net

54. Memorial Health, Savannah, Gawww.memorialhealth.com

60. St Luke�s Episcopal Health,Houston, Texwww.stlukestexas.com

Fortune is a registered trademark of Fortunemagazine, a division of Time Inc.

says Sydow. The program lasts from 6to 8 months.

Sydow budgets 12 FTEs a year forthis program, which has a retention rateof 65%. Currently, there are no staffopenings for the department. The ORhas 114 FTEs for its 21 main ORs, sepa-rate urology and GI areas, and a two-room ambulatory surgery center.

Another addition to the OR is a peri-operative nurse safety officer who isdedicated to patient safety issues. Sheoversees surgical site marking, lasersafety, latex allergy, and other issuesthat can affect an entire division.

Cared-for employees give good care

Leaders at St Luke�s EpiscopalHealth System in Houston believe well-cared-for employees make the bestcaregivers. The hospital system�sAcademy for Human Potential offersseminars on topics from career manage-ment to dealing with stress.

�It is not our building or the mortaror the bricks we hold out�it is ouremployees. That is who makes the dif-ference,� says Darlena Stevens, RN,MSN, CNOR, vice president of periop-

erative services and woman�s services. The best way to show employees

they are cared for is recognition fromtheir immediate supervisors, saysStevens. That doesn�t mean holding ameeting to say thanks for a hard day�swork. It means singling out specificpeople to tell them you noticed the waythey held a patient�s hand, interactedwith a physician, or solved a problem.

�You can�t just go out and saythanks everybody, here is a gift, and seeyou next year. You have to know whatyour employees are doing and respondto the positive things they are doing,�says Stevens. St Luke�s sets an expecta-tion for great leaders, she adds. The

organization seeks out good leadersand grooms them through a mentoringprogram and other means.

The OR management team has mini-mal turnover. Stevens says she has nothired a new manager for the OR forthree years, and most managers havebeen there 10 to 25 years. Presently, thehospital�s turnover rate for RNs is 13%,and the vacancy rate is 4%.

Stevens finds one of the best recruit-ment tools is nurturing students.Students from four baccalaureate pro-grams gain clinical experience in themedical center. If a student works witha nurse who does not treat the studentwell, that reflects on the whole hospital,Stevens notes. But if students workwith nurses and managers who helpguide them and teach them, they devel-op a positive feeling and are more like-ly to want to work at St Luke�s aftergraduation. ❖

�Judith M. Mathias, RN, MA

The 100 Best Companies to Work for arti-cle was in the Jan 12 issue of Fortune maga-zine. If you think your organization shouldbe on the list, send a brief explanation of whyto [email protected]



she does not forget what instrumentsshe is handling and where they are.

Because the robot would be labeledfor use in cases that can be done with aminor instrument tray, such as a lipomaexcision, emergencies would be rare.

Entering the marketPenelope is about nine months away

from use in the clinical setting, Dr Treatestimates. He anticipates review underthe Food and Drug Administration�s510(k) process.

�I think we can fill a need and savehospitals money,� he says. Penelopeshould be able to work for under $7 anhour. She will cost about $100,000 andshould last five years with softwareupgrades. And she will take call.

Dr Treat predicts there also will berobotic first assistants and eventuallyrobotic surgeons.

The military is especially interestedin the robots and is funding Dr Treat�sresearch through the Advanced Tech-nology Research Center of the U S

Army. He also receives funding fromthe New York State Office of Science,Technology, and Academic Researchand Telemedicine. Support has alsobeen received from the National ScienceFoundation. ❖

More information on Penelope is atwww.roboticsurgicaltech.com


“

“In effect, our leaders areour retention

officers.

Check our web site for practical help on personnel

evaluation, codes of conduct,and patient assessment.

Go to: www.ormanager.com

Look under The OR Manager’sToolbox.

OR Manager’s Toolbox

AONE policy statements onovertime, ratios, foreign RNs

Mandatory overtime should be thelast resort, limited to staffing crises thatwould put patients in danger of notreceiving basic requirements of safecare, the American Organization ofNurse Executives said in a policy state-ment released Feb 10.

AONE also adopted statements onmandated staffing ratios and foreignnurse recruitment. AONE says it doesnot support mandated ratios becausestaffing is complex, and ratios� �one-size-fits-all� approach cannot guaranteesafety or quality. ❖

�www.aone.org

12

Please see the ad for OLYMPUS ENDOSCOPYin the OR Manager print version.



services leaders are likely to find them-selves on a team for building orexpanding their surgical facilities, ifthey aren�t already.

Planners and designers say leaderscan expect to see the trends towardmore customer-friendly facilities,advanced technology, and data man-agement reflected in their plans for newfacilities.

Greater outpatient focusAnthony Roesch, AIA, a health facili-

ty planner with Boldt ConsultingServices, Chicago, says one trend amonghis clients is to consolidate surgery backto the hospital campus. Physicians find ittoo time-consuming to operate at multi-ple sites, he says. Plus, as hospital sys-tems in some areas have expanded andcornered the market, they see less needto build ambulatory surgery centers inoutlying areas unless they need to joint

venture with physicians. �A lot of the work being done is to

expand or change the ambulatory com-ponent,� he notes. �Hospitals tradition-ally have been designed for the highest-acuity patients, which are now 10% oftheir volume. Today, 90% of theirpatients are awake and alert and have ahigh level of mobility.�

Roesch is advising clients to allowfour times the square footage in theirpreoperative and recovery areas thatthey would have in the past. Not onlyare there more outpatients, but caselength is going down, meaning thereare more patients to care for in a shorteramount of time.

One of his clients, 200-bed West AllisMemorial Hospital near Milwaukee isadopting a customer-focused model,similar to its new women�s center, forits OR replacement project.

�They want to �brand� it for its dig-nity, privacy, and a patient-friendlyenvironment,� Roesch says. The ORs,preoperative, and recovery areas will beon the first floor where patients canwalk in from the parking area. Patientswill be cared for preoperatively andpostoperatively in hotel-like privaterooms. Some rooms could also be usedfor overnight stays, like a recovery care

center, instead of patients being trans-ferred to a med-surg unit.

Patient privacy is a big priority, notonly because of federal privacy regula-tions but also for patient satisfaction,notes Jane Stuckey, RN, of Freeman-White architects, Charlotte, NC. �Oneexecutive told me, �I want every patienttreatment area to have four walls and adoor,� and I think patients will demandit,� she says.

Big technology demands Larger ORs, pipelines for data, and

blurred lines between surgery andinterventional radiology are major fac-tors in the planning for operatingrooms.

Roesch finds high capital costs ofsurgical technology are another reason,in addition to time, that surgeons are�more amenable to coming back to thehospital� rather than building theirown facilities.

Strategically, he finds more hospitalsare positioning themselves as �centersof excellence� for surgery, an evolutionof the concept of centers of excellencefor obstetrics and cardiac care seen inprevious years.

�With the evolving technology and

Design trends forsurgical facilitiesOutpatient focus

Hospitals are seeking to make theoutpatient experience more conve-nient, comfortable, and user friendlyfor patients and family members.Amenities include close-in parking,valet services, and convenient accessto registration and clinical services.

Family friendlyFacilities include more space for

families to wait and be involved withthe patient. There are comfortablewaiting areas with refreshments andbusiness centers.

PrivacyPrivate rooms help protect patient

confidentiality and are better forinfection control.

SecurityHospitals are more aware of the

need for security for patients andtheir own operations.

High-tech ORsOperating rooms are larger.

Articulating arms keep equipmentavailable and off the floor. They havebuilt-in capability for managing mul-tiple data streams.



01994 1995 1996 1997 1998 1999 2000 2001 2002 2003

2

4

6

8

10

Hospital construction value(in billions)

Source: McGraw-Hill Construction.


capital expense�$1 million to $2 mil-lion per OR�you had better think ofyourself as a center of excellence,� headds.

A blurring of linesAs surgery uses more imaging, and

imaging becomes more interventional,some planners see a blurring of thelines between surgery and radiology.

�I believe the OR of the future isgoing to be more like the cath lab,� BillRostenberg, an architect with the SanFrancisco office of the architecturalfirm, the SmithGroup, told OR Manager.

With their similar needs for technol-ogy, patient flow, air handling, and pre-and postprocedure care, surgery andinterventional radiology have a lot incommon. He thinks more collaborationwould help reduce redundancies andconserve on staffing.

A big barrier, of course, is politics.Surgeons and interventional radiolo-gists have their own identities, as domanagers and staffs. They also have

their own professional guidelines forpractices such as infection control. ButRostenberg thinks they need to lookbeyond their differences so technologycan be used more cost-effectively.Writing in the Dec 1 Modern Healthcare,he urges leaders to set aside their turfbattles and develop more cooperativeapproaches.

How big should ORs be?New inpatient ORs at Barnes-Jewish

Hospital in St Louis will have 600 to650 sq ft as the norm. The new surgicalsuite, with 48 ORs and related services,is being built in two phases, with thefirst phase to be completed in 2005 andthe second in 2007.

