Fine-Tuning the Block Schedule? ASC Section on Page 26

The monthly publication for OR decision makers

July 2009 Vol 25, No 7

OR throughput Fine-tuning the block schedule? ASC section on page 26. Now could be the right time In this issue f you want to fine-tune the block make changes that are more politi- schedule, now may be the time. A cally challenging,” observes William MANAGING TODAY’S Isilver lining of the recession is Mazzei, MD, medical director of pe- OR SUITE. that surgeons and staff may be more rioperative services and clinical Seminars to teach accepting of changes to the schedule professor of anesthesiology at the management tools...... 5 than they might be otherwise. University of California, San Diego. LEGAL ISSUES. With the decline in elective “What is important to surgeons Settlement on kyphoplasty surgery from the economic down- is good use of their time at one fa- billing...... 6 turn, surgeons are less able to cility rather than playing one facil- OR THROUGHPUT. leverage one hospital against an- ity against another. They don’t A toolkit for managing other. have the business to do that any block scheduling ...... 9 In all, by the end of March 2009, more.” OR THROUGHPUT. 59% of hospitals were seeing a mod- Facilities may be able to enforce The research on OR time erate or significant decrease in elec- stricter rules to improve OR utiliza- allocation ...... 11 tive procedures, the American Hos- tion, he says. With more OR time OR BUSINESS pital Association reports. available, they may be able to en- MANAGEMENT. “This is allowing hospitals to Continued on page 8 A vendor policy for a large system ...... 16 OR business management OR BUSINESS MANAGEMENT. RACs: What is the OR’s role in readiness?...... 19 Solving the patchwork quilt JOINT COMMISSION. of credentialing for vendors Educating patients on SSI prevention ...... 21 ould you like to be on 60 “We feel industry representa- Minutes and answer the tives have a role in training and use PROCESS IMPROVEMENT. question as to why the of equipment,” says Fred Perner, Applying the Surgical W MBA, JD, vice president of busi- Apgar Score ...... 23 supplier who had TB was allowed in the OR?” asks Tom Hughes, MBA, ness development for AORN. “The AMBULATORY executive director for Strategic Mar- question is how do you balance SURGERY CENTERS. ketplace Initiative (SMI), a nonprofit that with patient safety?” ASCs seek to get policy One strategy is the booming message across ...... 26 consortium of providers and suppliers from the healthcare supply chain. business of vendor credentialing. AMBULATORY “Let’s head off that question.” But credentialing of vendors comes SURGERY CENTERS. Vendors play a valuable role in with its own challenges. A lack of Testing practices need a closer look ...... 28 the OR, but how can OR managers standardization for credentialing ensure staff and patients receive requirements, the need for vendors AT A GLANCE...... 32 what they need while managing to register for the multiple hospi- potential risks? Continued on page 14

