The Monthly Publication for OR Decision Makers

The monthly publication for OR decision makers

May 2009 Vol 25, No 5

Process improvement Lean thinking: Lessons of Toyota ASC section on page 26. to help improve surgical services In this issue hat could a surgical ser- to eliminate waste in OR processes vices director learn by and plant the seeds of a culture for JOINT COMMISSION. Wworking in a forklift fac- continuous improvement among Further changes for tory? A lot if the factory is in Japan staff, managers, and physicians. Read 2009 standards...... 10 and uses Lean manufacturing. about their efforts in this issue. Sandra Saltzer, RN, MPA, made PROCESS IMPROVEMENT. the trip to Japan in 2004 when she Special focus: Lean in the OR How to have a Leaner was at Virginia Mason Medical Cen- OR department...... 11 Page 11: How to have a leaner ter in Seattle. She says that because OR department she didn’t speak the language, she PROCESS IMPROVEMENT. Page 13: Getting staff’s buy-in had to observe the actual work Getting the staff’s buy-in for Lean for Lean...... 13 process closely. She came back with Page 16: The diary of one OR’s new eyes for weeding out waste and kaizen event PROCESS IMPROVEMENT. involving employees in making im- Page 18: Lean methods for The diary of one provements. weeding out waste OR’s kaizen event ...... 16 Saltzer is one of the surgical ser- Page 21: Using Lean to steer vices managers leading Lean efforts a department PROCESS IMPROVEMENT. Lean methods for weeding out waste...... 18 Health care and the economy

PROCESS IMPROVEMENT. Using Lean to steer With elective surgery down, ORs a department...... 21 reduce hours, try to avoid layoffs PROFESSIONAL he recession is bringing country. But there are common GUIDELINES. changes in OR staffing. Man- threads: Staffs worry about their AORN updates jobs, and managers are under in- recommended practices ...... 24 Tagers who have seen elective surgery fall are asking staff to re- tense pressure to meet productivity AMBULATORY duce their hours and trying to numbers. SURGERY CENTERS. avoid layoffs. Vacant positions, “The effect really depends on the Time to be proactive once hard to fill, are evaporating. Continued on page 7 in down economy ...... 26 Some veteran nurses are postponing retirement. Conference Issue AMBULATORY Major elective procedures in or- OR Business SURGERY CENTERS. thopedics and spine could decline Management Device reprocessing by double digits in 2009, according makes inroads in ASCs...... 28 Conference to one forecast (sidebar, p 8). May 20 to 22 AT A GLANCE...... 32 The impact of the economic Chicago downturn varies by area of the

Upcoming Editorial

Block scheduling ould the recession blunt ef- Now may be the perfect time to forts to address the nursing fine-tune your block schedule. Cshortage? There are worries Read why. that it could. Top-level“ The economic downturn is bring- Cesareans in the OR ing more nurses into the workforce visibility for Read how colleagues manage and causing those in the workforce to nursing. staffing and standards for perform- hang on to their jobs. With few va- ing cesarean births. cancies now, hospitals may lose sight of forecasts for a shortage that could The monthly publication balloon to 500,000 nurses by 2025. for OR decision makers “Let me respond“ right away be- We were heartened, therefore, to cause it’s not that complicated— hear that President Barack Obama nurses provide extraordinary care. May 2009 Vol 25, No 5 addressed nursing’s challenges di- They are the front lines of the health OR Manager is a monthly publication for rectly at the White House Health personnel in decision-making positions in care system,” he said. He went on to the operating room. Care Summit March 5 in Washing- make these points: ton, DC. Elinor S. Schrader: Publisher • “They don’t get paid very well. It helped to give nursing the visi- Patricia Patterson: Editor • ”Their working conditions aren’t bility it badly needs. Judith M. Mathias, RN, MA: as good as they should be.” Clinical editor The purpose of the invitation-only • “When it comes to nursing fac- Kathy Shaneberger, RN, MSN, CNOR: summit was, Obama said, “to deter- ulty, they get paid even worse Consulting editor mine how we lower costs for every- than active nurses.” Paula DeJohn: Contributing writer one, improve quality for everyone, Obama came down hard on im- Karen Y. Gerhardt: Art director and expand coverage to all Ameri- migration as a solution to the short- OR Manager (USPS 743-010), (ISSN cans.” The intent is to enact health age, saying it “makes absolutely no 8756-8047) is published monthly by OR care reform by the end of the year. Manager, Inc, 1807 Second St, Suite 61, sense. Santa Fe, NM 87505-3499. Periodicals Attending were political leaders, “There are a lot of people who postage paid at Santa Fe, NM and addi- government officials, and leaders would like to be in that helping pro- tional post offices. POSTMASTER: Send from business, the insurance indus- address changes to OR Manager, PO Box fession,” he continued. “Yet we 5303, Santa Fe, NM 87502-5303. try, advocacy groups, and health aren’t providing the resources to get OR Manager is indexed in the Cumulative care organizations as well as a few them trained. That’s something Index to Nursing and Allied Health Lit- members of the public. we’ve got to fix—that should be a erature and MEDLINE/PubMed. At least 2 nurses were on hand: no-brainer.” Copyright © 2009 OR Manager, Inc. All Becky Patton, RN, MSN, CNOR, We heard about his comments rights reserved. No part of this publica- president of the American Nurses tion may be reproduced without written from VHA’s vice president for nurs- permission. Association and a perioperative ing, Lillee Gelinas, RN, MSN, Subscription rates: Print only: domestic $99 nurse, and US Representative Lois FAAN. per year; Canadian $119 per year; foreign Capps (D-California). Capps is one “This is the first time I have heard $139 per year. Super subscriptions (in- of 3 nurses in Congress. cludes electronic issue and weekly elec- a president have command of the is- tronic bulletins): domestic $149 per year; A grasp of the issues sues nursing has had for years,” Canadian $169 per year; foreign $179 per Gelinas told us. year. Single issues $24.95. Subscribe online During his closing remarks, at www.ormanager.com or call Obama called on the audience for With this awareness from the top, 800/442-9918 or 505/982-1600. comments. He called on Rep Capps, perhaps there is hope nursing may Email: [email protected]. who talked about issues well known start getting the policy attention it Editorial Office: PO Box 5303, Santa Fe, to nursing that haven’t received needs. NM 87502-5303. Tel: 800/442-9918. —Pat Patterson Fax: 505/983-0790. much attention from policy makers— Email: [email protected] the expected shortage and the many Advertising Manager: Anthony J. Jannetti, applicants who can’t get into nursing Watch the White House Summit videos Inc, East Holly Ave/Box 56, Pitman, NJ school because of a lack of faculty. at www.c-span.org/Watch/watch.aspx? 08071. Telephone: 856/256-2300; MediaId=HP-A-15689 Fax: 856/ 589-7463. John R. Schmus, Obama chose to respond right national advertising manager. then, showing a remarkable grasp of Email: [email protected] nursing issues.

May 2009 OR Manager Vol 25, No 5 3 Perform. Verify. Document. Timeout Compliance at the Press of a Button INNOVATION OF THE YEAR 2008

KARL STORZ Endoscopy-America, Inc., 600 Corporate Pointe, Culver City, CA 90230-7600, USA, Phone: (310) 338-8100, Fax: (310) 410-5530, E-Mail: [email protected] KARL STORZ GmbH & Co. KG, Mittelstraße 8, D-78532 Tuttlingen/Germany, Phone: + 49 7461 / 70 80, Fax: 07461 / 70 81 05, E-Mail: [email protected] KARL STORZ Endoscopy Canada, Ltd., 2345 Argentia Road, Suite 100, Mississauga, Ontario, Canada L5N 8K4, Phone: (800) 268-4880, Fax: (905) 858-0933 KARL STORZ Endoscopia, Latino-America, 815 NW 57 Ave, Suite #480, Miami, Florida 33126-2042, USA, Telefono: (305) 262-8980, Telefax: (305) 262-8986 www.karlstorz.com A-308014 www.karlstorz-hd-endoscopy.com © 2008 KARL STORZ Endoscopy-America, Inc. Managing Today’s OR Suite The recession and the nursing shortage

year or so ago, managers What have you observed were worried about recruit- Qso far about the effect on Aing nurses and replacing nursing of the economic veteran staff. Suddenly, with the downturn? economic downturn, it’s a different story. Nurses are asking for more Buerhaus: In 2007, we saw a hours. They are willing to work rather significant increase in nurse overtime and even take call. Some employment, roughly 85,000, are postponing retirement. which is a large number. Of course, What effect will the recession we immediately suspected this re- have on the future of the nursing flected RNs sensing the potential of a recession with an increase in na- workforce? Peter Buerhaus, tional unemployment. Because 7 in A large nursing shortage is pre- RN, PhD, FAAN dicted starting around 2015 be- 10 RNs are married, a recession means that for many households, cause of 2 clashing trends—an date at a general session at the the RN may be the primary bread- aging RN workforce moving to- Managing Today’s OR Suite Con- winner. Undoubtedly, RNs were ward retirement just as an older ference Oct 7 to 9 in Las Vegas. also aware that housing prices population of Americans needs Buerhaus is the Valere Potter were declining in 2007. For most, more health care. Professor of Nursing and Director the house is their largest economic Will the recession affect those of the Center for Interdisciplinary asset. This reinforced the effect of predictions? Historically, during Health Workforce Studies at Van- rising unemployment and com- recessions, nurses seek more work derbilt University Medical Center pelled many RNs back into the as their families face an uncertain in Nashville, Tennessee. workforce. economy. Peter Buerhaus, RN, Buerhaus talked about the latest The preliminary data we have PhD, FAAN, a leading expert on developments in an interview with seen for 2008 suggests RN employ- the nursing workforce, is watching OR Manager in February. the trends closely. He’ll offer an up- ment increased again well above 2007 levels. We are submitting a manuscript on the new data to the Advisory Board journal Health Affairs and expect it to be published this spring. Renae Battié, RN, MN, CNOR Kathleen F. Miller, RN, MSHA, CNOR Seattle Senior clinical consultant, Catholic Health Ini- Ramon Berguer, MD tiatives, Denver Chief of surgery, Contra Costa Regional Med- David A. Narance, RN, BSN, CRCST If we are seeing more RNs ical Center, Martinez, California Manager, sterile processing, MedCentral in the workforce, will this Health System, Mansfield, Ohio Q Mark E. Bruley, EIT, CCE throw a wrench in plans to Vice president of accident & forensic Shannon Oriola, RN, CIC, COHN investigation, ECRI, Plymouth Meeting, Penn- Lead infection control practitioner, Sharp address the long-term shortage? sylvania Metropolitan Medical Campus, San Diego Jayne Byrd, RN, MSN Cynthia Taylor, RN, BSN, MSA, CGRN Buerhaus: That is a great worry. Associate vice president, surgical services, Nurse manager, Endoscopy & Bronchoscopy Rex Healthcare, Raleigh, North Carolina Units, Hunter Holmes McGuire VA Medical I envision that some policy makers Robert G. Cline, MD Center, Richmond, Virginia and/or employers will misinter- Medical director of surgical services, Munson Dawn L. Tenney, RN, MSN pret the reasons for increases in RN Medical Center, Traverse City, Michigan Associate chief nurse, perioperative services, employment. They might say, “No Franklin Dexter, MD, PhD Massachusetts General Hospital, Boston Professor, Department of anesthesia and health Judith A. Townsley, RN, MSN, CPAN more worries about the nursing management policy, University of Iowa, Iowa Director of clinical operations, perioperative City services, Christiana Care Health System, workforce. Let’s move on to other Dana M. Langness, RN, BSN, MA Newark, Delaware matters.” Senior director, surgical services, Ena M. Williams, RN, MSM, MBA That is short-term thinking. Regions Hospital, St Paul, Minnesota Nursing director, perioperative services, Yale-New Kenneth Larson, MD Haven Hospital, New Haven, Connecticut Clear messages need to be rein- Trauma surgeon, burn unit director, Terry Wooten, Director, business & material re- forced to policy makers and em- Mercy St John’s Health Center, sources, surgical services & endoscopy, Springfield, Missouri St Joseph Hospital, Orange, California ployers that the increase in em- Continued on page 6