�With rooms that are any larger, youprobably reach a point of diminishingreturns,� says Tom VanLandingham,architect with the firm of Christner Inc,St Louis, who is working on the project.

FreemanWhite also is seeing larger600-sq-ft ORs in its new projects. �They�re needed today for orthopedic andcardiovascular surgery, but mainly for thefuture,� Stuckey says. �And they have to

be flexible. You just don�t get an opportu-nity to build new ORs that often.�

The current Guidelines for Design andConstruction of Hospital and Health CareFacilities (American Institute of Archi-tects, 2001) call for a minimum of 600 sqft for ORs for cardiovascular, orthope-dic, neurological, and other specialtiesusing additional personnel and/orlarge equipment. The minimum is 400sq ft for general ORs, which some plan-ners now consider small.

At least as important as room size isthe planning for the space immediatelyaround the OR table, says VanLanding-ham. The Barnes-Jewish team is using ahuman factors approach, looking atother compact, high-tech work settingslike airplane cockpits and submarinesfor ideas. They also are adopting theclean-room ceiling concept from thesemiconductor industry, which allowsceilings to be accessed for upgrades.

Ceiling-mounted arms will keepequipment accessible and off the floor.A grid will be built into the ceiling withstructural support to allow booms to belocated around the OR table.



New ORs and preop area in the University of Washington�sPavilion Surgery Center are decorated in soft colors.

An OR and the waiting area in the Outpatient Care Center atMartha Jefferson Hospital in Charlottesville, Va. CourtesyFreemanWhite Healthcare.

�The infrastructure we have designedshould allow the hospital also to relocatelights and booms without requiring a�construction project,�� VanLandinghamsays.

To set the stage for technology plan-ning, the Barnes-Jewish team held aroundtable with hospital executives,surgeons, and key staff. Technologyvendors were invited to present theirvision of the future, an idea that waswell received, says Diane Desmond,RN, BA, perioperative construction pro-ject manager. After the roundtable, theteam decided that rather than buyingan integrated OR package from any onecompany, they would develop theirapproach.

Rivers of data�The data communication piece for

the ORs is huge,� Desmond says.�Everyone wants data at their finger-tips�like a �clinical desktop� in theOR.�

To keep track of all of the datasources that need to be accessible in theORs, she started a list�and the list keptgrowing. She now has a spreadsheetidentifying 52 data sources. A fewexamples are video equipment forlaparoscopic and orthopedics, the pic-ture archive and communication sys-tem (PACS, or digital radiology), videoconferencing for teaching purposes,and the nurse call system. The spread-sheet is a valuable tool for architectsand engineers as they plan the space.

After surgery, the emphasis is on pri-vacy, comfort, and family involvement.With faster recovery from anesthetics,Stuckey is seeing a lot of surgicalpatients�up to 50%�bypassing PhaseI postanesthesia care units, which aregetting smaller.

At the University of Washington�snew Pavilion Surgery Center in Seattle,which opened in November, the post-operative area has a wide hallway withnurses� stations in the middle so nursescan see the patients easily, says RenaeBurchiel Battié, RN, MN, CNOR, ambu-latory surgery nurse manager, who alsowas clinical coordinator for the pavil-ion�s design and construction.

The hallway is painted a soft yellow-beige, and patient rooms have threesides with curtains. There is room forfamilies, who can be with the patientsduring their postoperative recovery.

The pavilion incorporates windowsthroughout, including at the end of theOR hallways, which contributes to asense of calm and spaciousness, Battiésays.

Overhead paging is minimized. Manyof the staff have text pagers. Some staffmembers are provided with wirelessphones (not cell phones) that operate offof a hospital antenna, allowing them tobe mobile and easily reachable.

The project team made an effort tocontrol clutter. OR hallways havealcoves where stretchers can be tuckedaway. Nurses� stations are designed tohide supplies and paperwork. ❖

�Pat Patterson

Coming issues will profile new surgicalfacilities.



A track at the OR Business Manage-ment Conference May 12 to 14 inAlbuquerque, NM, is intended specifi-cally for those who are involved in thedesign and construction of new surgicalfacilities.

Preconference seminarPlanning and overseeing construc-

tion of new ORs is a huge job withmany people and details. At an all-dayseminar on Wednesday, May 12, enti-tled Working Through an ORConstruction Project, veterans of thisdemanding process will share usefulstrategies for managing a project frombeginning to end, including the topten things that can go wrong.

Breakout sessionsFive sessions on Thursday and

Friday, May 13 and 14, focus on:� Planning and Building a

Central Processing Area. Anurse CPD manager and plan-ner explain the process fordeveloping a department toserve 16 new ORs, includingorthopedics and neurosurgery.

� Designing Effective OperatingRoom Space. A nurse managerand architect planning a new 48-room surgical suite in an acade-mic medical center discussissues including advanced tech-

nology, IT integration, ergonom-ics, and cost management.

� Planning and Designing anAmbulatory Surgery Center.Two experts in ambulatorysurgery center developmentaddress approaches to designingand building a surgery center,whether freestanding or a sepa-rate unit of a hospital.

� Retrofitting an Existing OR forNew Technology. A technologyconsultant and nurse providetake-home ideas for bringingORs into the high-tech world,covering the planning process aswell as living through the con-struction.

� Did We Get Everything Rightthe First Time? In a video tour,the nurse manager who partici-pated in the design and con-struction of a teaching hospital�snew ambulatory surgery pavil-ion conducts a video tour of thework areas. She will share whathas worked well and what theteam might change if givenanother opportunity.

For a conference brochure, visit www.ormanager.com. Or phone 800/442-9918.

OR design and construction track atOR Business Management conference

Doctors, nurses trusted,online poll finds

More than nine out of 10 Americanstrust their nurses and doctors to do theright thing for their health care, accord-ing to a recent online Wall Street Jour-nal/Harris Interactive poll. Hospitalsweren�t far behind, trusted by 85%.

Lagging were managed care andinsurance companies, with only 41% and38% of respondents trusting them in thepoll results published in the Jan 27 WallStreet Journal. ❖

Check our web site for the latest news, meetingannouncements, and other

practical help. www.ormanager.com

16

Please see the ad for DUPONTin the OR Manager print version.


An elevator door opens and atechnician in the sterile process-ing department (SPD) at

HealthEast St. Joseph�s Hospital pushesa case cart filled with soiled surgicalinstrument sets into the decontamina-tion room.

Locating bar code labels attached tothe side of each set, a technician wavesa scanner across the label. The scanenters real-time data into specializedsoftware loaded in a desktop computerwhere it is time-stamped with the newlocation and the name of the technician.

In order of the SPD�s assembly-linetype process, instrument sets arewashed, inspected, assembled, andthen sterilized. Technicians can viewspecial instructions for handling sets.The information is displayed on com-puter screens, where technicians cancompare instruments listed for the setwith the ones in the tray. Techniciansnote any missing or damaged instru-ments.

Once wrapped and labeled, the setsare stored until they are needed in theoperating room, emergency depart-ment, or elsewhere.

To Mike Festa, director of sterile pro-cessing with the HealthEast CareSystem, St Paul, Minn, installing aninstrument tracking system (ITS) lastyear at each of the organization�s threehospitals and two surgery centers was acrucial step toward his goal of increas-ing department productivity and effi-ciency. Within the year, Festa believes,the ITS also will help him reduce costs,standardize sets, and improve quality.

But to garner the approximate$200,000 to purchase the software andcomputer equipment, he had to con-vince administrators of its worththrough a request-for-proposal process.

�Up until a few years ago, SPD wasviewed as a basement-level (process-ing) department not at the forefront ofadministrators� minds,� says Festa.�Now (with the emphasis on cost con-tainment and quality improvement andan ITS) it is seen as an integral part ofthe hospital.�

HealthEast�s ITS also had anotherimportant effect: improving employeemorale. �Employees are excited aboutusing the system,� Festa says. �They

feel like they are a more important partof the hospital team now.�

Growth predictedExperts estimate only 5% to 20% of

hospitals have installed instrumenttracking systems. In interviews withseveral ITS vendors and hospital users,most predict steady growth and a posi-tive return on investment.

�It will become the standard way ofdoing things within the hospital in afew years,� says Bonnie Court, seniormanager of sales and marketing forMcGaw Park, Ill-based CardinalHealth�s Impress ITS.

But experts say less than 25% of hos-pitals with instrument tracking systemshave implemented all components,including productivity improvement,quality assurance, sterilization monitor-ing, and staff accountability modules.

�Most people take (installation)slowly,� Court says. �It can take six tonine months to get the system up andrunning and maybe up to a year for fullimplementation where they are runningreports.�

Cost savings and quality improve-ments can accrue through data trackingand process changes, Court says.Impress, for example, provides morethan 70 reports.

Better management decisionsAt HealthEast, which uses Sterile

Processing Microsystem (SPM) fromMaterials Management Microsystems,Mequon, Wis, Festa says data generatedfrom the process will enable him tomake better management decisions.