Upcoming Editorial

SCIP: What’s the status? hy does health care cost Is all the work on the Surgical so much more in some Care Improvement Project making a Wcommunities than oth- difference? ers, with no apparent difference in Why“ are outcomes? Big variations have been A warranty for surgery documented for more than 20 years costs so much One price covers surgery and by the Dartmouth Atlas Project. higher? any complications for 90 days. One way to find out—hit the road. Learn how it works. That’s what surgeon and storyteller extraordinaire Atul Gawande, MD, The monthly publication did recently. He headed for McAllen, for OR decision makers What McAllen“ does have more of Texas, which has some of the nation’s are services—more testing, hospital highest costs for Medicare patients. treatment, surgery, and home care. July 2009 Vol 25, No 7 You may recognize his name as a dri- Dr Gawande observes there also OR Manager is a monthly publication for ving force behind the World Health personnel in decision-making positions in seems to be a higher prevalence of the operating room. Organization’s surgical safety check- physicians in McAllen who see their list and a major study on retained Elinor S. Schrader: Publisher patients as a revenue stream. foreign objects. He also wrote the Patricia Patterson: Editor As he talks with physicians and best-selling books Complications and Judith M. Mathias, RN, MA: executives, he hears that something Clinical editor Better. He tells his story about the trip began to change in McAllen about Kathy Shaneberger, RN, MSN, CNOR: to McAllen in the June 1, 2009, New 15 years ago—“the medical commu- Consulting editor Yorker. nity came to treat patients the way Paula DeJohn: Contributing writer McAllen providers spent on aver- subprime-mortgage lenders treated Karen Y. Gerhardt: Art director age $15,000 per Medicare enrollee in home buyers: as profit centers.” OR Manager (USPS 743-010), (ISSN 2006—almost twice the national av- In most communities, he ob- 8756-8047) is published monthly by OR erage. This got his attention, given Manager, Inc, 1807 Second St, Suite 61, serves, physicians have a mix of atti- Santa Fe, NM 87505-3499. Periodicals the predictions that Medicare could tudes about money; some place a lot postage paid at Santa Fe, NM and addi- be broke by 2017. tional post offices. POSTMASTER: Send of emphasis on revenue while oth- address changes to OR Manager, PO Box What’s up in McAllen? ers see it as secondary to patient care 5303, Santa Fe, NM 87502-5303. In McAllen, he searched for rea- and clinical interests. McAllen’s OR Manager is indexed in the Cumulative sons for higher costs. The city has a medical community, on the other Index to Nursing and Allied Health Lit- hand, tends to be “at one extreme” erature and MEDLINE/PubMed. high poverty rate and a high inci- in their focus on finances. Copyright © 2009 OR Manager, Inc. All dence of heavy drinking and obe- rights reserved. No part of this publica- sity, but its rates of heart disease, Dr Gawande then looks at com- tion may be reproduced without written smoking, asthma, and other condi- munities and organizations that permission. tions are lower than average. El Paso have controlled costs and achieved Subscription rates: Print only: domestic $99 County, further north along the higher quality. Among these are the per year; Canadian $119 per year; foreign Mayo Clinic; the city of Grand Junc- $139 per year. Super subscriptions (in- Mexican border, has basically the cludes electronic issue and weekly elec- same demographics but had tion, Colorado; and Intermountain tronic bulletins): domestic $149 per year; Medicare expenditures half of Healthcare in Salt Lake City. Canadian $169 per year; foreign $179 per The contrast between them and year. Single issues $24.95. Subscribe online McAllen’s in 2006, at $7,504. By at www.ormanager.com or call comparison, in Rochester, Min- McAllen, he believes, “is a battle for 800/442-9918 or 505/982-1600. nesota, home of the Mayo Clinic, the soul of American medicine.” To Email: [email protected]. Medicare spending is in the lowest him, the question the nation needs Editorial Office: PO Box 5303, Santa Fe, 15% in the country, at $6,688 per en- to ask is “whether the doctor is set NM 87502-5303. Tel: 800/442-9918. up to meet the needs of the patient, Fax: 505/983-0790. rollee in 2006. Email: [email protected] Dr Gawande finds no evidence first and foremost, or to maximize Advertising Manager: Anthony J. Jannetti, McAllen’s treatments and technolo- revenue.” Inc, East Holly Ave/Box 56, Pitman, NJ gies are better. McAllen’s 5 largest —Pat Patterson 08071. Telephone: 856/256-2300; Fax: 856/ 589-7463. John R. Schmus, hospitals actually performed worse Dr Gawande’s article is free at national advertising manager. than El Paso’s on 23 of Medicare’s 25 www.newyorker.com/reporting/ Email: [email protected] quality metrics. 2009/06/01/090601fa_fact_gawande