May 2009 OR Manager Vol 25, No 5 5 Managing Today’s OR Suite

Continued from page 5 day of spending, not a penny has gone into addressing this issue. I’m ployment is a short-term trend dri- an economist, and I prefer markets ven by the sudden severe contrac- This“ is the to work and leave the government tion in our economy. out of it. Markets are more innova- Now, we know the increased time to redouble tive, faster, and usually more effi- employment will have some influ- efforts. cient and thus less costly. However, ence on long-term forecasts and in the nursing education market, I will probably improve them. But it don’t think the private sector is won’t eliminate the future pro- going to mobilize enough re- jected large shortage of nurses. sources to get the job done. We tern that many“ areas have shown That is what hospitals must keep need a national overall policy. That improvement, or at least aren’t get- their eyes on. In fact, I would urge would have to come from Con- ting worse. That is unlike previous that this is the time to redouble ef- gress or the federal government, decades when studies showed the forts to address problems facing neither of which has done much work environment was mostly de- the nursing workforce. more than talk about the issue. teriorating. Now with the economy tanking, There have been improvements What should hospitals be we know a number of people will in job satisfaction, satisfaction with focusing on? think about nursing. When they Q career decisions, time spent with hear that unemployment is increas- Buerhaus: With many relieved patients—probably 10 indicators ing, they hear 2 sectors continue to of shortages for the time being, that suggest the nursing shortage is add jobs—health care and teach- hospitals have a chance to focus on having far less impact on the qual- ing. a couple of things. First, they can ity of care, the ability of nurses to So expect that many more peo- take a look at their workforce—it’s practice, nurse ratings of the qual- ple are going to want to become older. What does that mean? You ity of nursing care, and so forth. nurses and seek to enroll in nurs- have to invest in an ergonomic en- The willingness of nurses to rec- ing education programs. In fact, a vironment and improve it. Second, ommend the nursing profession national survey we conducted in we need to build up the physical has shot up dramatically. 2007 found 1 in 4 Americans at one strength of these older RNs. The best thing to do to deal with point in his or her life has thought If we can do that, we may en- the shortage is to take advantage of about becoming a nurse. sure fewer injuries while nurses are the recession’s increasing RN em- Given the economic incentives working and less cost for workers’ ployment and avoid the tempta- to go into nursing, I expect schools compensation. And it may prevent tion to think, “No more shortage.” are going to see an increase in ap- some older RNs from leaving the Instead, the focus should be on im- plications— only to have to turn workforce once the economy proving the work environment, many of them away—the very strengthens. particularly ergonomics. people we will need to replace our The good news is that many aging and soon-to-be retiring baby hospitals are moving forward with What is happening with boomer generation of RNs. investments in ergonomic environ- Qthe capacity problems in ments. Many firms have caught on nursing education, such as the Buerhaus is author of many peer-re- and are developing innovative shortage of faculty, that is viewed articles on nursing workforce technology aimed at making nurs- keeping new nurses from getting issues. He is author with Douglas O. ing work easier. into the pipeline? Staiger and David I. Auerbach of the Buerhaus: I don’t think that’s book, The Future of the Nursing There has been concern being addressed as forcefully as it Workforce: Data, Trends, and Im- Qthat working conditions in should have been, and we are plications (Jones & Bartlett, 2008). hospitals drive nurses away. Is likely to pay a dear price for that. that improving? Because we haven’t dealt with the The conference brochure was included Buerhaus: Our data from na- capacity problem, 2 things have rein the April issue. You can download tional surveys on RNs in 2002, sulted. During the past 3 or 4 years the brochure and register online at 2004, 2006, and 2008 reveal a pat- when Congress has gone on a hey- www.ormanager.com

6 OR Manager Vol 25, No 5 May 2009 Health care and the economy

Continued from page 1 Supporting geographic location and size of hos- the staff pital—you can’t generalize,” says We“ are Lillee Gelinas, RN, MSN, FAAN, Three issues to address, sug- vice president for nursing, for VHA calling staff gested by VHA’s vice president Inc, the 1,400-member hospital al- off. for nursing, Lillee Gelinas, RN, liance. BSN, MSN, FAAN: The biggest impact she is seeing is involuntary reductions in hours Offer employee for full-time employees. assistance “ Make sure employees know “The 40-hour employee is being Up and down in Ohio the hospital’s employee assis- pushed back to 32 hours and the Ohio illustrates the varying local tance program is available for (biweekly) 80-hour employee to 72 impact. The state’s jobless rate in counseling and support. hours,” she told OR Manager. RN February was 9.4%, compared to vacancy rates have fallen to 1% or 8.1% nationally, but ranges widely Keep listening 2% or even to 0% in some areas. from 18% to 6.3%, depending on Stay close to the pulse of the “Traveling nurses have taken full- the county. workforce with open forums time jobs. Part-timers have gone full In Zanesville, Ohio, east of and listening sessions. time. Nurses who planned early re- Columbus, surgery was up by 100 Unions are using this as a time tirement have delayed that,” Gelinas cases over a year ago for the Gene- to capitalize on staff worries. says. Cutbacks of ancillary personnel sis HealthCare System, though the “Some unions are saying, ‘If mean nurses must perform extra du- county’s unemployment is at you had a union in here, they ties like transporting patients and 12.9%. wouldn’t be able to reduce your making trips to the pharmacy. “We’ve been pairing with the hours,’” Gelinas notes. Though the recession’s impact is physicians and have recruited a uneven, Gelinas says the psycho- new neurosurgeon,” says Lisa Put ‘stuff before staff’ logical effect is being felt every- Fordyce, RN, MHA, CNOR, direc- Has the OR done everything it where—staff members are feeling tor of surgical services for 13 ORs can to reduce supply costs? Is vulnerable. She advises nurse lead- located on 2 campuses. She was the cost of physician preference ers to take steps to listen and sup- trying to fill 3 vacancies, for an RN, items like orthopedic implants port them (sidebar). surgical technologist, and OR assis- being addressed? “You are seeing hospitals con- OR managers adjust tant. The picture is different for fronting physician preference OR managers whose volumes Akron General Medical Center, a items now even more,” she says. have dropped are also coping by Level I trauma center with 18 ORs Many physicians are realizing not filling vacancies, reducing staff in Akron in northeast Ohio, where their product choices have an hours, and taking steps to avoid surgical volume was down by 2% impact on the hospital’s costs layoffs. compared to the same period last and could affect the staff’s em- In Peoria, Illinois, big-equip- year. ployment. ment manufacturer Caterpillar Inc, “We thought it would be off in which employs 2,800 workers, has orthopedics and maybe some tween Cleveland and Pittsburgh. had rolling layoffs. OSF Saint Fran- GYN, but we are seeing it in most Stedman is hearing from physi- cis Medical Center has seen its services,” says the director of surgi- cians’ offices that people are elective volume fall, but the ORs cal services, Patricia Stedman, RN, putting off elective surgery be- have not had layoffs. MSHA, FACHE. cause they don’t want to be away “We are calling staff off and ask- The local economy is depressed. from work. They worry their job ing them to leave early. We’re hav- “We are similar to southeastern won’t be there when they get back. ing to make adjustments almost Michigan. We’ve lost a lot of man- She has adjusted to the lower daily,” says Shelly Cunningham, ufacturing over the years,“ she volume by reallocating OR block RN, BSN, CNOR, clinical manager says. Akron is also in a highly com- time and condensing cases into 16 of surgery. petitive health care market be- Continued on page 8

May 2009 OR Manager Vol 25, No 5 7 Health care and the economy

First assistants and Forecast for productivity elective surgery One challenge managers are fac- Staff“ ing in meeting productivity num- The major elective procedures, are asked to bers is surgeons’ requests for first orthopedics and spine, could de- assistants, notes Kathleen Miller, cline by 13% and 20% in 2009 be flexible. RN, MHSA, CNOR, senior periop- compared with 2008, according erative clinical consultant for to a forecast from Sg2, a Chicago- Catholic Health Initiatives (CHI), a based company. Denver-based system with 80 hos- Outpatient surgery, down by “ pitals in 20 states. 5% by the end of 2008, could be hours, but volunteers are always Hospital executives don’t al- down by more than that this willing to go home early. ways understand that the assis- year, Sg2 and others predict. tants are necessary to recruit and A volunteer list Patient visits to physician of- retain surgeons. OR directors need A voluntary furlough plan helps fices were also off by about 22% to be prepared to defend that, she in adjusting staffing at Lehigh Valley by the end of 2008, meaning says. One hospital was able to woo Hospital-Cedar Crest, a Level 1 fewer patients are entering the a new surgeon, partly because it trauma center in Allentown, Penn- health care system and poten- promised him an assistant. sylvania. Having worked hard on tially deferring surgery. An in- “The procedures he does would recruitment and retention, OR lead- creasing number of patients are bring in $2 million a year, and an ers wanted a plan that could help accessing care through the emer- assistant costs $60,000 to $70,000. them adjust yet keep staff satisfac- gency department. Why wouldn’t you want to do tion high through volume fluctua- But the impact is varied. that?” she asks. tions. The idea for the voluntary fur- “We have heard mixed reac- Nationally, CHI has reduced po- loughs came from the department’s tions from clients across the sitions by about 1,200 since Decem- professional practice council. country,” says Steve Miff, PhD, ber 2008, through layoffs, reducing To be proactive, managers post vice president at Sg2. hours, and not filling vacancies. the schedule a week in advance “Some are doing well and are Miller is advising CHI’s periop- and ask for volunteers to take time able to maintain or even grow erative directors on ways to reduce off if needed. Volunteers are sought volumes. Others are very much staffing with the hope of avoiding from the 3 shifts and from full- challenged and have seen a de- layoffs. time, part-time, and per diem staff. crease in inpatient and outpa- One option is to ask full-time “When we finalize the surgical tient surgery.” The impact de- staff to reduce hours by 0.2 FTE for schedule at 12 noon the day before, pends on the local economy, the time being. “Then as your vol- we look at the volume, look at the competition, and consolidation. ume increases, you may be able to volunteers, and staff accordingly,” bring them back. Of course, you says Tammy Straub, RN, MSN, Continued from page 7 still have to pay benefits,” she says. CNOR, CRNP, administrator of Another suggestion is to consider preoperative services. Staff are staffed rooms, with 1 available for reducing staff in support roles like asked to be flexible. For example, if emergencies. clerical personnel, transporters, and a person does not want to be fur- The OR’s PRN pool has dried nursing assistants. Another tactic is loughed, and someone is needed up as nurses who were not getting moving service line coordinators on the night shift, the person is enough hours have sought steadier back into full-time OR positions in- asked to take that shift. work, a potential problem when stead of filling vacancies. she needs to flex staffing up again. With the volunteer list, furloughs Though the health system re- don’t fall disproportionately on the Nurses flock in cently laid off 145 FTEs, Stedman same shift or groups of staff. Managers used to recruiting dif- has been able to adjust OR staffing “This has helped us to meet de- ficulties are suddenly seeing a shift by not filling 3.5 FTE vacancies. partment needs while maintaining in nurses’ behavior. With a unionized staff, managers staff retention and satisfaction,” DeNene Cofield, RN, BSN, CNOR, are restricted in reducing staff Straub says. says she recently had 25 applicants for