�We are in essence a manufacturingprocess. Without data, we are planningand scheduling based on our percep-

tions,� says Festa. �Data can tell me if Ineed fewer or more FTEs. We can uti-lize our employees more effectively,and this can lower our costs andimprove quality.�

Festa says he eventually wants totrack instrument sets to individualpatients. �If a patient acquires a nosoco-mial infection, the data will enable us toconsider or rule out the sterile process-

Reports frominstrumenttracking systems

Gathering data from surgicalinstrument tracking systems is thekey to improving quality, productivi-ty, and reducing costs.

Here are a few types of reportstracking systems can produce:

� Productivity. Shows the time ittakes for each employee toassemble instrument sets andcan be used in employee evalu-ations and training.

� Usage. Can track how manytimes instruments are used todetermine if there are enoughinstruments to meet demand.

� Inventory transfer. Candemonstrate where operationalslowdowns occur.

� Refurbishment. Shows repairand maintenance schedules.

� Set comparison. Can identifysets and help in the efforttoward standardization.

� Sterilization. Allows staff totrack instruments by steriliza-tion load.

� Inventory management. Showscontents of each tray, date oflast repair, and refurbishmentor sharpening. Also shows whoprocessed the set, the length oftime it took, and such problemsas missing or damaged instru-ments.

�Jay Greene

Source: Interviews with ITS officialsand company documents.

Sterile reprocessing


“

“We have fewer calls

from the ORand doctors.

Gaining efficiency with instrument tracking

18

Please see the ad for KARL STORZ ENDOSCOPY-AMERICAin the OR Manager print version.

Stop by and see us at the AORN Meeting Booth #1525.

KENDALL: STRIP IN THE FOLLOWING TEXT LINE AT THE BOTTOMOF EXISTING AD. (OK TO SCALE UP OR DOWN TO FIT.)



AesculapCenter Valley, PaInstacount PLUSIntegrated software solution for instru-ment management and sterile goods.800/282-9000www.aesculap-usa.com

Cardinal Health McGaw Park, IllIMPRESSInstrument management software withbar code technology.1-800-SCOPE-1-2 (726-7312) www.cardinal.com/mps/servicesolution/EMS/ems.asp

Censis TechnologiesFranklin, TennCensitrac SystemIndividual-instrument tracking systemwith CensiDot label technology.888/877-3010615/468-8002www.censis.net

GetingeRochester, NYT-DOCEquipment tracking and asset manage-ment system.800/475-9040www.t-doc.com

JaritHawthorne, NYCIMS2Automated instrument tray manage-ment system.800/431-1123www.jarit.com

Key Surgical IncEden Prairie, MinnInfoDotIndividual-instrument tracking tech-nology with laser-engraved InfoDotlabels.800/541-7995www.keysurgical.com

Lawson SoftwareSt Paul, MinnApexion TechnologiesSurgical instrument tracking function-ality and a scalable mobile platformusing Windows CE operating system.800/477-1357 651/767-7000www.lawson.com

Materials ManagementMicrosystemsMequon, WisSterile Processing Microsystem (SPM)Software program for tracking surgicalinstruments and measuring data usingMicrosoft Access and Microsoft SQLserver version.262/240-9900www.mmmicrosystems.com

Rosebud SolutionsAnn Arbor, MichTray ControllerAutomated tracking for surgical traysand other components.888/980-8255www.rosebudsolutions.com

Specialty Medical SystemsKansas City, MoABACUS Instrument ResourceManagerBar-code based surgical instrument settracking system.800/945-4767www.spmedsys.com

Teleflex MedicalPilling SurgicalResearch Triangle Park, NCTrakkerPRO Bar Code Tracking SystemA system to locate instruments, sets, orequipment during the processing cycle.800/732-8302 ext 6646www.pillingsurgical.com. Look underHospital Solutions.

TerraGraphiX IncCarmel, Ind Alex Gold SoftwareTracks the location and status of surgi-cal instruments.800/732-1070www.terragraphix.com

Total Repair ExpressHillsborough, NJSaphyre Automated InstrumentTrackingNew software includes bar-code traylabeling system, computer-generatedcount sheets, and individual instru-ment tracking with InfoDot.888/926-8863www.epower-inc.com/etek/Saphyre/SaphyreMain.htmorwww.totalrepairexpress.com

Vertical Systems IncEden Prairie, MinnInformation Systems SolutionsInstrument tracking software withradiofrequency handheld scannerswith a WAN-based server applicationand interfaced to surgery schedulers.952/934-7533www.vertsys.com

We have attempted to provide a completelist. If any vendor has been omitted, weapologize.

Vendors of instrument management technology

ing element,� he says.There are a variety of tracking sys-

tems sold by surgical instrument manu-facturers, software companies, andother vendors. (See directory.)

Up-front costs can run between$30,000 for small hospitals and $300,000for larger facilities, according toexperts. Initial costs depend on the

number of modules and types of scan-ners, servers, and workstations needed.

But costs of the system can quicklybe recovered in increased productivityand instrument inventory savings, saysEd Becker, president of MaterialsManagement Microsystems, whichdeveloped SPM in 1991.

�We guarantee hospitals can savemoney,� says Becker. �In a hospitaldoing 10,000 procedures a year, you can

expect to find one-time savings of$100,000 from improved instrumentinventory management.�

For example, Becker says reportsmight show a hospital owns 12 majorinstrument sets when it only uses nineper day. �You disassemble those sets,each containing perhaps $3,000 worthof instruments, and you can use them



20

Please see the ad for TRUMPF MEDICAL INCin the OR Manager print version.



as backups rather than buying newinstruments,� he says.

William Beaumont Hospital, RoyalOak, Mich, has been using SPM since2000 to track 3,365 instrument sets, saysSusan Nielsen, RN, MSA, CNOR, cen-tral service administrator. She says thehospital already has recouped the sys-tem�s $84,000 initial cost.

�We used to go up and down thehalls looking for instruments,� Nielsensays. �I won�t say the system has curedour problem of lost instruments, but ithas really helped us save time.�

Standardizing in a systemTracking instrument sets is an even

more challenging task for FairviewHealth System, a seven-hospital healthcare organization in Minneapolis. In1994, Fairview became the nation�s firsthealth care organization to create a cen-tralized SPD for the system. During thepast year, Fairview upgraded its ITS,which was developed by Vertical

Systems of Eden Prairie, Minn, to helpmanage its 1,800 standardized, site-spe-cific and doctor-preferred instrumentsets in its eight surgery sites.

�We centrally perform decontamina-tion and assembly for about 70,000 sur-gical cases per year,� says RichardHuntley, director of Fairview�s centralprocessing center. In the center,attached to Fairview UniversityMedical Center, 60 SPD staff membersprocess more than 122,000 sets and 1million line items of individual instru-ments each year.

�We started out (in 1994) with morethan 500 different instrument sets,�Huntley says. �Through standardiza-tion we dropped that to about 100 setsin two years. We saved about $1 milliona year (in instrument replacement costs)for the first five years. We didn�t haveto buy instruments because we couldtrack them and manage them better.�

Huntley says Fairview also saves onstaffing. �Because we know what we needfor tomorrow, based on the volumes, wecan adjust our staffing,� he says.

Aside from cost savings and produc-tivity improvements, Fairview�s track-ing system has improved the ability ofstaff to locate instrument sets.

�If someone feels a case cart wasn�tshipped to them, the system enables usto look into the computer and showthem when it was shipped,� Huntleysays. �Anyone who has access to a com-puter can determine the status of anorder. We couldn�t do that at so manysites without a tracking system.�

But the biggest challenge was stan-dardizing instrument sets. �It tookabout three years and about 40 peopleworking with each surgery specialty tostandardize,� Huntley says.

Tracking individualinstruments

Last year, the Cleveland Clinic,which has used SPM since 1996, begana pilot program to test tracking of indi-vidual instruments, says RichardSchule, BS, CST, CRCST, CHMMC, FEL,manager of surgical processing.

With use of technology developedby Key Surgical, Eden Prairie, Minn,InfoDot bar codes were attached to sev-eral hundred specialty instruments sothey can be tracked.

InfoDots are small, round laser-printed labels that are applied directlyto instruments.

�This reduces (theft or misplace-ment) for these expensive instruments.(It also) offsets the need for some tech-nicians to know all the instrumentsbecause you scan the item, a label isprinted out, and you don�t have tothumb through a book or look at a digi-tal photo to see what it is,� Schule says.

While only a small number of hospi-tals track individual instruments, exec-utives at Key Surgical and CensisTechnologies of Franklin, Tenn, predictthose numbers will steadily increase.Censis also uses a small, round, two-dimensional bar code known as aCensiDot on each instrument.

These labeling systems are a newalternative to laser etching of instru-ments, which is more expensive andrequires a laser operator to mark instru-ments.

Should you track individualinstruments?

Peter Huck, general manager at Key


Selecting the right instrumenttracking system is most effectivewhen a hospital knows what it wants.

A request-for-proposal (RFP)process can help a hospital bothunderstand its own unique require-ments and give prospective vendorsan opportunity to show how theirproduct differs from the pack.