July 2009 OR Manager Vol 25, No 7 3 Don’t take a vacation from keeping up with the latest information on management of the OR. Summertime is a time for learning! Introducing the OR Manager webinar series. With many health care facilities reducing educational funding and restricting travel, OR Manager is making our education programs more accessible through a new series of webinars on OR management. Pour yourself some lemonade and brighten your summer with these outstanding presenters! The webinar All sessions are an hour long and offered on Thursdays series for new (unless otherwise noted) at 2:00 pm eastern time managers will begin (1:00 pm central; 12 noon mountain; 11:00 am Pacific). on October 22 and Learn and earn 1 CEU for each session. continue through December Connie Curran, RN, EdD, FAAN July 23 Developing a Balanced Scorecard July 30 Implementing the Balanced Scorecard Christy Dempsey, RN, MBA, CNOR August 6 Assessing and Developing of a Patient Flow Improvement Project August 13 Implementing a Successful Patient Flow Improvement Project Jo Manion, RN, PhD, NEA-BC, FAAN August 19 The Engaged Workforce: Keeping Morale High During Tough Times (Wednesday) Keith Siddel, MBA September 3 Improving the OR Revenue Cycle October 1 Taming the Charge Description Master William J. Mazzei, MD September 10 The Perils and Pitfalls of Block Scheduling

Get more information and register at www.ormanager.com Managing Today’s OR Suite Seminars to teach management tools anaging the Lean way, S-2: Orientation, block utilization, reduced case time keeping employees en- Onboarding, and after 5 pm, and more. gaged, stopping bad be- Employee Development M S-5: Management havior, improving patient flow, Judy Pins Strategies to Stop Bad and getting the most out of the Lessons from a progressive new Behavior for Patient sterile processing department are hospital about bringing employees Safety among topics for 8 all-day semi- on board successfully and keeping Grena Porto nars being offered Wednesday, Oct them engaged throughout their ca- The speaker offers a road map 7, at the Managing Today’s OR reers. Suite Conference. The conference for recognizing bad behavior, set- runs Oct 7 to 9 at Caesars Palace in S-3: Financial Skills for ting behavioral standards, and de- Las Vegas. New Managers veloping a code of conduct to im- Especially for new OR man- Sherry Church, Gina Brennan prove patient safety. agers, a seminar on financial skills This session will help managers S-6: Appreciative will provide tools managers need learn the vocabulary of finance and Leadership: Focus on to make and support good deci- acquire financial skills needed to What’s Going Right sions. understand reports and make good Jo Manion management decisions. S-1: Operational In this energizing session, the Excellence: Using Lean in S-4: Moving Beyond the speaker explores elements of ap- the OR Double Doors: A Journey preciative leadership and concrete, Jenn Lingenfelter, Pamela on Improving Patient Flow positive approaches for addressing Murphy Christina Dempsey, Sherron C. issues in the work environment. Weeding waste out of OR Kurtz, Kenneth G. Murphy S-7: SPD and the OR: processes will be the focus of this A hospital shares its journey to Different Issues, Common seminar focusing on Lean manu- optimize flow, resulting in less wait Goals facturing, pioneered by Toyota. time for urgent patients, better Cynthia Spry, Martha Young The speakers will offer strategies for building a foundation so Advisory Board both departments can understand

Renae Battié, RN, MN, CNOR Kathleen F. Miller, RN, MSHA, CNOR each other’s needs and improve Seattle Senior clinical consultant, Catholic Health Ini- processes. Ramon Berguer, MD tiatives, Denver Chief of surgery, Contra Costa Regional Med- David A. Narance, RN, BSN, CRCST S-8: Magic of Frontline ical Center, Martinez, California Manager, sterile processing, MedCentral Leadership: Secrets of Mark E. Bruley, EIT, CCE Health System, Mansfield, Ohio Vice president of accident & forensic Shannon Oriola, RN, CIC, COHN Accountability and investigation, ECRI, Plymouth Meeting, Penn- Lead infection control practitioner, Sharp Engagement sylvania Metropolitan Medical Campus, San Diego Jayne Byrd, RN, MSN Cynthia Taylor, RN, BSN, MSA, CGRN Brian Lee Associate vice president, surgical services, Nurse manager, Endoscopy & Bronchoscopy Rex Healthcare, Raleigh, North Carolina Units, Hunter Holmes McGuire VA Medical An expert on employee satisfac- Robert G. Cline, MD Center, Richmond, Virginia tion teaches about creating incen- Medical director of surgical services, Munson Dawn L. Tenney, RN, MSN tives to improve productivity and Medical Center, Traverse City, Michigan Associate chief nurse, perioperative services, Franklin Dexter, MD, PhD Massachusetts General Hospital, Boston offers practical tools for creating Professor, Department of anesthesia and health Judith A. Townsley, RN, MSN, CPAN world-class patient, staff, and management policy, University of Iowa, Iowa Director of clinical operations, perioperative City services, Christiana Care Health System, physician satisfaction. Dana M. Langness, RN, BSN, MA Newark, Delaware Senior director, surgical services, Ena M. Williams, RN, MSM, MBA Download a conference brochure and Regions Hospital, St Paul, Minnesota Nursing director, perioperative services, Yale-New Kenneth Larson, MD Haven Hospital, New Haven, Connecticut register online at www.ormanager.com Trauma surgeon, burn unit director, Terry Wooten, Director, business & material re- Mercy St John’s Health Center, sources, surgical services & endoscopy, Springfield, Missouri St Joseph Hospital, Orange, California