8 OR Manager Vol 25, No 5 May 2009 one same-day surgery position in her organization, Tanner Health System Prominent postop pain researcher in Carrollton, Georgia, near Atlanta. accused of fabricating study data “People are flocking in from ambulatory surgery. They say they cott S. Reuben, MD, a well- NSAIDs and COX-2 inhibitors and can’t get their hours in. They want known anesthesiologist and concludes that: to come here for overtime or extra Sresearcher on postoperative • COX-2 inhibitors have consis- hours.” pain, has been accused of fabricat- tently been shown to improve She’s concerned health care has- ing study results. analgesia, reduce opioid-related n’t seen the full brunt of job losses Based on its investigation, effects, and improve quality of on surgery yet. Many laid-off Baystate Medical Center, Spring- patient recovery in the early and workers still have COBRA health field, Massachusetts, where Dr intermediate postoperative peri- care coverage, which doesn’t ex- Reuben was a researcher, has asked ods. Long-term clinical benefits pire for 18 months. medical journals to retract his arti- need to be confirmed by other re- cles, according to the March Anes- searchers. Avoiding RN layoffs thesiology News. • There is no longer unequivocal A national expert on the nursing Dr Reuben is known for his work evidence supporting the preemp- workforce, Peter Buerhaus, RN, on multimodal analgesia, including tive effect of NSAIDs and COX-2 PhD, FAAN, of Vanderbilt Univer- use of nonsteroidal anti-inflamma- inhibitors on postoperative pain. sity, says he thinks hospitals will tory drugs (NSAIDs) and cyclooxy- • The ultimate clinical effect of do everything they can to prevent genase-2 (COX-2) inhibitors such as NSAIDS and COX-2 inhibitors on RN layoffs. celecoxib (Celebrex) for postopera- bone fusion remains unclear. Fur- Research over the past few tive pain. Some of his research was ther investigation is needed. years has shown nursing makes a funded by pharmaceutical compa- • The ability of multimodal pre- difference in the quality of care. nies, according to the April 7 Wall emptive analgesia to prevent ”If you increase the numbers Street Journal. chronic pain after major orthope- and kinds of nurses in your institu- In February, the journal Anesthe- dic surgery is unproven. tion, you decrease the risk of poor sia & Analgesia retracted 10 of Dr The allegedly fabricated studies outcomes,” he says. Reuben’s reports and posted on its were discovered during a routine Those findings could play to website a list of 21 articles that audit in 2008 of research by nursing’s advantage at a time Baystate alleges were based on fab- Baystate faculty. The audit found 2 when hospitals are under eco- ricated data based on its investiga- studies submitted by Dr Reuben nomic pressure to reduce adverse tion. had a potential flaw—neither ap- events. peared to have approval of A major question is whether Impact on practice Baystate’s institutional review hospitals will maintain the man- The results could be far-reach- board (IRB). Further investigation agerial and ancillary support that ing. An editorial to be published in found IRB approval was lacking enables nurses to continue provid- the May Anesthesia & Analgesia by because the data were fabricated. ing care effectively. Paul F. White, MD, PhD, and col- In many cases, the patients were —Pat Patterson leagues says “the retraction of Dr fabricated, Hal Jenson, MD, Reuben’s articles compromises Baystate’s chief academic officer, How is the economy every meta-analysis, editorial, and told Anesthesiology News. affecting your OR? systemic review of analgesic trials None of Dr Reuben’s coauthors that included these fabricated find- Is your elective surgery is believed to have been aware of ings and every lecture and continu- the fraud, and Baystate says no pa- down? Or is it unaffected? ing medical education course on Are you reducing staff hours? tients were harmed by the decep- perioperative analgesia that in- Or are you recruiting new tion, reports Anesthesiology News. cluded these studies.” perioperative staff? Has your — Judith M. Mathias, RN, MA facility down-sized its The retraction is unprecedented management staff? for the specialty, says Dr White, who is chair of anesthesiology at Reference OR Manager would like to the University of Texas Southwest- White P F, Kehlet H, Liu S. Periop- hear from you. Contact ern Medical Center in Dallas. erative analgesia: What do we still know? Anesth Analg. May [email protected] The editorial assesses the litera- 2009;108. In press. ture on perioperative use of

May 2009 OR Manager Vol 25, No 5 9 Joint Commission Further changes for 2009 standards

n March 26, the Joint Com- actually be final until CMS ap- pleted by an individual qualified to mission issued a further re- proves them, expected by the end administer anesthesia no later than Ovision of its 2009 standards. of 2009. 48 hours after surgery or anesthe- The revision, among other things, sia. Surgery-related removes specific language about —EP 8. The evaluation is com- requirements OR supervision and circulating du- pleted in accord with law, regula- These are highlights of new EPs ties that had appeared in a Jan 5 tion, and policies and procedures relating to surgery remaining in draft. approved by the medical staff. the March 26 document. For fur- The Joint Commission said the ther discussion, see the February Lab policies on surgical changes were a result of its negotia- OR Manager (p 21). specimens tions with the Centers for Medicare PC.03.01.08 and Medicaid Services (CMS) over Timing of medical record A new requirement says the lab its deeming authority. entries has a written policy covering The Jan 5 language restored to RC.01.01.01.EP 19 which tissue specimens require the Human Resources chapter at A time will now need to be doc- only a macroscopic examination HR.01.02.01 OR-specific require- umented for all medical record en- and which require both macro and ments from the CMS hospital con- tries, including orders. Previously, microscopic examination. ditions of participation (CoPs) that entries had to be dated but not nec- had long been absent from Joint essarily timed. OR record requirements Commission standards. In the RC.02.01.03 EP 15 History and physical March 26 document, that specific A requirement is added to re- language is removed. The commis- PC.01.02.03 quire a “complete and up-to-date sion says these requirements were There are minor changes in the operating room register,” with a “already covered in existing ele- timing of the history and physical list of required items. In effect, this ments of performance” or are ad- (H&P) and update prior to surgery. is the intraoperative documenta- dressed in the survey process. The new language says a patient tion that facilities already have. Specific staffing language was will have an H&P no more than 30 also removed for other depart- days prior to, or within 24 hours Why all the changes? ments, such as medical records, di- after, inpatient admission or regis- Because of reforms passed by etary, pharmacy, and nursing ser- tration but prior to surgery or (in Congress in 2008, the Joint Commis- vices. an added phrase) “a procedure re- sion must reapply to CMS for deem- quiring anesthesia services.” ing authority for hospital accredita- What the changes mean tion. Deeming authority allows an Anesthesia evaluation No new requirements were accrediting body to “deem” that a added between the Jan 5 and March Several requirements are added health care organization meets CMS 26 updates, the Joint Commission for anesthesia evaluation before standards. says. and after surgery. The commission says it submit- The Jan 5 document had added • PC.03.01.03. EP 10: A time frame ted its deeming application to CMS 165 elements of performance (EPs) is added to the preanesthesia in February and expects a decision to bring the standards in line with evaluation to say the evaluation by the end of 2009. the CoPs. The number is reduced must be completed and docu- Joint Commission officials say to 87 EPs in the March 26 documented by an individual quali- they are confident the commission ment. Some of the new EPs apply fied to administer anesthesia will retain its deeming authority to surgery. within 48 hours prior to surgery from CMS. The Joint Commission says the or anesthesia. new EPs will be surveyed starting • PC.03.01.07. Two requirements A side-by-side comparison of the Jan 5 April 6, but noncompliance will are added for postanesthesia and March 26 language is at not affect accreditation decisions evaluation: www.jointcommission.org until July 1, 2009. The EPs won’t —EP 7. The evaluation is com-

10 OR Manager Vol 25, No 5 May 2009 Process improvement How to have a Leaner OR department

here’s plenty of buzz (and confusion) about “Lean Principles of Lean Thealth care.” Many wrongly In their classic book, Lean assume Lean is simply applying Ask“ if Thinking, James P. Womack and Toyota lean manufacturing tools to each step Daniel T. Jones define 5 princi- health care. Unfortunately, many adds value. ples that characterize a Lean en- approach it that way. At the Uni- terprise: 1. Specify value from the stand- Special focus: Lean in the OR point of the customer. 2. Identify all the steps in the versity of Tennessee, we define waste and should“ be challenged. value stream, eliminating Lean health care as “…the applica- The goal is to remove non-value- every step, action, and prac- tion of concepts, tools, and man- added activities that rob the staff of tice that does not create value. agement prescriptions to improve productive time. 3. Make the remaining value-cre- the operating processes that create A second category of waste is ating steps occur in a tight and value for the patient.” excessive resources such as space, integrated sequence so the The management prescriptions inventory, or equipment beyond product will flow smoothly to- are straightforward—eliminate what is reasonably needed. As ward the customer. waste, achieve flow, and develop processes are reviewed, each activ- 4. As flow is introduced, let cus- your people. Concepts and tools ity is challenged for whether it is tomers pull value from the for applying Lean in health care value-added or not. If not, is there next upstream activity. are somewhat distinct from manu- a way to eliminate or reduce it? 5. These steps enable managers facturing. But they are just as In an OR, the most common and teams to eliminate fur- proven, robust, and able to be forms of waste include: ther waste and pursue perfec- adopted by virtually all health care • Movement of staff when gathering tion through continuous im- workers. supplies, equipment, or informa- provement. How does Lean health care tion. Ask yourself, “Is there a way apply in a surgery department? On to shorten or eliminate move- Reference the day of a surgery, a patient un- ment through a better layout and Womack J P, Jones D T. Lean dergoes a process that includes organization?” One way to start preop preparation, surgery, and Thinking. New York: Free is to focus on the 10 highest-vol- Press, 2003. postanesthesia care. There are also ume procedures and make sure supporting processes, such as pick- the rooms, supplies, and equip- For more on Lean, visit the Lean En- ing instrument trays, sterilization, ment are located to minimize terprise Institute at www.lean.org equipment preparation, and room waste of movement. setup. Improving such processes • Defects or preventable rework such can yield better quality, greater effi- plenishment or management sys- as rerunning lab tests or repick- tems. Such inventories consume ciency, and a more rewarding work ing a tray. Ask yourself, “Is there environment. valuable space and must be an assurance that activities are counted and managed. Eliminating waste done correctly the first time?” Waste can fall into several cate- Perhaps work standardization or Achieving flow gories. One is that waste is any ac- checklists would help. Toyota achieves “flow” of its tivity that does not add value to • Excessive inventories of supplies, parts by maintaining low invento- the patient care process. An easy instruments, or equipment. Of ries throughout the production test is to ask if an activity was elim- course, an OR must be prepared process. In this way, parts are con- inated or reduced, would it dimin- for the variation in types and vol- tinually marching toward their ish the quality of care? If the an- umes of surgery, but we often place in a finished car. swer is no, the activity is probably find excessive inventories that are In health care, flow is achieved the consequence of unreliable re- Continued on page 12