Vendors say RFPs are becomingincreasingly common. But RFPsaren�t always carefully prepared orspecific enough to allow for a goodcomparison. In many cases, RFPs areprepared by purchasing departmentsthat don�t understand sterile process-ing.

CS managers noted that sometracking systems don�t allow reportsto be customized to the specific needsof the hospital.

Jon Wood, sales manager withVertical Systems, Eden Prairie, Minn,says the type of database is veryimportant to know when purchasinga system.

�You want a (Microsoft SQL) serverdatabase,� Wood says. �Some compa-nies are pushing Access databases,

but that can hamstring hospitals.Access isn�t designed for multiusers.You are not able to integrate withbilling or scheduling. Enterprise-based systems are much better.�

Wood also suggests including inthe RFP whether the company hasknowledge in wireless networks andhandheld devices.

Some other important questions toask:

� What is the scope of trainingand support not only duringimplementation but also beforeand after?

� How many days are spent intraining? Are trainersemployed by the company, orare they under contract?

� If a decision is made to discon-tinue the product, and the ven-dor owns the hardware, can thehospital keep the database?

� What is the initial system cost?What is the annual mainte-nance cost?

� Are upgrades free, or underwhat circumstances do theycost extra?

Do homework before sending RFP



Surgical, says SPD managers should con-sider four criteria when deciding if theyshould track instruments individually:� Are instruments loaned in or out of

the hospital? � Do they have high-cost instruments? � Do they want to track instruments

for preventive maintenance? � Do they want individual pictures of

the instruments linked with theircurrent software system? Schulesays the InfoDot technology is com-patible with the clinic�s SPM soft-ware. InfoDot costs 45 to 60 centsper instrument.Huck says most software companies

are adding modules that allow InfoDot-labeled instruments to be scanned intothe system.

Standard instrument tracking sys-tems use a one-dimensional bar codescanner. Reading InfoDot requires atwo-dimensional bar code imager (usu-ally two at $600 to $800 each).

An aid for specialtyinstruments

Schule says specialty instrumentsare located in each of the clinic�s 13 ser-vices. �If a physician wants one, every-body has to drop what they are doingand look for it,� he says. �With barcodes, you go into the history, and thedatabase tells you where to locate it.This can be a difference of 25 minutesmultiplied by the number of FTEs look-ing for the device, and huge savings areachieved.�

Moreover, each of the clinic�s 9,000instrument sets is scanned into SPM atsix key points in the reprocessing anddelivery process. With the clinic�s 59 ORsand 36,000 annual procedures a year,Schule says tracking instruments is nowa critical part of the surgical process.

Reports aid productivity SPD technicians can be individually

tracked to determine how well theyperform their tasks as compared to hos-pital-specific benchmark times.

�Hospitals can use the productivityreports in the annual employee evalua-tion process,� Becker says. �An averagetechnician should achieve 100% pro-ductivity. The best technicians mightwork at 130% to 140%.�

Reports also can help SPD employ-

ees identify quality breakdowns.�The system allows us to print out a

list of instruments in the sterilizer. If wehave a biological indicator that is posi-tive, we can identify what was in theload,� Nielsen says. �If there is a prob-lem with the sterilizer�it didn�t meetthe parameters for time, pressure�youknow that fairly soon, within twohours, and you can take action.�

Hospitals also use ITS to reduce lossof surgical instruments, says Becker. �Ihave heard some hospitals spend$200,000 to $300,000 a year to replacelost or damaged instruments.�

Cardinal�s Court estimates trackingsystems can reduce hospital instrumentreplacement budgets by 20% to 30%.�They are not purchasing instrumentsthey don�t need because Impress allowsthem to track sets and items,� she says.�They can use reports to compare setsand start to standardize, which canreduce the number of sets.�

Looking to the future The future of ITS will be through the

greater use of wireless personal digitalassistants (PDAs) and integrating track-ing software with surgical schedulingand billing, says Jon Wood, sales man-ager with Vertical Systems.

�(Instrument manufacturers) arelooking at placing radiofrequency IDsinside specialty instruments,� Woodsays. �Twenty percent of the industrywill go to individualized bar codes inthe next two years. Once hospitals startto identify where they are spendingmoney, they will look more closely atcentralizing processing.� ❖

�Jay Greene

Jay Greene is a freelance writer in StPaul, Minn.


Continued from page 21 OR Benchmarks to conduct fourprocedure studies

In 2004, OR Benchmarks will con-duct surgical procedure studies on fourprocedures: � hernia repair (open and closed)� anterior cruciate ligament (ACL)

repair� carotid endarterectomy� lumbar laminectomy (with and

without hardware).OR Benchmarks surgical procedure

studies compare costs among facilities,showing how costs, staffing, and casetimes compare. The reports identifyareas for improvement for each facility.

Surgical procedure studies includedirect costs for supplies, labor, andanesthesia. Time comparisons includepatient preparation, preinduction, pro-cedure, and turnover times.

For more information on the 2004program including the schedule, regis-tration, and fees, visit www.orbench-marks.com or call Judy Dahle, RN, MS,director, at 877/877-4031 or e-mail herat [email protected]. ❖

“

“We can utilize our

employees moreeffectively.

Hospital noise approaches chain-saw levels

Hospital din can be so loud at nightthat it approaches the levels of chainsaws or jackhammers, making it nearlyimpossible for patients to sleep, accord-ing to a new study from the MayoClinic.

Nurses found steps as simple as clos-ing the door to a patient�s room and sti-fling the clatter of clipboards can help.

Peak noise readings were 113 deci-bels, usually around the shift change at7 am. The average noise level was 45decibels. A chain saw can produce 120decibels.

Authors Cheryl Cmiel, RN, andDawn Gasser, RN, slept overnight in aroom set up with equipment usuallyfound on a thoracic unit. Gasser wasawakened at 1:15 am by an IV pumpalarm and at 3:15 am by a portable x-raymachine rolling into the room. Thestudy was in the February AJN.❖


Part 1 of a two-part series on perfor-mance improvement in perioperative ser-vices by Patrice Spath.

Quality in health care servicesmeans doing the right thing, thefirst time, in the right way, and

at the right time. To be a model of excellence, perioper-

ative caregivers must commit themselvesto delivering services of the highest qual-ity by emphasizing continuous improve-ment of processes, communication,teamwork, and measurable results. Thisgoal is complex and requires new waysof thinking and new skills.

To be successful, perioperative ser-vices needs a planned, systematicapproach that supports departmentalexcellence.

The recently revised Quality andPerformance Improvement Standardsfor Perioperative Nursing from theAssociation of periOperative RegisteredNurses (AORN) serve as a good start-ing point for developing a worthwhileperformance improvement initiative.

This two-part article builds on theAORN standards by providing practi-cal guidance for achieving and main-taining excellence as the focus of peri-operative services.

Key elements of improvementThree key elements are necessary for

improving the quality of perioperativeservices: � an understanding of how to mini-

mize the �human� factors that affectthe quality and safety of periopera-tive systems of care

� application of methods to measureand analyze performance

� continuous improvement of periop-erative services by acting on perfor-mance information. Part 1 of this series addresses the first

two elements. Continuous improvementis covered in Part 2.

Minimize the human factorsActions to improve the individual

and systematic aspects of perioperativeservices must consider the human fac-tors associated with performance.Human factors strongly influence twoaspects of departmental performance:

� work environment � actions needed to improve perfor-

mance. For the work environment to sup-

port performance excellence, managersand staff members must trust oneanother and have a shared commitmentto quality. Trust can be fostered by acredible, nonpunitive attitude towarderrors that encourages people to shareinformation about quality problemsand participate in actions to preventrecurrence. Part of the trust alsoincludes the belief that managementwill make every effort to deal with theconditions that negatively affect indi-vidual and system performance.

Management must also make clearthat it is important to the department tohave data defining the nature and fre-quency of errors and system problems.Without data, process improvementstrategies are only �best guesses� aboutwhat actions are needed.

A “forgiving system”Often clinicians still believe that

humans are �perfectible� and that the�blame and train� tactic is the bestroute to improved patient care. When ahuman error happens, the traditionalresponse is to blame the human andinstitute new training.

But when the vast majority of quali-ty problems or medical accidents areattributed to human error, it indicatessomething is wrong with the system,not the people.

Consider this: How would youapproach a problem caused by a noisyenvironment over which you have nocontrol? You wouldn�t blame the noise.Instead, you would design a process thatcould function effectively regardless of

the noise. This is exactly the approachthat should be taken in response tohuman error: Redesign the process to fitthe people who must use it.

Once we accept the notion thathuman mistakes are inevitable, itbecomes clear that improvementactions focused solely on changingindividual performance will not resultin sustainable quality gains. The qualityof perioperative services will beadvanced only by designing systems

Performance improvement

Practical guide for improving performance


“

“Measurewhat matters

most.