July 2009 OR Manager Vol 25, No 7 5 Legal Issues Settlement on kyphoplasty billing

n the first settlement of a national investigation, HealthEast What is the False ICare System agreed in May to Claims Act? pay the federal government $2.28 Settlement“ million to settle allegations that 3 is only the The False Claims Act and its of its hospitals overbilled Medicare amendments create incentives for for kyphoplasties. beginning. people who know about fraud Some 100 hospitals are under in- against government programs vestigation, according to the legal like Medicare to disclose the in- expert who represented Health- formation by filing a whistleblower (qui tam) lawsuit. East. The investigation is being led quired Kyphon“ in 2007. The com- Some specifics: by the US Attorney for the Western pany did not admit wrongdoing. District of New York in Buffalo. • Anyone who presents or The settlement involves kypho- Whistleblower allegations causes to be presented false or plasties performed from 2002 The whistleblowers’ original fraudulent claims to the US through 2007 at St Paul, Min- complaint, filed against Kyphon government or makes false nesota-based HealthEast’s St and a Buffalo hospital and recently statements to induce the gov- Joseph’s Hospital, St John’s Hospi- unsealed, alleged Kyphon started ernment to pay false claims is tal, and Woodwinds Hospital. in 1999 to develop a marketing liable for a civil penalty of The investigation stems from a scheme “to exploit high reimburse- $5,500 to $11,000 for each whistleblower lawsuit filed in 2006 ment under inpatient DRGs to per- claim, plus 3 times the by 2 former employees of Kyphon, suade hospitals to perform kypho- amount of damages the gov- Inc, the company that developed plasty.” ernment sustains. balloon kyphoplasty. Kyphon was highly profitable, • Anyone having information Kyphoplasty, a treatment for according to the court filings, with about false claims can bring spinal fractures caused by osteo- the profit margin on its products an action for herself or him- porosis or cancer, involves using a ranging from 87% to 92%. self and the government and balloon catheter to create a cavity DRGs that Kyphon recom- share in any recovery, receiv- in the fractured bone and filling the mended paid hospitals about ing 15% to 30% of the total cavity with bone cement. $6,000 to $10,000 depending on the amount recovered. The suit alleged that Kyphon area of the country. That compared • The act provides protections conducted a fraudulent marketing with outpatient reimbursement of for whistleblowers. campaign that induced hospitals to about $2,000 in 2005, according to bill Medicare for kyphoplasty as an the court filing. whether the patient had been ad- inpatient procedure even though Billings for unnecessary inpa- mitted for an inpatient stay. If not, the procedure can be performed tient admissions are considered the sales rep allegedly would safely as an outpatient procedure. false claims, which are illegal arrange for the physician to sign “By keeping patients overnight, under the federal False Claims Act orders for inpatient admission in hospitals could seek greater reim- (sidebar). the OR. bursement from Medicare and Among allegations are that Also part of the allegedly fraud- make much larger profits on kypho- Kyphon representatives met with ulent scheme was to market an in- plasty,” said Kathleen Mehltretter, coders and medical record depart- strument for performing bone acting US Attorney in Buffalo. ments to explain how to code and biopsies during kyphoplasties. The HealthEast says it “cooperated bill the charges to ensure payment company, according to the whistle- fully” with the investigation, and no under the DRGs. blower suit, advised physicians penalties are involved. Court documents also say sales they had to perform bone biopsies In 2008, the government reached reps would be present in the OR on every patient regardless of med- a $75 million settlement with during kyphoplasty and were ical history or condition. Medtronic Spine LLC, which ac- taught to ask the OR nurses