May 2009 OR Manager Vol 25, No 5 11 Process improvement

Continued from page 11 prepping the room for the next the respect shown to workers by surgery should be clearly notified. simply asking them to devise a bet- by moving patients swiftly from ter way and implement it. From a Reduce variation one value-added activity to the practical standpoint, the individu- next. For example, at the facility Reduce variation where you als actually doing the work have level, patients progress without can. Many aspects of surgery have the greatest knowledge about how delay through an outpatient variation that cannot easily be in- the process can realistically change surgery center. At the health care fluenced, for example, the time it and have a vested interest in mak- system level, a patient who discov- takes a patient to awaken after ing it work. Getting your staff to ers a lump in her breast should surgery. But many other sources of this point usually requires some have ready access to a primary care variation can be influenced. For ex- training in Lean concepts, tools, physician, speedy referral to a spe- ample, the times to clean or set up and problem-solving methods. cialist for a biopsy, and, if needed, a room should be fairly predictable quick access to surgical and ther- through standardization, staging, The bigger picture apy services. and proper training. Because Lean is an ongoing process, a Lean transformation re- Eliminate waste Waiting in line quires commitment from leadership In both situations, delays occur For highly utilized services or and key stakeholders. Instead of as the result of queuing. Queuing providers, make a special effort to fighting among themselves, Toy- is when a waiting line forms, and a reduce or eliminate waste. Pay at- ota’s management, workers, and patient (or entity) must wait for tention to the location of supplies suppliers realized long ago that if service from a provider who is or equipment to decrease wasted they focused on creating value for busy with others. Obviously, an movement. Organize these loca- the customer, all would benefit. imbalance between demand and tions to make it quick and easy to Similarly, true Lean health care oc- capacity is one determinant of gather required items. curs when an OR’s administration, whether queues will form. Schedule to reduce queuing staff, surgeons, and anesthesiolo- A second less obvious cause of Schedule cases and staff to miti- gists focus on the patient and work queuing is variation both in the together to create surgical services time between requests for service gate queuing effects. Most ORs perform a mix of elective and that are efficient, high in quality, and and in the time it takes to provide accessible. In the end, all will benefit the service. emergent/urgent surgeries. Al- though emergent cases arrive at through increased volumes handled Unlike repetitive manufactur- random times, their average “rate” with improved efficiency. ing, which has a steady pace and —Charles E. Noon, PhD predictable cycle times, health care of arrivals can be determined throughout the day. Once the ran- Professor, Management Science has considerable variation. When University of Tennessee (UT), health care delivery systems are dom arrival rates are characterized, elective cases should be scheduled Knoxville viewed as a “network of queues,” —Hank Schiffers, MD, MBA it’s easier to target the causes of to avoid systematically overload- ing key staff or resources. Director, Lean, Europe, Middle delay and to work toward achiev- East & Africa, Stryker Corporation ing flow. Develop your people —Jody Crane, MD, MBA A smoother OR process The success of process improve- Emergency physician, Within an OR, flow can be im- ment depends largely on how it is Mary Washington Hospital, proved by considering the following: attained. If the improvement is de- Fredericksburg, Virginia veloped and imposed by a man- Faculty, UT Physician EMBA Waiting for service ager or a consultant, the chances of Program Make sure each provider or staff success and sustainability are mini- member knows when something mal. If the improvement is devel- The University of Tennessee offers a or someone is waiting for service. oped by the front-line staff who 1-week Lean for Healthcare program This is accomplished by use of will actually implement it, it has a through its Center for Executive clear visual signals. If a room is va- much better chance of being work- Education (thecenter.utk.edu). cated and ready to be turned, all able and sustainable. staff involved in cleaning and Some of this effect is because of

12 OR Manager Vol 25, No 5 May 2009 Process improvement Getting the staff’s buy-in for Lean hen Pam Murphy, RN, vice (CS) personnel. Murphy had director of surgical ser- planned for coverage 6 weeks ahead Wvices at 144-bed Pied- by arranging for per diem staff and mont Newnan Hospital in Newnan, Case“ carts having other staff report earlier in Georgia, first heard a Lean presenta- were affecting the day. tion, she says, “It made sense, be- ‘Going to the gemba’ cause we are so process driven. The turnover. After an introduction to Lean, the whole focus is, ‘What is touching the RPI team went to the OR and CS de- patient, and what is value added?’” partments to observe the case cart Piedmont Newnan’s ORs were process. In Lean, this is called “going the pilot site for a Lean project for “ to the gemba”—going to where the the Piedmont Healthcare system. Getting started Since the Lean project started in actual work is done. Getting the Special focus: Lean in the OR December 2007, the ORs have con- team out of their daily routine helps ducted two 5-day Lean rapid them to spot activities that waste time and energy. The hospital has 8 ORs on 2 cam- process improvement (RPI) projects The team split up to observe the puses. Piedmont was aided by Geor- (also called kaizen events), one on instrument flow in the CS depart- gia Tech’s Enterprise Innovation In- case carts and the other on turnover ment, case-cart picking, and the stitute in Atlanta. time. opening of case carts and setup in Developed by Toyota, Lean in The hospital wanted to start with the OR. They gathered baseline data health care brings clinicians and turnover time, but Lingenfelter by timing how long it took to pick a other staff together to improve urged the team to step back and take case and assemble a case cart. processes that waste time and re- a wider view of the surgical process. The observers helped pique inter- sources. In doing so, they realized one issue affecting turnover time was that case est of the rest of the staff. Involving the staff carts weren’t available and supplied “The team would say, ‘This is Murphy knew the staff’s partici- correctly, which meant rework be- what we’re looking at. What do you pation would be critical. She also fore cases. think?’ That helped to spread the ex- knew they would have a concern: Murphy recognized that if she and citement,” Murphy notes. Does Lean mean doing more with the staff could improve the case cart Mapping the process less? Would people lose their jobs? process, they would attract buy-in After the observations, the team Backed by the administration, from other staff and physicians and met in a conference room to map out Murphy assured them no one would build momentum for other projects. the process on the wall. They noted lose their jobs because of Lean. These are the steps they took. which steps were value added and Another concern—with staffing which involved waste. tight, how do you get staff off to par- Training for staff Themes emerged: ticipate in a project? How might that In Lean, improvement initiatives • The preference lists were in rea- affect productivity numbers? bubble up from the front lines, so the sonable shape but needed tweak- Again, Murphy had top-level staff is critical to Lean. Lingenfelter ing. The lists are computerized support. A Lean account was set up began by introducing managers and but didn’t include locations for charging employees’ time so an initial group of staff to Lean. By where supplies were stored. managers wouldn’t be penalized for the end of her involvement, 90% to • There was not a formal way of lower productivity. 100% of the OR staff had basic Lean picking a case. “That was a key decision by the training. • The staff didn’t trust one another executive team,” says Jenn Lingen- Selecting a team to pull cases accurately because felter, project manager for Georgia For the case cart RPI, a cross-func- everyone did it in a different way. Tech’s Health Care Performance tional team of front-line OR staff was • Items were not placed in standard- Group, who worked with Piedmont selected, including nurses, surgical ized locations on the case carts. Newnan. technologists (STs), and central ser- Continued on page 14

May 2009 OR Manager Vol 25, No 5 13 Process improvement

Continued from page 13 was added to the case carts. All such supplies for a case are placed in the • In the OR, many items were bin when a case is picked. After the opened “just in case” instead of The“ staff case, the bin with any unopened sup- held in reserve, as indicated on came up with plies goes back to CS with the case the preference list. That caused a cart, and the supplies are restocked. lot of waste. the ideas. The savings—$118,000 over a Whirlwind of improvements year. The team divided into smaller After the RPI, the overall case cart teams to tackle each issue. accuracy rate rose from 50% to 98% accuracy to 100% accuracy in No- “We prioritized ideas and fo- • entering supply“ locations on the vember and December 2008, Mur- cused on those we could do that preference cards phy says. week. It was like a whirlwind,” Lin- • labeling shelves and bins in the genfelter says. automated supply cabinets Keeping up the momentum One focus was a standardized • cautioning staff not to pull cases Lean is meant to be a cultural case-picking method. from memory but to use the pref- change, not a short-term project. “In manufacturing, a distribution erence cards—even if they had How do you keep it going? center is arranged so you go down been there for 20 years. “You have to continue to monitor Aisle 1 and pick items, then you go Updating preference cards and measure. Otherwise, the staff to Aisle 2, and so forth. With the case loses sight of where they are,” Mur- The team also fine-tuned the carts, staff were zig-zagging and phy says. She reports the preference process for updating preference backtracking,” she says. card accuracy rate to the staff regu- cards: The team worked with the IT de- larly. • The person picking the case prints partment to develop a systematic The spirit of Lean needs to be- out the preference card and high- pick path. come part of everyone’s thinking, lights any missing items, such as The preference lists were stan- Murphy notes. Many of the staff an instrument set still in CS. dardized to mirror the layout of the have been involved in Lean projects. • The preference card goes with the supply room so the person pulling a “The only reason we succeeded case cart to the OR. case would always start in the same was because of the staff,” Murphy • In the OR, the OR staff write any location. Another breakthrough was says. “The staff were the ones who missing items on the preference to eliminate pulling all of the cases came up with the ideas.” card. the day before. That had caused If a process slips, they will say, • After the case, the preference card some case carts to be incomplete, “Wait a minute. That’s not part of is taken to a designated location. meaning rework to look for supplies our Lean process.” The cards are tallied for missing before a case and “stealing” from When performance drops off, the items to determine an accuracy case carts already pulled. staff who were on the RPI teams “will rate. Instead, the team decided that the sit back down and look at what’s • Preference cards needing changes only cases pulled the day before going on. They’re the ones who own are transferred to another box would be the first cases of the day. it and drive it,” Murphy says. where one person does the up- That reduced the space needed for Success can be infectious. dates, typically within 2 or 3 days. case carts and eliminated incomplete “This project was so much fun,” case carts. The staff’s biggest concern An ‘aha moment’ Lingenfelter says. “You feel like was that case carts would not be The RPI’s biggest win and great- you’ve made a difference. You see a ready, but Murphy says that has not est savings came from an “aha mo- difference not only in the bottom line been an issue. ment” during the observations. but in the culture.” A standard arrangement “We found people had gotten —Pat Patterson The team also developed a stan- into the habit of opening everything dard arrangement of items on the cart for a case,” Murphy says, even items Learn more at an all-day Lean seminar so items needed first are on the top labeled on the preference card as “do with Murphy and Lingenfelter at the shelf and so forth. Other changes were: not open unless needed.” Managing Today’s OR Suite Conference In an easy fix, a “do not open” bin Oct 7 to 9 in Las Vegas.