Patient safetyand humanfactors

Analysis of accidents of the WorldWar II Air Corps (today�s Air Force)revealed that poorly designed cock-pits often led pilots to make mistakes.They were highly trained personnel,but the controls before them did nottake into account the effects of intensestress on their perception and cogni-tion. The analysis led to cockpitdesign improvements that becamethe model for a new era of dramati-cally safer military and commercialairplanes.

This understanding reflects the sci-ence known as human factors, oftenlinked to pioneering organizationalpsychologist James Reason.

Human factors is a disciplinedevoted to studying the interaction ofpeople and equipment and the vari-ables that affect the outcomes of thecontact. It is rooted in the awarenessthat the successful performance of the�operator� within large systems�whether in manufacturing, the mili-tary, or health care�depends on anarray of complex and interdependentforces. And if those forces are poorlyunderstood and not accommodatedin the design of the process or equip-ment, the stage is set for error andpossible disaster�near misses, acci-dents, and even fatalities.

Source: Institute for HealthcareImprovement, www.qualityhealthcare.org

24

Please see the ad for GETINGE/CASTLE INCin the OR Manager print version.


that are forgiving of human errors. A�forgiving system� is one that is resis-tant to errors and process failures orcan easily recover if a problem occurs.

One solution is to force people tostop and think twice before proceedingto the next step in the process. Anexample is the �time out� before thestart of a surgical procedure. Thisprocess change is intended to reducethe likelihood of a wrong-site, wrong-procedure, or wrong-person surgery.Creating a pause in the process is oneway of making it more forgiving oferrors. Computerized technologies relyon alert messages, alarms, and undocommands to help people avoid incor-rect actions and recover from mistakes.Manual perioperative processes wouldbenefit from similar tactics. More abouttechniques for creating safer systemswill be covered in Part 2 of this series.

The first step in performanceimprovement is to acknowledge thaterror is inevitable.

Such acknowledgment is paramountto creating a work environment support-ive of excellence. Without a supportiveculture, quality problems are likely toremain hidden rather than brought outinto the open and analyzed.

Human errors cannot be avoided.Rather, error needs to be managedthrough culture changes, systemwidestrategies, and better process design.Use the self-assessment questionnaireon this page to determine your depart-ment�s progress in minimizing thehuman factors associated with perfor-mance.

Measure performanceEffective performance improvement

depends on the collection, analysis, anddissemination of relevant information.In the cycle of never-ending improve-ment, performance measurement playsan important role in:� tracking progress against depart-

mental goals� identifying opportunities for improve-

ment� comparing performance against both

internal and external standards� formulating the direction of strategic

activities� achieving quality and productivity

improvements.

Making constructive use of measure-ment data is critical if department per-formance is to improve.

Two issues to keep in mind in select-ing performance targets are:

1. Select the right measures.If the right measures are not select-

ed, people will focus on activities thatdo not move perioperative servicestoward desired performance goals. Acombination of structure, process, andoutcome measures can be used.

For efficiency�s sake, it is best to con-centrate on a few essential, meaningfulmeasures. If there are too many, peoplemay become too intent on measure-ment and lose focus on improvingresults. A guiding principle is to mea-sure what matters most. Although eachdepartment is unique, there are ques-tions to keep in mind when selectingperformance measures: � Are perioperative services contribut-

ing to the overall success of the organi-zation by assisting in the achievementof strategic goals? How can the depart-ment�s contribution be measured?

� What performance does the depart-ment want to improve? What criticalactivities and outcomes should bemeasured?

� What are the essential requirementsof the customers of perioperativeservices? What is most important topatients and other internal cus-tomers? How can these customerexpectations be measured?

� What is important to accreditationand regulatory agencies? What arethe national or local topics that affectperioperative services and how canthese issues be measured?

2. Establish performance expectationsor targets for each measure.

Performance targets are quantifiableestimates or results expected for a givenperiod of time. Targets can be brokendown into:� goals for discrete short-term inter-

vals (eg, the next two quarters)� medium- or long-term performance

targets. Performance targets not only should




Are you minimizing the human factors? Place a check (✔) in the low, medium, or high box to indicate how strongly youagree with each of these statements as they relate to your department.

People in this department . . . Low Medium High

1. Believe that even competent, well-trained ❏ ❏ ❏professionals can make mistakes.

2. Cooperate with one another to resolve ❏ ❏ ❏problems.

3. Feel comfortable reporting quality problems or ❏ ❏ ❏unsafe conditions to their superior.

4. Regularly report all patient incidents and ❏ ❏ ❏near misses.

5. Believe that there are process changes that ❏ ❏ ❏can be made to reduce the likelihood of a medical mishap.

6. Are willing to change some of their old habits ❏ ❏ ❏in order to improve quality and patient safety.

7. Believe that the department’s leaders are ❏ ❏ ❏committed to continually improving performance.

8. Take time to discuss and act on the department’s ❏ ❏ ❏performance results.

9. Believe that reducing process steps and handoffs ❏ ❏ ❏will lessen the risk of errors.

10. Use information about errors and performance ❏ ❏ ❏problems to make changes and improvements to process and/or systems.

Source: Patrice Spath


promote a high-quality and safe environ-ment but also be realistic. The best tar-gets are those that stretch the capabilitiesof staff members and the department butare still possible. Stretch targets not onlyresult in genuine improvement but alsohelp to build staff pride and confidence.On the other hand, impossible perfor-mance targets de-motivate and stifleinnovation.

Whenever possible, performance tar-gets should be derived from baselinedata about the department�s past per-formance or comparison data from sim-ilar organizations. The OR Benchmarksprojects sponsored by OR Manager, Inc,are an example of a comparative datasource that can be used to establishstretch performance goals.

Analyze performance resultsIf properly constructed, periopera-

tive service performance measures willresult in data that are meaningful forimproving departmental performance.The data should be timely, relevant, andconcise. Assessment results should pro-vide information on how well currentperformance compares to intendedgoals and on the effectiveness ofdepartmental activities and operationsin their specific contribution to perfor-mance goals.

Among factors to consider whenanalyzing performance results: � Are the right measures being used to

evaluate performance?

� Do the measures provide a betterunderstanding of the cause-and-effect relationship between perioper-ative processes and outcomes?

� Do the measures reflect organiza-tional or departmental priorities?

� Do the data indicate any undesirableperformance trends over time?

� Do the data suggest improvementopportunities in areas other than theones being assessed?

� If performance targets are not met,what inhibited successful perfor-mance?

� If performance targets are signifi-cantly exceeded, are there additionalbenefits to be gained in terms ofreducing costs or improving qualityor safety?

Share resultsEveryone in the department should

be informed of the results. Share brief-ings that summarize and track resultsover time at staff meetings or throughother means. Use simple, eye-catchingtables or graphics such as run charts tosummarize performance data. Don�tmake people �hunt for the needle in thehaystack.� Use color or other tech-niques to highlight improvementopportunities. Use the same report for-mat for all measures because it is easierfor people to comprehend the resultsquickly. The illustration on this pageshows a sample of a straightforwardperformance report.

The critical elements of a good per-

formance measurement system are sim-ilar to those required for any qualityimprovement activity:� leadership and commitment

� good planning and a sound imple-mentation strategy

� appropriate staff member involve-ment

� simple measurement and evaluation.The payback from performance mea-

surement comes from using the data toimprove performance. If the results arenot used, employees will not take per-formance measurement seriously norwill they trust that management is real-ly committed to dealing with problems.When the hard work of data collectionyields nothing more than periodicreports, staff can quickly lose trust inmanagement�s commitment to excel-lence. The information must be used tomake positive changes that contributeto achieving departmental goals andobjectives. How to make this happen iscovered in Part 2. ❖

�Patrice L. Spath, BA, RHITBrown-Spath & Associates

Forest Grove, Ore

Patrice L. Spath is a health care qualityspecialist and author of Clinical Pathwaysfor Perioperative Practice (OR Manager,Inc, 1998) and The Patient Safety Im-provement Guidebook (Brown-Spath &Associates, 2000). She may be reached [email protected]



Sample performance reportPerformance measures Target

1st quarter

2ndquarter

3rdquarter

4thquarter

Previous year

Target Actual

ManagingToday’s OR Suite

SeventeenthAnnual

Chicago HyattRegencyOctober 6–8, 2004

Sneak previewGeneral session speakers already on board� � Carl Hammerschlag, MD, The Way it Was is Not

The Way it Is� Michael Roberto, Harvard Business School,

Leadership Lessons Learned from the EverestDisaster

� Mary Murphy, RN, 2002 OR Manager of the Year

You’ll have eight all-day seminars and more breakout sessions to choosefrom. A sampling of what’s to come…

All-day seminars� Transformational Leadership � Six Sigma for Process Improvement� Working with Difficult People� Managing a Central Processing Department� Supply Chain Management

Breakouts� Creating a Just Culture� Ambulatory Track: Holistic Patient-Centered

Model, Credentialing� Fire Safety� Pain Management� Improving Patient Flow� Managing Intraoperative Medication� Service Recovery Programs� OR of the Future

And much, much more…Networking, receptions, exhibits, and other educational opportunities

28

Please see the ad for TOTAL REPAIR EXPRESSin the OR Manager print version.