6 OR Manager Vol 25, No 7 July 2009 Legal Issues

Only the beginning dressed are less likely to consider fil- The HealthEast settlement is ing a whistleblower suit. only the beginning, says Ronald H. One way he judges if a hospital “ has a good compliance plan is to Clark, PhD, JD, the legal consultant who represented HealthEast and Consequences ask any employee, “Who’s your an expert on the False Claims Act. can be severe. compliance officer?” If he gets a “Basically, every hospital per- blank stare, he knows something is forming kyphoplasty could poten- lacking. tially be a subject of this investiga- Every employee should have tion,” he says. easy access to pertinent parts of the compliance plan. Two ideas are to He says HealthEast ran into “Have your“ plan reviewed. provide color-coded notebooks or problems despite having what he Make sure it is effective, supported post information about the plan on calls “the best compliance plan I with adequate resources and that the hospital’s intranet. have ever seen in a hospital. This you have a good compliance offi- “The consequences of not being shows you no compliance plan will cer,” he advises managers. proactive for hospital management catch everything.” The settlement holds other are severe,” he says. “It can mean The settlement holds lessons for lessons. Be sure the hospital has a huge amounts of money, affect hospitals and OR leaders, not only policy stating that contact between your Medicare eligibility, and if on billing for kyphoplasty but for employees and outside vendors you have a building project, it can any new technology introduced in and independent physician groups affect any bonds that require ap- a hospital. must be authorized, he advises. proval from HHS.” The immediate lesson—if the Compliance officers need to be US Attorney comes calling, cooper- aware of whom employees have Ronald Clark’s website is at ate, Clark advises. Kyphoplasty contact with because under the http://fcaexpert.com billing problems are easy to un- law, the hospital will be treated as cover, says Clark, who was for- though it was fully aware of what merly a senior counsel in the Civil was going on. Fraud Division of the US Depart- Also, though nothing precludes C difficile ment of Justice. Investigators can a salesperson from being in the OR simply run a computer report on a to make sure a device is used cor- infection rising hospital’s claims. If most kypho- rectly, “the danger is that in many in hospitals plasties come up as inpatient, hospitals in which kyphoplasty that’s a red flag. was performed, sales personnel Clostridium difficile is more He says HealthEast came out were giving billing advice,” he prevalent in hospital patients than reasonably well because it cooper- says. “That can work its way into previously estimated. The majority ated fully with the US Attorney. becoming a billing rule, and that of cases appear to be health care as- Clark outlines the approach hos- becomes a problem.” sociated, finds a new survey. pitals should take in his blog at Another lesson: Include the The survey, completed by 648 http://fcaexpert.blogspot.com/20 compliance officer in the product hospitals, found 13 in 1,000 inpa- 09/02/new-national-kyphon- evaluation process to make sure tients were either infected or colo- plasty-enforcement.html procedures involving new prod- nized with C difficile—a rate 6.5 to For those who don’t cooperate, ucts are billed appropriately. 20 times higher than previous esti- he says penalties can be much mates, which the authors say is a more severe. The government can Educate employees minimal estimate. William Jarvis, assess $5,500 to $11,000 per each Employees and managers need MD, the principal investigator, said piece of paper associated with a to be educated about the compliance preventing C diff development and false claim plus treble damages. plan, Clark adds. They should know transmission should be a top prior- who the compliance officer is and Best defense ity for every institution. feel comfortable going to the officer —Jarvis W R, Schlosser J, Jarvis A Clark says a hospital’s best de- with any concerns. Employees who fense is to invest in a “top-notch A, et al. Am J Infect Control. feel comfortable reporting concerns 2009;37:263-270. compliance plan. and know their concerns will be ad-