14 OR Manager Vol 25, No 5 May 2009 OROR BusinessBusiness ManagementManagement ConferenceConference

May 20-22, 2009

The Drake Hotel Chicago

Go to the OR Manager website, www.ormanager.com, for the conference brochure and to register online and make your hotel reservations. Process improvement The diary of one OR’s kaizen event

f you could huddle for 5 days with a few people who really Lessons learned Iunderstand your patient flow Lessons on Lean from Integris and you had the resources, what A simple“ Southwest Medical Center: could you achieve? question: Where • Copying Lean tools without A team at Integris Southwest is the patient? understanding your own Medical Center in Oklahoma City process doesn’t work. • Reach consensus on defini- Special focus: Lean in the OR tions. For example, what does it mean when someone says, took that approach and came up utilization, resource“ management “Is the patient ready?” To a with a surprisingly simple and in- (for example, there are only a cer- nurse, it might mean, “I’m fin- expensive tool to address a funda- tain number of fluoroscopy units ished with my part of the mental obstacle—communication. for the OR), how patients get from process.” To the surgeon, on The 5-day project is known as a one area to the next, and the pre- the other hand, it means, “The kaizen event in Lean management. dictability of the OR schedule. patient is ready for the inci- (Kaizen means continuous improve- “We decided to ask a simple sion.” ment in Japanese.) These short, fo- question: ‘If Dr S has an 8 am • Keep asking why to get to the cused projects gather key team surgery, where is the patient?’” heart of a process. Probe be- members in one place to improve a says Dr Booth. “It hit me that the yond the usual answer, process. The team needs the support problem was not that we didn’t “We’ve always done it that and resources to put improvements have enough people. It was that way.” into effect immediately. we didn’t have fluid communica- • The team for a kaizen event The Integris team included circu- tion among the departments.” must involve individuals who lating nurses; holding area nurses; That was the problem the team have working knowledge of surgical technologists; the OR set about solving. the patient care process. If the scheduler; the OR financial consul- right people aren’t at the table, tant, Bradley Cox; and the chairman Tuesday you start out behind. of anesthesiology, Keley John Booth, Focus: Learn about the process. • Make technology support the MD. Dr Booth, who has an interest Map the workflow of the current state. process instead of forcing the in the Toyota Production System Tuesday was spent mapping the process to support the technol- where Lean was first developed, patient flow process, based on sev- ogy. took time off from his practice to eral hours of detailed observation • Lean is not just another im- participate. Assisting was Richard of the current process. provement initiative—it’s a Tucker from consultants Healthcare By the end of the day, the team better way of doing things. Performance Partners. understood how tangled the Here’s a diary of their kaizen process was, even for answering journey. the simple question, “Where is the Wednesday patient?” Focus: What was clogging the Monday “We knew we had bitten off process? How can the process be Focus: Define the scope and pur- quite a bit,” Dr Booth comments. streamlined? pose of the project. Dig to the root of “We started to worry it was too Analyzing the process, the team the problem. Decide what problem to much to tackle.” identified 2 major themes: solve first. The team had also learned a lot • “We have to be able to communi- At first, the team planned to ad- about the process and began to ap- cate.” dress turnover time between cases. preciate the cost of the inefficiency. • “We have to be able to identify But as the members talked, they re- “It was sobering to realize its where patients are at each stage alized how many issues were af- complexity. We knew we could do of the process.” fecting the flow of patients—room better,” he says. They asked themselves what

16 OR Manager Vol 25, No 5 May 2009 Process improvement

changes would allow that to happen. Two ideas were to use a white board or to adopt a technology solution. New technology is expensive and has a long lead time. “It’s not the intent of Lean to open your wallet,” Dr Booth notes. “Plus, Lean is about changing the process today, not in the future. We wanted to know how to change our process today.” The solution they settled on used a resource already at hand—Microsoft Excel. To aid com- The Lean team at Integris Southwest Medical Center munication, the developed a spreadsheet as a patient-tracking tool. team decided to develop a simple shared Excel spread- Friday sheet that personnel in multiple de- Focus: Presented the spreadsheet to partments could use to enter and ac- OR leaders and hospital executives. cess information about a patient’s You don’t“ have For the presentation, the team de- status (illustration). to spend a cided to take a risk and do a live The hospital had tried commer- demonstration of the spreadsheet. cial patient-tracking software in the million dollars. As leaders and executives watched, past, but the staff and clinicians they accessed the spreadsheet and found it didn’t fit their process. tracked a fictitious patient through Excel, on the other hand, is easy to every step in the process. format and customize, and it is sheet was ready“ to test. To run the Dr Booth played the role of a easy to train the staff to use it. test, the team invented a fictitious pa- surgeon’s office calling to book an By the end of Wednesday, the tient and used the spreadsheet to emergency case to be added and team was excited about the spread- track and communicate about the pa- performed within 2 hours. As the sheet idea. They planned to develop tient’s status. They found they could demonstration showed, the only the spreadsheet and work with the track the patient almost without phone call required was the one IT department on how to share and phone or fax. from the surgeon’s office. The only store it. Steps were taken to make “We were surprised by how ele- purchase—$99 for a wireless com- sure the spreadsheet was compliant gant and simple it was,” Dr Booth puter keyboard. The test was with patient privacy rules. says. judged a success. Thursday By late Thursday, the spread- Epilogue Focus: Ran a trial to test the con- sheet was being fine-tuned, and After the kaizen event in No- cept. the team prepared for a presenta- vember 2007, the OR used the By the next morning, with Tuck- tion on Friday morning. spreadsheet for 5 months. OR leader’s help, the first draft of the spread- Continued on page 20

May 2009 OR Manager Vol 25, No 5 17 Process improvement Lean methods for weeding out waste

hat can a surgical ser- how long the process was taking. vices director learn The solution seemed obvious— Wabout running the OR have patients receive preop care in by working at a forklift factory? “ the location where they will have During 2 weeks in Japan in 2004, Ask ‘why’ surgery. To make this change more Sandra Saltzer, RN, MPA, had a 5 times. manageable, the team decided to chance to tour 3 factories and actu- start not with the first patients of ally work in one. At the time, she the day but with those having sub- sequent cases. Once the process Special focus: Lean in the OR was stabilized, they began including first patients of the day. This is how“ Lean principles are With this change, they identified was director of surgical services at being applied at UW. Virginia Mason Hospital in Seattle, 6 hours of nursing time that were a leader in Lean thinking for health Weeding out waste no longer consumed. On-time care. The hospital regularly takes A principle of Lean is to identify starts also improved. The next step managers to Japan to learn about and eliminate waste from the work is to discharge patients from the the Lean management approach process. Saltzer says, “For me, this same area where they have their pioneered by Toyota. means asking, ‘What are we doing procedures. Saltzer says she learned a lot, to inconvenience our patients?’ Standardizing work even though she doesn’t speak ‘What aspects of the process create Standardizing a process helps to Japanese. “When you can’t ask opportunities for error?’ And, prevent errors and reduce waste. people what they are doing, you ‘How can we keep from wasting UW is standardizing work in have to observe the actual work nurses’ time?’” the preanesthesia clinic by plan- process,” she says. That helped her The preoperative project was a ning a standard format and se- see things differently when she got candidate for wasteology. At UW, quence for electronic documenta- back. surgery is performed in 2 build- tion and paperwork. Nurses will “Because my background is pe- ings, the main hospital and the then have a consistent format to rioperative, I think I know what pavilion. Previously, all patients follow in their assessments, Saltzer OR people are doing. My experi- registered and received preopera- notes, which may help reduce vari- ences in Japan helped me to really tive care in the pavilion. Those ability in the length of the preanes- understand work as it actually oc- having surgery in the main hospi- thesia appointments. curs, not as it is described in a pol- tal were transported to the main “We hope to reduce the wait icy or procedure.” preop area where most of the time for patients and eliminate She’s also more aware as a con- process was repeated. Patients had missing or incorrect information,” sumer. At the airport, for instance, to arrive earlier than necessary and she says. she has noticed that Alaska Air- wait longer for their surgery. It also lines has 2 stations with one atten- consumed additional nursing Ask why 5 times dant for checking bags. As one pas- hours and transport time. A Lean method for better under- senger completes the check-in Value-stream mapping standing a process is to ask “why” process, the attendant can immedi- 5 times. In Lean, value-stream mapping ately move to the next passenger, “When you ask, ‘Why do we do is one step toward eliminating shortening the wait and dramati- that?’ sometimes the first response waste. All of the steps in a process cally decreasing the queue. is not the real answer. Asking are identified, with an eye to elimi- Saltzer, who is now the director ‘why’ 5 times helps get to the ac- nating every step that does not add of surgical services at the University tual reason,” Saltzer says. value. of Washington (UW) in Seattle, is In one situation, she asked a For the preop project, the team applying Lean concepts to improve charge nurse about the variability mapped and timed the process the preoperative and discharge in the medical assistants’ arrival from arrival to the OR and realized processes for surgical patients. Continued on page 20

18 OR Manager Vol 25, No 5 May 2009 22nd Annual Managing Today’s OR Suite Oct 7 to 9, 2009 Caesars Palace Las Vegas

With the AORN Leadership Specialty Assembly Process improvement

Continued from page 18 The visual information helps man- Diary of kaizen event agers and staff take ownership of a Continued from page 17 times. Some started at 8:30 am and process. others at 9 am, disrupting the flow ers also worked with the IT depart- of patients. Sustaining the process ment on a more long-lasting solu- The first response to, “Why do Part of the Lean philosophy is to tion. A consultant was brought in we do that?” was a common one— create a culture of steady, continu- to produce a case-tracking system “We’ve always done it that way.” ous improvement. How do you similar to the spreadsheet. The new Further questioning revealed that keep up the momentum? Saltzer, a system draws on information from in the past, one medical assistant certified Lean trainer, says the best the surgical scheduling system to arrived later because of the city bus way is to “make the change visible, avoid duplicate data entry. schedule. That schedule continued keep checking on it, and keep re- The kaizen event enabled the long after the medical assistant left. porting it.” OR to learn what it wanted in a pa- Understanding the real reason Changes in the preop process tient tracking system, Cox ob- made changing the schedule easier. were made over 10 months. serves. “Each time we made a small ad- ”If we had just looked at a [com- Creating a visual justment, we needed to communi- mercial] patient-tracking system, I workplace cate the change, implement it, and don’t think we could have done it,” In a visual workplace, staff and then measure,” she says. he says. “With the spreadsheet, we managers can see the status of a A lesson learned: “If leadership could make case tracking fit our process at a glance. Producing a loses focus on the process, the needs.” monthly report doesn’t achieve process will drift back to what is Adds Dr Booth, “It proves you that objective. more familiar. It requires vigilance don’t have to spend a million dollars The staff at UW wanted to be to maintain the change and iden- to get efficiency. You need the right able to monitor the status of pa- tify future improvements.” people asking the right questions, tients on the morning of surgery. For example, the postanesthesia with the appropriate support.” The goal is to have patients arrive care unit (PACU) has a target Dr Booth’s enthusiasm for Lean in the OR by 7:20 am. To monitor length of stay of 2 hours. But the continues. Other Lean projects their status, the staff decided to staff doesn’t necessarily focus on have been conducted, including post a laminated board in both that target as they care for each pa- one for patient flow in the cardio- preop areas. tient, and some patients stay thoracic service. “When a patient is ready to go longer than they need to. “Lean is a tool and a strategy for to the OR, we put a dot on the One idea under discussion is to solving problems without waiting chart next to the time,” she ex- put a whiteboard by every PACU years and spending millions to plains. “As the manager makes bed. When a patient is admitted to achieve your goal,” he says. rounds, she can immediately see if the unit, the nurse would write the —Pat Patterson patients are running on time or be- expected discharge time. This vi- hind schedule. sual cue helps all caregivers plan “If they need more staff, we can toward the targeted discharge do a good job. They want to im- deploy more staff. Or if they’re on time. It also assists the charge prove the process for patients and time, we can congratulate them,” nurse to identify times when there themselves. If you communicate Saltzer says. may be obstacles to patient flow. the reasons for change and the ef- The board was also a help to the “I think the key to Lean is to en- fects, they can be engaged and charge nurse, who had been re- gage the staff in the process and move the process forward.” questing more staff. Saltzer ex- keep the information in front of plained that if he filled out the on- them,” she says. “People want to Reference time chart, they could both have Goldratt E M, Cox J. The Goal: A the information they needed to see Process of Ongoing Improvement. what staffing was required. Check our website A novel. Great Barrington, Mass: “He began to see places where for the latest news, meeting North River Press, 2004. announcements, and other http://www.goldratt.com/ he needed to add staff in the mo- practical help. ment, rather than adding a person www.ormanager.com Womack J P, Jones D T. Lean Think- for the whole morning,” she notes. ing. New York: Free Press, 2003.