Despite ambulatory surgery cen-ter (ASC) policies that patientshave an escort to drive them

home after receiving sedating drugs,such a policy is not always followed,and it can be hard to enforce.

The consequences can be serious. In2002, a Minnesota man died when hecrashed his car while driving homeafter receiving sedation (sidebar).

Medicare�s conditions of participa-tion for ASCs state that �all patients aredischarged in the company of a respon-sible adult, except those exempted bythe attending physician� (42 CFR Part416.42 c).

But patients may not always heedthe policy or the information they aregiven. Patients have been seen gettinginto a car with an escort, going to theend of the hospital driveway, gettingout of that car and into their own, anddriving home, says Nancy Burden, RN,MS, director of health services for theBayCare Health System, Tampa, Fla.

�Patients have a tendency to fib,�observes Jerry Henderson, RN, BS,CNOR, CASC, executive director of theSurgiCenter of Baltimore, OwingsMills, Md. Her center has had patientsarrive and depart with an escort, drivearound the block, come back to their

own car, and drive themselves home. Lack of an escort not only is a patient

safety issue, it is a major factor indelayed discharges. A study found sys-tem factors were the leading cause of dis-charges being delayed�and lack of anescort accounted for 53% of these sys-tem-related delays (Pavlin D J, et al.Anesth Analg. October 1998; 87: 816-826).

What can ASCs do to enforce theirescort policies? And what is an ASC�slegal liability if a patient leaves withoutan escort, and there is an adverse out-come?

Legal liability�ASCs have an obligation not to let

patients function in an impaired state.The obligation is not that we make surethey have an escort,� says Jane

McCaffrey, MHSA, DFASHRM, presi-dent of the American Society forHealthcare Risk Management.

Facilities have a responsibility toensure patients are discharged appro-priately. That means if there is thepotential for patients to be impairedbecause of interventions at the ASC, theASC is obliged not to allow the patientto function in an impaired state. Theneed for an escort stems from thatobligation. The ASC�s responsibility isthe patient; the ASC does not have anobligation to screen escorts ahead oftime, McCaffrey says.

Legal liability hinges on whether theASC adhered to its discharge policyand what the ASC could have prevent-ed, Burden notes. Once a patient hasleft the facility, the ASC doesn�t haveany control over the patient�s actions.

Process begins with preoppreparation

Henderson adds that if there is anincident, lawyers can try to hold anASC responsible for a person leaving,but whether they are successful woulddepend on what the ASC did to try tokeep the patient from leaving alone.She has gone as far as to call the policeand told them she had a sedated patientwho should not be driving but refusedto stay at the center.

The ASC�s legal liability comesdown to what actions it took before thepatient drove. That process begins withthe preoperative instructions. From thetime patients are scheduled for surgeryat the doctor�s office, through preopera-tive registration, and upon arrival at theASC, instructions should emphasizethey will need someone to take themhome, says McCaffrey.

Patients should be instructed toarrange for an escort and should begiven the time the escort should arrive.Some centers insist that the escort be pre-sent before the procedure and stay at theASC during the procedure. If the escort

What’s ASC’s obligation for escorts?

Gwendolyn Grothouse, RNAdministrative directorApple Hill Surgical CenterYork, Pa

Barbara Harmer, RN, BSN, MHASenior consultantHealthCare Consultants, IncCelebration, Fla

Jerry Henderson, RN, BS, CNOR, CASCExecutive directorThe SurgiCenter of BaltimoreOwings Mills, Md

Diana Procuniar, RN, BA, CNORNursing administratorWinter Haven Ambulatory Surgical

CenterWinter Haven, Fla

Donna Gelardi-Slosburg, RN, BSN, CASCNational surgery specialistHealthSouthSt Petersburg, Fla

Rhonda Tubbe, RN, CASC, CNORAdministratorThe Surgery Center of NacogdochesNacogdoches, Tex

Ambulatory Surgery Advisory Board

“

“The key is to identify any

problems preoperatively.


30

Please see the ad for MEDLINE INDUSTRIESin the OR Manager print version.

can�t stay, nurses ask for a phone orpager number and call the escort as soonas the patient is in the recovery area.

Says Henderson, �We don�t take apatient�s word for it that the escort willcome after the surgery. We want to seethat escort preoperatively.�

Rebecca Craig, RN, CNOR, CASC,

administrator of the Harmony Ambu-latory Surgery Center, LLC, Fort Collins,Colo, finds it surprising how manypatients who come to the surgery centersay they don�t have anyone to take themhome. The center has started tellingpatients that unless they arrange for anescort, their surgery will be canceled. �Itis amazing who they will find and howfast they will find them,� she says.

Plan for difficult scenariosOne suggestion for addressing

escort issues is to have plans for a vari-ety of situations. Have a staff meetingand invite the staff to tell about experi-ences they have had with difficult dis-charges. Have them think about scenar-ios that involve patients such as thefrail elderly, homeless people, orteenagers. Then have them plan whatactions they could take to help ensure asafe discharge.

Compile a list of resources thatcould assist patients who don�t haveescorts. There are community andchurch volunteer groups that are will-ing to drive patients home. Some hospi-tals have services such as �Care-A-Vans� that transport patients who can�tmake other arrangements. If the patientis a homeless person without friends orfamily who drive, the ASC may be ableto arrange ahead of time with a home-less shelter for transportation and theavailability of a bed for a couple ofdays.

Taxi driver not good escortA taxi driver is not an adequate

escort for a sedated patient and shouldnot be given that responsibility,McCaffrey notes. What if the patientneeds help getting into the house oncrutches, and no one is home to help?�You need someone who can see thatthe patient gets home and into thehouse. I wouldn�t want the cab driverto have to deal with it,� she says.

SurgiCenter of Baltimore will not leta patient take a taxi unless all otheroptions have been exhausted, and there


AmbulatorySurgery Centers

“

“Can a teenagerbe considered a responsible

escort?

A Minnesota man died of injuries in2002 after crashing his car while drivinghome after receiving sedation in a hos-pital outpatient clinic.

In an investigation, the state healthdepartment found, among other things,that nurses failed to educate the patientabout side effects of sedating drugs hewas given. The patient was not askedabout transportation arrangements. Infact, the nurse who discharged him saidshe knew he was planning to drivehome because she told him how to gethis parking ticket validated.

The health department cited the hos-pital for not complying with Medicaredischarge standards.

The patient, a 50-year-old man withCrohn�s disease, had received an ironinfusion at the hospital about 10:30 am,according to the health department. Healso received hydrocortisone plus 50 mgIV of diphenhydramine (Benadryl), and2 mg of oral lorazepam (Ativan). About11:15 am, the patient asked the nursingstaff to call his physician and ask him toorder something to help him relax. Hisphysician ordered an additional 50 mgIV of diphenhydramine and 2 mg IV oflorazepam.

When the man was discharged at3:15 pm, the nurse gave him anothertwo 1 mg lorazepam tablets to takeafter he got home. The tablets, whichwere not labeled and did not includeinstructions, were found in his car afterthe crash. The physician and pharma-cist said they intended the tablets to begiven in the clinic.

Nurses who cared for the patient said

he became agitated during the infusion,and the second dose of diphenhy-dramine and lorazepam did not calmhim down. One of his nurses recalledhim saying diphenhydramine hadmade him hyperactive in the past. Butby the time he was ready to go home,the nurse who discharged himdescribed him as stable, ambulatory,alert, oriented, not agitated, and withclear speech. She said he did not appearsedated. She told investigators sheknew he was driving himself homebecause he had a parking ticket, andshe instructed him to get a parkingsticker. She said she never thought todiscuss transportation arrangementswith him because �he never sat still�during his stay.

A corrective action planThe hospital submitted a corrective

action plan to the health department inwhich it agreed to:

� educate the outpatient IV nursingstaff on medication safety, take-home drugs, and instructions fortake-home drugs

� review department procedure forhandling physicians� orders sentfrom the office

� implement review by a pharma-cist for take-home medications

� educate all nursing staff aboutthe sedation and analgesia poli-cy

� institute guidelines for communi-cating patient status when thereis a variance in outcomes

� monitor patient record comple-tion.


Patient crashes car, dies after sedation


Fifth Annual

OR Business Management Conference

May 12-14, 2004 •• Albuquerque, NMAn expanded program…for those concerned with the financial management of the ORIn addition to the two-day conference, three all-day preconference seminars will be offered:

• Management of a Bariatric SurgeryProgram

• Working Through an OR ConstructionProject

• Managing the Inventory Supply Chain

The two-day conference will focus on collaborative improvements to OR efficiency.

The conference will be at the HyattRegency in historicAlbuquerque.

The brochure for the conference is available on the OR Manager website,www.ormanager.com.


The Joint Commission on Accre-ditation of Healthcare Organiza-tions is tailoring its National

Patient Safety Goals to make the goalsmore applicable to settings outside thehospital, including ambulatory surgerycenters (ASCs).