July 2009 OR Manager Vol 25, No 7 7 OR throughput

Continued from page 1 managing the block schedule, says Stephanie Davis, RN, MS, CNOR, courage surgeons to stay at the fa- assistant vice president, surgical cility longer than they might have Policies“ services for the HCA Clinical Ser- in ordinary times. must be vices Group of HCA Inc, the na- For example, if the OR has al- tional health care company based lowed some surgeons to have half- transparent. in Nashville, Tennessee. day blocks, which is not optimal The surgeon’s office often sched- for utilization, it may be easier to ules the cases. The office may be make these full-day blocks. scheduling some cases outside the If the surgeons object, the facil- block because these other times are ber of studies “on OR time alloca- ity might respond by saying it will more convenient, she notes. tion, including use of contribution convert these blocks to open time “If we are not transparent with margin (related article, p 11). into which anyone can schedule surgeons about their utilization, cases. In this environment, most Good governance they may not know they are not surgeons will accept the change, Nothing is more important to ef- meeting the target. They may vol- says Dr Mazzei, who is also with fective block scheduling than unteer on their own to adjust their Surgical Directions LLC, Chicago- strong, active leadership, these ex- block,” she says. based consultants. perts say. The block scheduling Open communication is also It may also be easier to match system must be governed by poli- part of customer service. staffing more closely to the surgical cies and procedures endorsed by “If you have a good relationship schedule, he notes. In a down the medical staff and enforced by with your surgeons, they will trust economy, staff may be more ac- the OR’s governing body. Policies you to manage blocks fairly,” says cepting of scheduling changes. must be transparent. Davis, who has assembled a block The business of blocks “The system must be scrupu- scheduling toolkit for HCA Inc’s With fewer cases, ORs need to lously fair. If there is any fa- 165 hospitals (related article, p 9). voritism, the surgeons will sniff it pay close attention to how sur- Starting a conversation out, and it will never work,” geons’ block time is affecting their Good relationships make it eas- stresses Tom Blasco, MD, MS, an business, comments Jerry Ippolito, ier to start a conversation if a sur- anesthesiologist and intensivist at MBA, MHSA, of consultants OR geon’s block utilization is not what Advocate Lutheran General Hospi- Efficiencies LLC, Naples, Florida. is expected. Davis says that when tal, Park Ridge, Illinois, and a con- When a surgeon asks for block she was a perioperative director, sultant with Surgical Directions time, he suggests the question should she talked to the surgeons about LLC. be: “What are you going to bring low utilization as soon as she The OR governing body must us?” How will the surgeon’s cases found out. be committed to ongoing measure- benefit the hospital? He advises pos- She might say, for example, “Dr ment and evaluation, Ippolito ing the same question to surgeons Smith, I hope you got your letter adds. “Many organizations allocate who already have block time. about block utilization. Did you re- block time to a surgeon and never The block time analysis should alize you were only running about look at it again, whether the sur- include not only how much of their 35%? Do you want to move your geon uses it or not.” block time surgeons are using but block to a different day? What can I When blocks are poorly man- also the contribution margin of do to help you get your utilization aged, surgeons have bad experi- their cases. (Contribution margin = where it needs to be?” ences and may end up rejecting revenue – variable costs, such as Efforts to manage the block block scheduling all together. (For implants and specialty staffing). schedule can be worth it because more on OR governance, see the The contribution margin should be everyone benefits, Dr Mazzei ob- July 2008 OR Manager.) calculated before indirect costs are serves. allocated and should include rev- Communication is a “The workday is more enjoyable enue and expenses for the sur- corollary for physicians and staff alike in geon’s patients hospitalwide, not Communicating with surgeons hospitals that have completely full just for the OR, he adds. about their blocks is essential in The literature includes a num- Continued on page 12