20 OR Manager Vol 25, No 5 May 2009 Process improvement Using Lean to steer a department hen a perioperative nurse stock or a piece of equipment is was recently promoted to missing. Examples are labels on Wbe the OR’s clinical coor- shelves and taped “footprints” dinator, she inherited a department Bad-day“ for equipment on the floor. badly in need of coordination. The phone calls • Are OR staff following consistent OR manager was frequently out of processes? For instance, is there a the department at meetings, leaving dropped off. standardized process for room no one to coach the team. turnover? Is everyone playing Not an experienced manager, the assigned role? the coordinator needed a way to The coordinator monitored these processes to see how well get traction. Lean methods offered To start building“ a framework, they were working. Were person- he advises asking what it would Special focus: Lean in the OR nel following the right steps in the take to prevent nasty phone calls. right sequence? Did each player What are the key things to look know his or her role? Were they a framework to use as she assumed for? Then start to focus on those. meeting the right time frames? her new responsibilities. Here are 4 Lean management If the coordinator spotted a “This was a perfect opportunity methods outlined in Lean Hospitals. for what we in Lean call ‘leader- problem, she didn’t reprimand the ship standard work,’” says Lewis Standup meeting team member. Instead, she said: “I Lefteroff, a Lean consultant. The first Lean method the new noticed you weren’t able to follow The Lean methods he suggested coordinator adopted was to hold a the standard process. Why is that? are described in the book Lean Hos- standup meeting at 7:30 am right Did you not have things you pitals by his colleague, Mark Gra- before the surgical schedule begins needed? Did you not have the in- ban (Productivity Press, 2008, at 8 am. This quick meeting information or training you needed? www.leanhospitalsbook.com). volved the daily management How can I help you do better next Graban and Lefteroff are consul- team and covered critical issues time?” tants with ValuMetrix Services, a such as any major schedule Though the word “audit” can unit of Ortho-Clinical Diagnostics, changes, facility issues, or changes have a negative connotation, “the a Johnson & Johnson company. in personnel. From this meeting, audit is really a coaching guide,” Pioneered by Toyota, Lean the OR coordinator developed an Lefteroff says. “An audit includes teaches a way of thinking, operat- audit list. specific things you look for. Then ing, and managing focused on cus- you coach people if they are not tomer value, rooting out waste, Daily audit meeting expectations. and fostering continuous improve- The audit list provided a guide “It’s not about being a police of- ment. Adopting Lean is easier if of issues the coordinator needed to ficer—it’s about being a coach and the hospital already has embraced monitor that day for the OR to be mentor. The idea is that leadership a Lean culture. But any manager successful. Some examples: is there to support the staff, help could use Lean principles as a • Make sure supplies and equip- them be successful, and hold them framework to help set a department are in the right place. Each accountable.” ment on a steadier course, Lefteroff day, she selected 1 or 2 ORs and Key performance suggests. checked supplies in those rooms. measures “One of my favorite questions She also checked the central core Key performance measures are to ask a manager is, ‘How do you to make sure mobile equipment guideposts for monitoring the de- know if you are having a bad day? was stored where it belongs. partment’s performance. Examples And how do you know if you are Lean management advocates es- are late starts, turnover time, case having a good day?’” he says. The tablishing a “visual workplace.” delays, and how long cases run most frequent answer: “If I don’t A “visual workplace” has visual over at the end of the day. get yelled at or get a nasty phone cues that allows anyone to see immediately if a supply is out of call, it’s a good day.” Continued on page 22

May 2009 OR Manager Vol 25, No 5 21 Process improvement

Continued from page 21

Monitoring is more than collect- ing data and generating reports, Lefteroff says. It also means monitoring teams’ performance—and letting them know you are monitoring it. The data needs to be visible. By sharing information with the staff regularly, leaders help the staff feel they are trusted and re- spected. “If the manager is in an office down the hall, and staff and physicians never see the manager, they may think no one cares. They may think the measures are just numbers in the computer.” For example, as the coordinator conducted her rounds, she might An employee suggestion board helps a sterile processing manager see that it was 8:30 am, and one OR capture and track the staff’s ideas for improvements. hadn’t started yet. She would ask the team, “Why is there a delay? Turning suggestions into improvements Has this been recorded as a late case? Let’s make sure we are cap- The staff is one of the best • working on turing why the case is delayed so sources of ideas for continuous im- • not ready to go forward we can address it later.” provement. The secret to eliciting • completed. As the day went on, the coordi- good suggestions is convincing A staff member with a sugges- nator would continue to do audits, employees their suggestions mat- tion writes it on a card and pins it make sure teams had resources ter. Having a way to manage em- to the board. The manager checks they needed, monitor work, and ployee suggestions captures good the board every day, reads each check on whether performance ideas and helps the staff feel re- new suggestion, and talks to the measures were being met. spected and involved. person about it. Suggestion management in- Then he signs the card, dates it, Capturing the staff’s ideas volves 3 steps: and moves it to another section of The staff is one of the best 1. Help the staff to feel it is worth- the board. If the card is moved to sources for improvement ideas. By while to make suggestions. the “not ready to go forward” sec- harnessing their ideas, leaders help 2. Help them channel suggestions tion, he explains why to the em- create a culture of continuous im- to aid the department in im- ployee, saying “Tell me more about provement. It also helps employees proving performance. it, and we’ll see if we can take it feel involved and valued (sidebar). 3. Provide the staff with regular further in the near future.” The secret to eliciting good, ac- feedback on their suggestions. Happily, the most crowded part tionable suggestions from the staff of the board is the “completed sug- “is convincing people their ideas An effective suggestion gestions” part, Lefteroff says. program and suggestions will be used,” says “This way, suggestions don’t go Lefteroff. Here’s how one sterile process- into a box or a computer where no Toyota has a 99% implementa- ing department developed an ef- one sees them. They are on the tion rate for suggestions. fective employee suggestion pro- board for everyone to see. It says to “That doesn’t mean 99% of the gram. employees, ‘Maybe this manager is suggestions were perfect to start The manager put up a bulletin serious about implementing our with,” he notes. “It means some- board with 4 sections labeled: suggestions.’” one went back to the people who • new suggestions

22 OR Manager Vol 25, No 5 May 2009 Process improvement

made the suggestions and said, lation rate has been 14% to 19% for Lefteroff says. “Management is a ‘Can you explain this to me a little the past 2 months. title—leadership is a behavior. This more? What is the problem you are At the standup meeting the next is about leadership, which is get- trying to solve?’” day, the OR coordinator could say, ting people to have trust and be Leaders help employees convert “By next Friday, I’d like each of constructive.” their ideas to sound suggestions. you to come back with 2 sugges- Bad-day calls drop “That’s where leadership comes tions you think can help improve Using these Lean methods, the in—mentoring employees to bring our cancellation rate.” Then she new OR coordinator was able to their ideas to the point where they and other leaders would help de- meet one of her objectives: Bad-day can actually solve problems for the velop those suggestions and work phone calls dropped off dramati- organization.” with the staff to implement them to cally, Lefteroff notes. The focus is on improving the de- reduce the cancellation rate. For these strategies to be effec- partment’s performance. While it The coordinator could ask for tive in the long term, a coordinator might be nice for a staff member to suggestions on other processes, such needs backing from senior man- suggest a new reading light for the as: How can we improve communi- agement. Achieving sustainable lounge, and the department might cation among colleagues? How can improvements in measures like OR do it eventually, that is not going to we improve handoffs between the delays and turnover time requires drive performance, Lefteroff notes. preoperative area and the OR? resources and leadership support. Encourage suggestions Give regular feedback Otherwise, some staff and physicians will think they just need to He gave an example of how to Regular feedback is crucial to wait out the current coordinator, encourage suggestions. Say the successful suggestion manage- and steady monitoring of their per- OR’s cancellation rate for the previ- ment. Coaching and feedback “are formance will stop. ous day was 17% of cases, and the one of the big differences between —Pat Patterson day before it was 18%. The cancel- management and leadership,”

How much do infections cost hospitals? Estimates of the annual direct cost to hospitals of treating health care-associated infections (HAI) from the Centers for Disease Control and Prevention. The cost is adjusted for inflation to 2007 dollars using the Consumer Price Index for all urban consumers (CPI-U), and the CPI for hospital inpatient services.

CPI-U CPI-hospital inpatient Annual average direct cost of HAI to hospitals $28.4 to $33.8 billion $35.7 to $45 billion Surgical site infection (SSI) • Average per-patient costs $11,087-$29,443 $11,874-$34,670 • Aggregate hospital costs $3.22-$8.55 billion $3.45-$10.07 billion

What would be the benefit of preventing HAI? • $5.7 to $6.8 billion if 20% were preventable (CPI-U) to • $25.0 to $31.5 billion if 70% were preventable (CPI-hospital inpatient)

Source: Scott R D. Direct Medical Costs of Healthcare-Associated Infections in US Hospitals and Benefits of Prevention. CDC, March 2009. www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf

May 2009 OR Manager Vol 25, No 5 23 Professional guidelines AORN updates recommended practices

ORN offered updates on 3 use if unused for more than 5 days. of its recommended prac- The advice is based on 4 studies Atices for 2009 at its annual Endoscope“ that found endoscopes have grown Congress in March in Chicago: recommendations organisms after 5 days when • high-level disinfection stored in closed cabinets. • cleaning and processing of flexi- are greatly Speaking from the floor, one ble endoscopes expanded. person said she thought tracking • surgical hand antisepsis. when scopes have been re- The first 2 recommended prac- processed would be “a huge chal- tices appear in the 2009 Periopera- lenge.” tive Standards and Recommended added, one on“ the Spaulding clas- A tip was offered by Carla Mc- Practices book. The third will be is- sification with examples of devices Dermott, RN, CNOR, liaison to the sued in a new electronic document in each category, and one with committee from the International that can be purchased through the Food and Drug Administration Association of Healthcare Central AORN website (www.aorn.org). (FDA)-cleared chemicals for high- Service Materiel Management. At AORN says all of its standards and level disinfection. her facility, when hanging flexible RPs will soon be available electron- scopes in the cabinet after disinfec- ically as a collection and as indi- Cleaning and processing tion, the staff clips the strip from vidual documents. of flexible endoscopes the reprocessing machine to the Here are some highlights from The recommendations for the hanger with the scope. When the RP update session. These are reprocessing of flexible endoscopes preparing for a procedure, a tech- highlights only. Managers will and accessories are especially criti- nician takes the strip, identifies it want to review the complete lan- cal because these instruments have with the patient, and places the guage. been linked to more infection out- strip in the log book. breaks than any other type of de- “It’s a handy way to keep track,” High-level disinfection vice. The intricate channels and McDermott said. It helps, for exam- The recommendations for high- connections make them difficult to ple, with choledochoscopes and pe- level disinfection, consistent with clean and disinfect. diatric scopes that may not be used those from other organizations, are The RP is greatly expanded, with within 5 days of disinfection. based on the familiar Spaulding 16 recommendations compared to 6 A question was also raised classification, which defines devices in the previous 2003 version. about the recommendation to have as critical, semi-critical, and noncriti- The update was completed be- physically separate areas for de- cal. The reprocessing method is se- fore the Centers for Disease Con- contamination, clean items, and lected according to the type of de- trol and Prevention (CDC) issued patient care, which many GI labs vice and how it will be used. its long-awaited Guideline for Disin- don’t have. Not having separate The RP guides users through fection and Sterilization in Healthcare areas is “less than ideal,” AORN’s the steps of cleaning, decontamina- Facilities in November 2008. But the nurse consultants commented. tion, selection of a chemical for RP was reviewed by the CDC liai- high-level disinfection, and pro- son to AORN’s RP committee and Hand antisepsis tecting devices from contamination found to be consistent with the The revised hand antisepsis RP during transport to the point of CDC recommendations, committee was previewed at the session, use. Also covered are safety for member Peter Graves, RN, BSN, though it is not in the 2009 stan- personnel and chemical disposal. CNOR, assured the audience. dards book and was not available Like all, it includes sections on ed- electronically at deadline. Questions on recommendations ucation and competency valida- “What’s new is not so much the tion, documentation (if appropri- A couple of new recommenda- content but the evidence that sup- ate), policies and procedures, and tions raised questions from the au- ports good practice,” said Renae quality control. dience. Battié, RN, MN, CNOR. Two helpful tables have been One recommendation is to re- The RP’s purpose is “simple but process flexible endoscopes before