The new project, announced Feb 4,has two phases. Phase 1, issued on thesame date, is to modify wording of thegoals for ambulatory settings and pro-vide a grid showing the goals that applyto each setting.

For ASCs, all seven of the 2004 goalsapply, and wording changes are minor(sidebar). For example, Goal 4a is modi-fied to say surgical site marking appliesto the �surgical or procedure site� tomake it clear marking is expected notonly for surgical operations but also forprocedures in settings like the cath lab,notes Michael Kulczycki, director ofJCAHO�s ambulatory care division.

In Phase 2, JCAHO will work to devel-op patient safety goals not only with hos-pitals in mind but other settings as well.JCAHO develops the goals using infor-mation from the Sentinel Event databaseand other evidence gathered from thefield. If JCAHO finds evidence that a goalis needed for a particular setting, such asambulatory clinics, a goal could be issuedspecific to that area, Kulczycki says. In thefuture, there likely will be a core set ofgoals that applies to all settings with addi-tional goals for particular settings. The2005 National Patient Safety Goals arescheduled to be approved in July and willbe effective Jan 1, 2005.

How will goals be surveyed?Compliance with the goals will be

checked as part of the regular surveyprocess.

�We are not adding any specific com-ponent to the survey for the patient safe-ty goals,� Kulczycki says. There is noexpectation for any special reports ordocumentation for the goals.

Compliance could be assessed in anumber of ways under JCAHO�s newsurvey process, which started in January.The new process is moving away from a

review of paperwork to focus more onhow care is actually delivered. Surveyorswill spend less time with leaders and

more time talking with the staff and evenpatients.


Differences between ambulatory careand hospital goals are in italics.

1. Improve accuracy of patientidentification.

a. Use at least two patient identi-fiers (neither to be the patient�sphysical location identifier) when-ever taking blood samples oradministering medications orblood products.

b. Prior to the start of any surgicalor invasive procedure, conduct afinal verification process, suchas a �time out,� to confirm thecorrect patient, procedure andsite, using active�not passive�communication techniques.

2. Improve effectiveness ofcommunication amongcaregivers.

a. Implement a process of takingverbal or telephone orders orcritical test results that requiresa verification �read-back� of thecomplete order or test result bythe person receiving the order ortest result.

b. Standardize the abbreviations,acronyms, and symbols usedthroughout the organization,including a list of abbreviations,acronyms, and symbols not touse.

3. Improve the safety of usinghigh-alert medications.

a. Remove concentrated elec-trolytes (including, but not lim-ited to, potassium chloride,potassium phosphate, sodiumchloride >0.9%) from patientcare areas.

b. Standardize and limit the num-ber of drug concentrations avail-able in the organization.

4. Eliminate wrong-site,wrong-patient, wrong-pro-cedure surgery.

a. Create and use a preoperativeverification process, such as achecklist, to confirm that appro-priate documents (eg, medicalrecords, imaging studies) areavailable.

b. Implement a process to mark thesurgical or procedure site andinvolve the patient in the mark-ing process.

5. Improve the safety of usinginfusion pumps.

a. Ensure free-flow protection onall general-use and PCA(patient-controlled analgesia)intravenous infusion pumpsused in the organization.

6. Improve the effectiveness ofclinical alarm systems.

a. Implement regular preventivemaintenance and testing ofalarm systems in accordance withmanufacturer�s guidelines.

b. Assure that alarms are activatedwith appropriate settings andare sufficiently audible withrespect to distances and compet-ing noise within the patient carearea.

7. Reduce the risk of healthcare-acquired infections.

a. Comply with current CDC handhygiene guidelines.

b. Manage as sentinel events allidentified cases of unanticipateddeath or major permanent lossof function associated with ahealth care-acquired infection.

Source: Joint Commission on Accredi-tation of Healthcare Organizations.

JCAHO tailors safety goals for ambulatory care 2004 Ambulatory Care NationalPatient Safety Goals



are extenuating circumstances. �A taxicab driver has no vested

interest in the patient,� Hendersonnotes. �A driver is not going to andshouldn�t have to take on that account-ability and responsibility.�

Though Burden does not consider ataxi driver a responsible escort, herfacility has used taxis when there is noother alternative. In those rare situa-tions, the facility has had the patientstay a couple of extra hours, then putthe patient in a taxi but only after call-ing to make sure someone was at thehouse to meet the taxi.

Burden�s organization has a policythat if a patient leaves against the dis-charge criteria, which say a patientmust be discharged to a responsible

adult, there must be a specific physicianorder. She has had physicians writeorders that a patient may be dischargedto a taxi driver.

Another question is whether ateenager can be considered a responsi-ble escort. Burden believes a responsi-ble 16-year-old can be better than anirresponsible 40-year-old, so she doesnot dismiss the option of allowing alicensed teenage driver to take thepatient home.

�I think the real key is that youidentify preoperatively anybody youthink is going to be a problem,� saysBurden.

Leaving against medical advice�When you let someone leave

against medical advice (AMA), youhave to think about what is going tohappen,� cautions McCaffrey. An ASCcan have patients without escorts signout AMA, but if they are impairedbecause of drugs particularly, the centershould try to get them to stay, even if ithas to call the police.

If the patient leaves AMA or withoutan escort, has an automobile accident,and injures or kills others or himself, itcould be alleged that the patient�s treat-ment at the ASC contributed to that sit-uation. That, of course, would have tobe proven.

If the ASC has a sound policy, haseducated the staff about the policy andmonitored their compliance, has thor-oughly instructed patients about thepolicy preoperatively, has documentedthe preoperative instructions, and fol-lows the policy to the extent that is rea-sonable, at least its defense would besolid. ❖

�Judith M. Mathias, RN, MA


Professionalguidelines onsafe dischargeAmerican Society ofAnesthesiologists www.asahq.orgPractice guidelines for postanestheticcare, 2001, recommend in part:�Outpatients should be discharged toa responsible adult who will accom-pany them home and be able toreport any postprocedure complica-tions.� American Society ofPeriAnesthesia Nurses www.aspan.org2002 Standards of PerianesthesiaNursing PracticeCriteria for discharge assessment andmanagement include in part recom-mendations to:� verify arrangements for safe trans-

portation home� reinforce discharge planning with

patient and family/accompanyingresponsible adult as appropriate;provide written discharge instruc-tions

� verify arrangements for safe dis-charge home.


For example, surveyors will use the�tracer methodology,� meaning they willselect a patient and use that person�srecord as a roadmap for assessing com-pliance with standards and systems ofcare. A surveyor might, for instance, pulla chart for a patient who is havingsurgery in the facility that day.

�For site marking, we might ask thepatient how that process was implement-ed,� Kulczycki explains. The surveyorthen might ask a staff nurse how he con-ducted the site verification, includingidentifying the patient, marking the site,and holding the time-out. Then the sur-veyor might dig deeper, asking to seepolicies and procedures and queryingstaff about education they received.

Surveyors will expect to see a trackrecord for compliance�12 months fororganizations already accredited and 4months for those being accredited for thefirst time. They will look for consistentimplementation of the recommendations.They might ask leaders, �How do youknow if this is being consistently done ona day-to-day basis?�

What are biggest complianceissues?

Ambulatory care organizations hadthe toughest time in random unan-nounced surveys in 2003 with thesepatient safety goals:� Goal 1a: Using two patient identifiers� Goal 2b: Standardizing abbreviations

For Goal 1a, JCAHO expects use oftwo identifiers, such as the patient�sname plus birth date or Social Securitynumber�not including the patient�sphysical location.

�We are looking for active involve-ment of the patient, not just nodding orsaying yes,� Kulczycki adds.

On Goal 2b, JCAHO helped by issu-ing a minimum list of five never-useabbreviations. Organizations can add tothat list, but those are a minimum. ❖

For more information, go to www.jcaho.org and look under National Patient SafetyGoals. The list of never-use abbreviations isunder frequently asked questions.

Have an idea?Do you have a topic you’d like to see

covered in OR Manager? Have you completed a project you think would be

of help to others?

We’d be glad to consider your sugges-tions. Please e-mail Editor Pat Patterson at

[email protected]

JCAHOContinued from page 33

Please see the ad for OLYMPUS ENDOSCOPY

in the OR Manager print version.

Please see the ad for PERIOPTIMUM


36

Please see the ad for SPECTRUM SURGICAL INSTRUMENTSin the OR Manager print version.

New York State nursing board proposesBSN requirement for RNs

The New York State Board for Nursing hascalled for state legislation or regulations requiringRNs with a diploma or associate degree to obtain abachelor�s degree in nursing within ten years afterthey become licensed. The proposal would notaffect currently licensed RNs or those currently inschool when and if the policy takes effect.

�This is not an entry-into-nursing proposal. Theassociate degree still would be the entry level,�stressed Barbara Zittel, RN, PhD, the board�s execu-tive secretary.

The proposal has many hurdles to jump, includ-ing public hearings and approval by the state�sBoard of Regents before regulations or legislationcould be drafted.

The Healthcare Association of New York Statesays the proposal would worsen the state�s nursingshortage.

Acknowledging �there is no good time� for sucha measure, Zittel said the board decided to actbecause other countries, such as Canada, England,and Australia, as well as federal agencies such asthe armed forces, have moved to require the BSNand because research has found BSN-prepared RNsare associated with better patient outcomes.

RN turnover at 15.5%The RN turnover rate is 15.5%, higher than for

allied health categories (13.1% average), accordingto a poll of 151 health care recruiters sponsored bythe Bernard Hodes Group. The survey did not pro-vide information specific to perioperative areas. Theaverage RN cost-per-hire is $2,651. Most expensiveto hire are radiology techs at $2,748.

�www.hodes.com

Milwaukee hospitals shift from agencyto pool nurses

Milwaukee-area hospitals are developing theirown pools of staff nurses to cut agency costs. Thearea has some of the highest health care costs in thenation and is in the midst of a nursing shortage,according to the Jan 19 Milwaukee Journal Sentinel.

Covenant Health Care saved $500,000 in the past6 months by using an internal pool of 145 nurses atits four hospitals. Covenant nurses average $28 anhour, and pool nurses receive $5 to $8 more, still lessthan the $40 to $70 an hour Covenant paid foragency nurses. Aurora Health Care is saving an esti-mated $1 million a year by using its own pool nurs-es for staffing vacancies.

Agencies dispute the hospitals� cost claims butadmit their revenue has dropped dramatically as aresult of hospitals forming their own pools. ❖

�www.jsonline.com

March 2004

Please see the ad for PENONLINE


Workplace


AHA asks OSHA to withdrawdecision on respiratoryprotection for TB

The American Hospital Associationon Jan 29 urged the Occupational Safetyand Health Administration to withdrawits decision to make TB respiratory pro-tection subject to the general industryrespiratory standard. AHA said theaction is unnecessary because hospitalsalready have stringent measures to pro-tect employees from TB, which have con-tributed to the disease�s record low rate.

AHA says the OSHA standard wasdeveloped for chemicals, and there is noevidence it is effective in preventingspread of communicable diseases such asTB. The standard was effective Jan 1,with a six-month educational periodbefore enforcement begins.

Battles over specialty hospitalsheat up

Battles between hospitals and physi-cians investing in specialty hospitalsare breaking out around the country.

OhioHealth revoked the hospitalprivileges of 17 physicians who areinvestors in a competing specialty hos-pital. The eight-hospital OhioHealthsystem estimated it could lose as muchas $20 million annually to the NewAlbany (Ohio) Surgical Hospital,according to the American HospitalAssociation.

Meanwhile, in Wisconsin, West AllisMemorial Hospital�s board refused to val-idate the election of a physician as chief ofinternal medicine because of her invest-ment in a competing cardiac hospital. AColorado legislator has introduced a billthat seeks to prohibit doctors in that statefrom referring patients to specialty hospi-tals in which they have a financial stake.

In its Medicare reform bill signed inDecember, Congress placed an 18-monthmoratorium on physician investment insurgical hospitals.

A new HIPAA standard:National identifiers

The Centers for Medicare and Medi-

caid Services (CMS) adopted a standardfor National Provider Identifiers (NPI)on Jan 23. The NPI is a unique new num-ber health care providers will use in fil-ing claims. The purpose is to improveefficiency by eliminating the need forproviders to have multiple ID numbersfor health plans they bill.

All health care providers covered bythe rule must obtain NPIs. Providersare covered if they transmit any elec-tronic data for which the Department ofHealth and Human Services has adopt-ed a standard. Providers can startapplying for NPIs on the standard�seffective date, May 23, 2005. The com-pliance date for all but small healthplans is May 23, 2007. Small healthplans must comply by May 23, 2008.

The standard is at www.cms.hhs.gov/hipaa/hipaa2/regulations/identifiers.Frequently asked questions are also atwww.cms.hhs.gov. Click on FAQ linkat top of page. Then for Category,choose HIPAA. For Search Text, enterNPI. ❖

Please see the ad for TVL HEALTHCARE INCin the OR Manager print

version.

Nominate ORManager of Year

Each year at the Managing Today�s OR Suite conference,a manager or director is named OR Manager of theYear.

This year�s conference will be Oct 6 to 8 in Chicago. The OR Manager of the Year will receive an expense-paid

trip to the meeting, in-cluding air fare, hotel,meals, and registration.

In recognizing an indi-vidual manager, theaward honors all ORnurses for their importantrole. It is a way of cele-brating nursing manage-ment in surgical services.

Readers of OR Manager are invited to nominate a manag-er for the award. Simply write a letter of about 300 wordsdescribing what makes the manager deserving of the award.

Send the letter to OR Manager, Inc, OR Manager of theYear Award, PO Box 5303, Santa Fe, NM 87502-5303. Thedeadline for entries is July 1.

Nominations are judged by the OR Manager advisoryboard. The winner will be notified in August. ❖

A conference brochure will be included in the April issue. Thebrochure and registration information also will be available atwww.ormanager.com

Health Policy & Politics

39

Full Page AdCODE

4/c(Pickup)

Please see the ad for SKYTRON INC


Visit us at AORN Booth #2433 in San Diego, CA.

KENDALL: STRIP IN THE FOLLOWING TEXT LINE AT THE BOTTOMOF EXISTING AD. (OK TO SCALE UP OR DOWN TO FIT.)


P O Box 5303Santa Fe, NM 87502-5303


At a Glance


Periodicals

CJD prions found in skeletal muscle

More sensitive testing has foundprion protein in spleen and skeletal mus-cle from humans who had the sporadicform of Creutzfeldt-Jakob disease (CJD),Swiss researchers report.

The testing found prion protein in 10of 28 spleen samples and 8 of 32 skeletalmuscle samples from 36 Swiss patientswith confirmed sporadic CJD. Threepatients had prion protein in both spleenand skeletal muscle.

The authors say the finding reinforcesthe need for single-use needle electrodesand special protocols for sterilization ofinstruments used for muscle biopsies.

The cause of sporadic CJD, the mostcommon prion disease in humans, isunclear. Sporadic CJD is distinguishedfrom variant CJD, which evidence sug-gests is caused by transmission of bovinespongiform encephalopathy to humans.

�Glatzel M et al. N Engl J Med. Dec 16,2003;349:1812-1820. www.nejm.org.

Subscription or purchase required.

JCAHO posts frequent questionson surgical site marking

Is the Universal Protocol for surgicalsite verification a requirement or justadvice? How does the protocol relate tothe National Patient Safety Goals? Doesthe site need to be marked for all proce-dures or just for right/left procedures?

These and other frequently askedquestions are posted on the Joint Com-mission on Accreditation of HealthcareOrganizations�s web site.

The protocol is required for accredita-tion starting July 1.

�www.jcaho.org

National forum issues 15nursing quality measures

More than 200 groups have endorseda set of 15 nursing-sensitive performancemeasures, the National Quality Forumannounced Jan 30. The forum says theevidence-based performance measurescan be used for evaluating the quality ofnursing care. Also endorsed were fiveresearch recommendations and six otherrecommendations for nursing.

Examples of the 15 measures aredeath of surgical inpatients with treat-able serious complications (failure to res-cue), pressure ulcer prevalence, preva-lence of falls, nursing care hours perpatient day, and voluntary turnover.

The forum is a public-private partner-ship created in 1999 to develop a nation-al strategy for health care quality mea-surement and reporting.

�www.qualityforum.org

Local, regional anesthesia catch on for postop pain

A move to nonopioid pain relief isstarting to catch on, even for major oper-ations such as open-heart surgery, mas-tectomy, cesarean section, and abdomi-nal hysterectomy, according to a Jan 20Wall Street Journal article by AmyDockser Marcus. In a 2003 study atSouthwestern Medical Center in Dallas,cardiac surgery patients had cathetersinserted at their sternotomy sites to

infuse local anesthetic for 48 hours aftercardiac surgery. Patients were able to getup and walk around sooner and hadshorter hospital stays than patients whohad morphine. Anesthesiologists saythey are increasingly using Cox-2inhibitors like celecoxib and rofecoxib tomanage pain after surgery. �www.wsj.com. A subscription is required.

AHA endorses recall alert service

The American Hospital Associationhas endorsed a web-based system formanaging alerts and recalls called RAS-MAS (Risk and Safety ManagementAlert System). The system was devel-oped by Mitretek Systems, a nonprofitorganization, to improve content andreadability of more than 4,000 productand safety alerts health care providersreceive each year.

The system requires no softwareimplementation and minimal trainingtime, says AHA, adding that the systemalso creates more efficient workflow andsatisfies JCAHO, Food and Drug Admin-istration, and other requirements.

Mitretek has worked closely withJohns Hopkins in Baltimore to improveits alert and recall process. Flaws in theprocess were blamed for failure to catcha bronchoscope recall in 2001. Twopatients died, and others became ill afteran outbreak of bacterial infections thatmay have been related to contaminatedscopes. ❖

�www.aha.com�http://rasmas.mitretek.org

the monthly publication for or decision makers...the place that performs the highest vol-ume of that...

Documents