24 OR Manager Vol 25, No 5 May 2009 Government plans to survey Fasting could be ASCs on infection control relaxed for women during labor he government plans to start a tion control deficiencies in this set- nationwide pilot to survey ting,” said the official, Don Wright, study suggests surgical Tambulatory surgery centers MD, MPH, principal deputy assis- fasting rules could be loos- (ASCs) on infection control practices, tant secretary for health. Aened for obstetrics. Hospi- the ASC Association reports. The He said the funds would allow tals may not need to apply strict plans were outlined by an official states to hire additional surveyors. In surgical fasting rules to women in from the US Department of Health recent years, funding has allowed labor, finds a study in the March 24 and Human Services testifying be- ASCs to be surveyed only once every British Medical Journal. 10 to 14 years. Dr Wright noted ASCs fore Congress on April 1. Fasting is intended to protect have been the fastest growing type of The surveys would use a new in- women in labor from pulmonary fection control tool and tracer provider in Medicare. aspiration if general anesthesia is methodology developed by the Cen- More frequent surveys needed for a cesarean section. ters for Medicare and Medicaid Ser- “This new funding will enable Researchers tracked more than vices (CMS) and the Centers for Dis- CMS to perform targeted survey and 2,000 women in labor, with half fol- ease Control and Prevention. A certification activities much more lowing the traditional liquid diet tracer tracks a patient’s care from ad- frequently,” Dr Wright testified. mission to discharge to see how care fast and half given permission to The survey process was pilot is given. Under the plan, ASCs eat a light meal. tested in 2008. would be surveyed about every 3 They found no difference in ce- The testimony, which focused on years. sarean rates, rates of complications, HHS efforts to reduce health care-as- The project, to be funded by or vomiting if the women were sociated infections, was given before money from the economic recovery given the chance to eat. the House Appropriations Subcom- act, was chosen because “the avail- —O’Sullivan G, Liu B, Hart D, mittee on Labor, Health and Human able survey tool was developed for et al. BMJ. 2009;338:b784. Services, Education, and Related ambulatory surgical centers and be- www.bmj.com Agencies. cause of the likely continuing infec-

profound,” she said. The purpose of for the surgical hand scrub was re- hand hygiene is to prevent infection. emphasized. The Joint Commission includes “Brushing disrupts the resident hand hygiene in its National Patient A brush“ flora and causes it to multiply,” Safety Goal for reducing the risk of Battié noted. Though some prod- health care-associated infections, is not ucts still come with a brush, she and there is a focus on “never necessary. said, “The brush is not necessary as events” related to infection. part of the scrub process and may The recommendations include actually have a negative effect.” guidance on hand hygiene, surgical hand antisepsis and hand expanded and“ includes a useful scrub, and selection of related References products. The recommendations table. Two essential criteria for hand AORN. Perioperative Standards and not to wear jewelry or artificial antisepsis products are: Recommended Practices. Denver: nails in direct patient care reap- • documented persistence AORN, 2009. www.aorn.org pear. For nails, the definition of • cumulative activity. Rutala W A, Weber D J, Healthcare what not to wear has been ex- “Persistence, persistence, persis- Infection Control Practices Advi- panded to include “any enhance- tence,” Battié stressed. Once gloves sory Committee. Guideline for Disinfection and Sterilization in ment or resin-bonding product,” are on, micro-organisms can grow. “We need a product to help us Healthcare Facilities, 2008. At- reflecting new nail technology. In- lanta: Centers for Disease Con- tact nail polish is still OK. with the issue of growth while we trol and Prevention. deliver care.” www.cdc.gov/ncidod/dhqp/ Persistence is key Though not new, the recommen- pdf/guidelines/Disinfection_ The section on product selection is dation that a brush is not necessary Nov_2008.pdf

May 2009 OR Manager Vol 25, No 5 25 Time to be proactive in down economy

ike their hospital and physi- their jobs, they are still seeing their cian practice counterparts, stocks go down.” Lambulatory surgery centers From the South, in Springdale, (ASCs) are feeling a financial The recession“ Arkansas, Sonia Bates reports an pinch. Or are they? is hurting equally cloudy scenario. Bates is So far, the effects of the recession treatment plan coordinator at Max- have manifested in different ways everybody. Surge Healthcare Solutions, a com- for ASCs, and hard data on nation- bination ASC and medical clinic. wide trends are hard to find. “We don’t have numbers yet,” “It’s too early to tell,” Cathy she says, but in general, business Head, RN, MHA, CASC, says in “has decreased tremendously. necticut. Surgical“ services manager reply to a question about the effects Many patients are not doing elec- Elizabeth Casey, RN, says volume on outpatient volumes. She is ad- tive procedures.” actually increased since the ASC ministrator of Evansville (Indiana) The clinic side of the facility has reorganized under a management Surgery Center. Procedure vol- already let some employees go, company, but she does not believe umes remain steady so far at and the ASC is contemplating the that experience is typical. Evansville, located in a suburban same move if the downturn contin- area in southern Indiana, but Head Recession’s hurting ues. “The recession’s hurting sees growing evidence of tighten- everybody everybody,” Bates says. ing of health care budgets. The southern part of Connecti- While some ASCs may consider “There is still a need for elective cut, where Guilford is located, is selling the business or merging with procedures,” Head says. “I am home to executives who commute hospitals, that is not an option for more concerned about the effect of to New York’s financial district or MaxSurge, which specializes in oral the unemployment rate in our Hartford’s insurance and banking and cosmetic surgery, which are not community. If people are not work- centers. typical hospital service lines. ing, they still need health care. “A lot of affluent people tend to From elective to We’re seeing more bad debt and have elective procedures done, es- emergency more charity care.” pecially cosmetic, and they are In a research paper released in The story is the same at Shore- now faced with the loss of in- February, “The Current Recession line Surgery Center, Guilford, Con- come,” she says. “Even if they keep and US Hospitals,”Thomson Reu-

Ambulatory Surgery Advisory Board

Lee Anne Blackwell, RN, BSN, EMBA, Rebecca Craig, RN, BA, CNOR, CASC LeeAnn Puckett CNOR CEO, Harmony Surgery Center, Fort Materials manager, Evansville Surgery Director, clinical resources and educa- Collins, Colorado and MCR Surgery Cen- Center, Evansville, Indiana tion, Surgical Care Affiliates, ter, Loveland, Colorado Birmingham, Alabama Donna DeFazio Quinn, RN, BSN, MBA, Stephanie Ellis, RN, CPC CPAN, CAPA Nancy Burden, RN, MS, CAPA, CPAN Ellis Medical Consulting, Inc Director, Orthopaedic Surgery Center Director, Ambulatory Surgery, BayCare Brentwood, Tennessee Concord, New Hampshire Health System, Clearwater, Florida Rosemary Lambie, RN, MEd, CNOR Lisa Cooper, RN, BSN, BA, CNOR Nurse administrator, SurgiCenter of Balti- Executive director, El Camino Surgery more, Owings Mills, Maryland Center, Mountain View, California

26 OR Manager Vol 25, No 5 May 2009 Ambulatory Surgery Centers

ters reported that at least within hos- one-third as patients turned to pitals, outpatient procedure vol- creams and other noninvasive umes did not decrease through De- treatments. cember 2008. While colonoscopy People“ take Also declining are bariatric volumes varied from month to more time surgery and radiology. Casey says month before falling off in Novem- Shoreline’s radiology volumes are ber, the volumes for 4 other com- to pay. down by about 300 cases since a mon procedures remained flat all year ago. “People put off their year: knee arthroscopy, cardiac mammograms if they’ve lost their catheterization, cardiovascular stress insurance.” test, and cataract surgery. Evansville recently added Health care “adds jobs Where hospital outpatient vol- bariatric surgery, and Head says According to the Bureau of umes did decline, Thomson Reuters she expects declines in the future, Labor Statistics, health care re- attributes the drop to patients choos- “but so far, it’s doing well.” mains one of few bright spots in ing “nonhospital sites” and con- In any case, Evansville is in a the national employment picture. cluded there had been no overall good strategic position to weather Unlike most industries, health care drop in elective surgery as of that the recession because of the range added jobs in February, including date. of specialties it includes: orthope- 16,000 in ambulatory health care, Another industry expert foresees dics, ophthalmology, ear, nose and which includes ASCs. One of a different scenario. Jody Hatcher is throat, general surgery, gynecol- those, in fact, was Evansville, president of the group purchasing ogy, and urology. which hired an OR nurse and in- organization Novation, Irving, Its ownership, shared by a strument technician. Texas, which counts ASCs among its physician group and Deaconess No current employment sur- members. In an interview with the Hospital, requires the center to veys appear to focus on ASCs online supplier newsletter StratCen- treat patients with government in- specifically. The ASC Association, ter.com, Hatcher says many people surance such as Medicare and Alexandria, Virginia, does not who put off elective surgery now Medicaid or with no insurance. Re- track patient volumes and has con- will end up in the emergency room, imbursements are slow and declin- ducted no formal survey of how meaning outpatient services will ing, and payments are late or the recession is affecting its mem- lose volume to their acute-care missed. bers. Spokeswoman Kay Tucker neighbors. “You see your accounts receiv- says individual reports vary, with “What’s happening,” Hatcher able aging, as people take more some ASCs losing business while says, “is that as people lose their time to pay. We try to collect up others see no change for now. “It’s insurance, rather than getting care front, but that is not always possi- too soon to see consistent results,” earlier from their primary care ble,” Head says. Tucker says. provider, they are now waiting It’s time to be proactive until it’s more severe and they’re Impact varies by specialty Even if right now the recession walking in to the ER. One reason for the inconsistent seems to be happening to someone “As you have more and more effect may be that ASCs vary by else, no ASC can afford to be com- uninsured, you have a greater specialty and ownership. Cosmetic placent. As hospitals show, health number of hospital walk-ins. And surgery, for example, has seen vol- care is no longer recession-proof. any elective procedures are also umes decline dramatically. In Janu- Head recommends preparing negatively impacted by coverage ary, the American Academy of Cos- for the future by working harder levels, as well as people just hold- metic Surgery reported that 79% of than ever to reduce costs, stan- ing off if and when they can; this its members said the recession has dardize on supplies, and maintain affects nonacute sites.” affected their practices, and aver- fee collections. Financial analysis age procedure volume declined by Continued on page 29

May 2009 OR Manager Vol 25, No 5 27 Ambulatory Surgery Centers

Device reprocessing makes inroads in ASCs

here are 3 ways to handle suring sterility and device integrity. used disposable medical-sur- The Association of Medical De- Tgical devices: throw them out vice Reprocessors (AMDA) was after a single use (as the manufac- Investigate“ formed to promote the use of third- turer recommends); reprocess them the company party reprocessing companies, according to strict Food and Drug whose operations are set up to com- Administration (FDA) guidelines; or thoroughly. ply with manufacturing and report- hire a specialty company to collect, ing regulations. Currently, the reprocess, and return them. AMDA has 2 members, Assent and The first option is expensive, SterilMed, Minneapolis. Together, the association says they account for compounding the costs of supply the finished product“ is as good as 95% of the US market in disposable purchases and disposal. new,” Boyle says. “Of course, we device reprocessing. The second choice, even most have the occasional problem with In March 2008, the Government large hospitals agree, is problematic an item, but you have that with Accountability Office (GAO) re- because of the need to follow com- new products as well.” ported to Congress that use of re- plex standards used in manufactur- Craven participates in Ascent’s processed devices “does not indicate ing. For an ambulatory surgery cen- ServiceExpress program, designed that use presents an elevated health ter (ASC) or any outpatient facility, it for facilities that want to manage risk.” is completely impractical. their reprocessing programs inter- That leaves the third choice, con- nally. Each ServiceExpress cus- Capacity, service tracting with a third-party reproces- tomer works with a specialty ser- important sor. While it is not clear how many vices manager, who serves as the While Thousand Oaks Surgical surgery centers have decided to re- primary Ascent contact. Hospital in California is not an process this way, those who have Since January 2006, Craven ASC, its experience illustrates what tried it report good results, both clin- Surgery Center has reprocessed an ASC might expect when estab- ically and financially. 2,200 devices, saved 206 pounds of lishing a reprocessing program. Electing to reuse used medical supplies from being The facility has 7 ORs and 20 inpa- As director of materials man- added to landfills, and saved tient beds, but 80% of its proce- agement at Craven Regional Med- $82,000 in supply costs. dures are outpatient. ical Center, New Bern, North Car- Increased oversight Thousand Oaks began working olina, Joanne Boyle also handles assures quality with Ascent in August 2008 and projects annual savings of $50,000. materials management for its affili- The FDA has been regulating the The OR manager, Linda Michaelis, ated Craven Surgery Center. reuse of single-use devices since RN, says the smaller reprocessors In 2003, Craven selected Ascent 2001. The agency publishes an ex- she tried were not certified to re- Healthcare Solutions, Phoenix, Ari- tensive list of devices that could be process as many items as the hos- zona, to provide reprocessing ser- reprocessed, with increasingly strin- pital needed. vices. From September 2007 to Au- gent guidelines for higher risk de- “It is critical for somebody look- gust 2008, the surgery center saved vices, especially those that penetrate ing into a reprocessing company to about $41,000 reprocessing items the mucosa. investigate thoroughly their capac- such as arthroscopic shavers and The oversight began after origi- ity, quality, and reputation,” she burrs, trocars, saw blades, and soft nal equipment manufacturers notes. tissue ablators. (OEMs) complained that hospitals Ascent is certified for a long list “In light of the regulations As- were reusing the devices without of items, and what it cannot recent has to follow in reprocessing the appropriate procedures for en- and remanufacturing our supplies, process it accepts and discards

28 OR Manager Vol 25, No 5 May 2009 Ambulatory Surgery Centers

through its own facilities. Cur- ing remains the subject of public re- rently, Thousand Oaks reprocesses lations wars between OEMs, whose all sequential compression sleeves, revenues are threatened, and third- many arthroscopic shavers and Some“ need party reprocessors, who seek to ex- blades, and laparoscopic instru- to confront pand their market. ments and cannulas. It also sends “I think everybody knows about out saw blades and drill bits that skepticism. it,” Puckett says of the reprocessing are opened but not used. option. “The main issue is pushback from surgeons. It’s usually because Setting up the service of OEMs. But with the economy the Materials management director way it is, I can’t imagine more peo- other devices, “also through Ascent. Frank Melia, who manages the op- ple aren’t going to look at it.” Evansville also participates in a recy- eration, says, “You set it up how- —Paula DeJohn ever is best for your facility.” cling program in which the company Ascent charged a $200 start-up provides a “green” sharps container fee to deliver a set of bins, similar (not for needles, however) that the Down economy to biohazard bins, for collection of company picks up. For those prod- used items. At the beginning, ucts the company does not have Continued from page 27 FDA clearance to reprocess, it recy- Melia ordered pickup every other will show which volume trends are cles them or uses them as test items week “to get the idea of the flow of cyclical (such as surgeons’ annual in reprocessing trials. The program, product” but soon changed that to spring vacations) and which are notes Evansville’s materials manager, a weekly pickup. Technicians col- warnings of economic distress. Lee Ann Puckett, “is a huge cost sav- lect the bins and remove them to “Financial analysis is more im- ings for us” and conserves space in an Ascent facility where they are portant than ever,” Head says. “If the local landfill. sorted. After discarding or recy- you are not financially healthy, Like many ASCs, Evansville had cling items that cannot be re- then you’ll get into trouble.” to confront skepticism among sur- processed, they send Melia a list of Watching the news for signs of geons and staff members. Puckett available reprocessed items. local economic trends, such as recalls vendor sales reps warning “Then I give them a PO [pur- mass layoffs, are also tools of physicians how “bad” recycling de- chase order]. The whole process analysis. Capital investments may vices could be. takes about 3 weeks.” have to wait, and vacant positions “Some of our surgeons and staff The returned items are not neces- go unfilled. went to tour the Ascent plant,” she sarily the same items the hospital “Be proactive,” Head warns. says. “Once they saw the science, originally purchased but are consid- “You can’t just sit back and wait for they were fine with it.” ered equivalent. If a needed item is the next shoe to drop.” Management, she notes, en- not available, Melia says, “then we —Paula DeJohn buy an OEM product new.” dorsed the idea from the start be- The $50,000 annual savings is cause of savings, which average net of what Ascent charges to re- 40% to 50% per device. process each item. Savings also in- At Craven, on the other hand, Share your clude $1,600 not spent on biohaz- Boyle says it took her 2 years to con- success! ard bins and $7,600 per year on ac- vince management to endorse re- Has your ambulatory surgery center tual disposal of the used items. processing. Meanwhile, at Thou- made major strides? Have you sand Oaks, “they were pretty much improved care or found ways to be Some need convincing more efficient? Share your success on board to start with,” Michaelis with your colleagues. Evansville Surgery Center in Indi- says of her top management. Contact Pat Patterson, editor, for a ana reuses orthopedic burrs, bits and Even with stricter regulations possible interview at shaver blades, handpieces, sequential and demonstrated safety, reprocess- [email protected] compression device sleeves, and

May 2009 OR Manager Vol 25, No 5 29 Nominate OR Manager of Year

ach year at the Managing Today’s OR Suite conference, a manager or director is named EOR Manager of the Year. This year’s conference will be Oct 7 to 9 in Las Vegas, Nevada. The OR Manager of the Year will receive an ex- pense-paid trip to the meeting, including airfare, hotel, meals, and registration. In recognizing an individual manager, the award honors all OR managers for their important roles. It is a way of celebrating nursing management in surgical services. Readers of OR Manager are invited to nominate a manager for the award. Simply write a letter of about 300 words describing what makes the manager deserv- ing of the award. Supporting letters may also be sent. Send the entry to OR Manager, Inc, OR Manager of the Year Award, PO Box 5303, Santa Fe, NM 87502-5303. The deadline for entries is July 1. Nominations are judged by the OR Manager advisory board.

A conference brochure is included in the issue. You can register online at www.ormanager.com

Each module is a compilation of recent articles from OR Manager. You have the advantage of The OR having all the current articles on these topics Management at your fingertips. One module: $55 Series Two modules: $100 Three new modules! Three modules: $150 Plus $14.95 shipping and handling. Patient Safety in the OR, Second Edition OR Efficiencies Order at www.ormanager.com Materials Management in the OR or call 800/442-9918.

30 OR Manager Vol 25, No 5 May 2009 NuBOOM® is an all-in-one equipment management and visualization system that will change the way you think about upgrading ORs. With NuBOOM your current ORs can quickly become integrated MIS surgical suites. Reclaim critical ﬂoor space, even small rooms with low ceilings can now become integrated MIS ORs. Our Perfect Placement® installation process will ensure the HD monitors are positioned exactly where they are needed for every case.

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P O Box 5303 Santa Fe, NM 87502-5303

At a Glance

sooner, and have fewer complica- gists at $500. Physicians in multispe- AORN, AdvaMed issue guide tions, the Washington Post reported cialty groups reported higher com- for vendor credentialing March 31. Readmissions have fallen pensation than those in single-spe- AORN and AdvaMed (the Ad- by 44%, and in-hospital deaths have cialty groups. vanced Medical Technology Associ- dropped from 1.5% to 0%. Neurosurgeons in the East re- ation) have proposed joint recom- Geisinger says it achieved its received 71% higher compensation mendations for credentialing indus- sults through standardization. The than those in the West ($2,850 vs try representatives. The groups program guarantees every bypass $1,667). General surgeons in the East want the recommendations, en- patient will receive 40 action items, received half as much as those in the dorsed by 8 other organizations, to such as receiving antibiotics within Midwest ($500 vs $1,000). be considered a national standard. 30 minutes of the procedure. —www.mgma.com/press/ The recommendations, which Under the warranty, Geisinger article.aspx?id=27764 cover vaccinations, liability insur- charges a flat fee and pledges to ance, background checks, hospital bear the additional cost if complica- orientation, and training documen- tions arise or the patient is readmit- Whistle-blower lawsuit over tation, are intended to apply to clini- ted. The program has been extended Infuse dismissed cal reps who are in the immediate to other procedures, including hip A whistle-blower lawsuit alleg- vicinity of patient care. The guide- replacements, cataract operations, ing that 120 leading spine sur- lines are intended to help bring and cath lab procedures. geons accepted kickbacks for pro- more uniformity to current policies, —www.washingtonpost.com moting use of Medtronic’s bone which vary widely, increasing costs morphogenic protein product In- and administrative burdens. fuse in unapproved ways was dis- —www.aorn.org/PracticeResources/ Survey: 38% of physicians missed in March by a federal SafetyResources/HCIRCredentialing/ not paid for taking call judge in Massachusetts, according Some 38% of physicians receive to the Minneapolis-St Paul Star Tri- no additional compensation for on- bune. Heart surgery warranty call coverage, according to a Med- The suit, filed by former employ- pays off ical Group Management Association ees of Medtronic’s spine business, In the 3 years since introducing survey. alleged surgeons were paid consult- its 90-day warranty for elective The survey found on-call com- ing fees totaling $8 million to pro- heart surgery, Geisinger Health Sys- pensation varies by specialty, group mote off-label use of Infuse in the tem based in Danville, Pennsylva- size, and region. Neurosurgeons re- neck. Infuse has not been approved nia, has reduced its coronary artery ported the highest daily on-call by the FDA for use in cervical fu- bypass costs by 15%. Patients spend compensation at $2,000, compared sions. less time in intensive care, go home with pediatricians at $895 and urolo- —www.startribune.com

32 OR Manager Vol 25, No 5 May 2009