8 OR Manager Vol 25, No 7 July 2009 OR throughput A toolkit for managing block scheduling

CA Inc, the national health care company, has devel- Suggested block Hoped a block scheduling release times toolkit for its 165 hospitals. The Open“ time toolkit includes decision points, al- is a strategic Burn service (inpatient) 1 day gorithms for managing blocks, and Cardiac 1 day sample policies. issue. General surgery 7 days Here are HCA Inc’s 10 decision Gynecology 7 days points for block scheduling. Head and neck 7 days Is this the right time for Neurosurgery 4 days . block scheduling? such as ENT and“ ophthalmology, 1 Ophthalmology 7 days and can schedule far in advance. About 75% to 80% of HCA Inc’s Even in an OR with all open Orthopedics (joint) 14 days hospitals use block scheduling, es- time, surgeons tend to establish Orthopedics (spine) 3 days timates Stephanie Davis, RN, MS, patterns that are, in effect, like Pediatrics 7 days CNOR, assistant vice president, block time. surgical services for the HCA Clini- Plastic (cosmetic) 14 days Leaders may have success get- cal Services Group, Nashville, Ten- Radiology 3 days ting the surgeons to accept block nessee, who developed the toolkit. scheduling if they show them data Vascular 2 days If an OR isn’t using block sched- demonstrating that their cases al- Thoracic 3 days uling, she suggests asking: “What ready fall into regular patterns, he are the reasons for not offering this suggests. Source: William J. Mazzei, MD; service? Are those reasons still How much time should be Tom Blasco, MD. OR Manager. valid in today’s environment?” blocked? Typically, 55% to 80%, 2004;20(11):1, 9-12. Not every OR decides to use though how much open time to block allocations. “If you don’t offer depends on the situation, Ip- have a lot of volume and are trying Davis says monitoring of blocks re- polito says. A high-volume trauma to get every case you can, you quires discernment: “Your OR gov- center can’t allocate as much time might not want to rock the boat ernance team has to look at each as an OR with a more predictable with the medical staff,” she notes. situation and be able to back up its caseload. How much time to leave In some parts of the country, decisions with facts.” open is also a strategic issue. A “surgeons are really anti-block,” (From a scientific point of view, more mature setting may have 80% says Jerry Ippolito, Jerry Ippolito, adjusting blocks according to uti- to 85% of its time blocked, while a MBA, MHSA, director of periopera- lization isn’t the best choice, notes a facility trying to attract new sur- tive services and pain management leading researcher, Franklin Dexter, geons will want more open time business development, Southeast MD, PhD. See related article, p 11.) available. Anesthesiology Consultants, Char- • Automatic block release times are lotte, NC. Does your block scheduling stated and enforced consistently That can happen if they have 2. policy include key elements? for all surgeons. In a general OR with a lot of specialties, a 72-hour had a bad experience. To some, Davis suggests key elements of block scheduling means “preferen- release is appropriate, Davis says. the policy should include: “Some will argue 48 hours is bet- tial treatment.” Surgeons may be • A block utilization rate is calcu- more receptive to another term, ter; others will argue 1 week. You lated monthly and reported to have to decide with your group such as “reserved time,” he sug- each surgeon quarterly. The gests. what fits.” One option is release toolkit recommends a block uti- times by specialty (sidebar). An OR schedule with all open lization rate of 70%. But there is time has its own problems, he • The policy states that if a sur- no hard-and-fast rule, Davis says. geon notifies the OR in advance adds. Open time favors surgeons “It’s up to our facilities to set the who perform mostly elective cases, level they think is appropriate.” Continued on page 10

July 2009 OR Manager Vol 25, No 7 9 OR throughput

Continued from page 9 John’s Regional Health Center, a regional trauma center in Spring- to release block time, unused field, Missouri, to increase its sur- time will not count against the Accurate“ gical volume by 5%, increase sur- surgeon in the block utilization data is geon revenue by 4.6%, reduce the report. Advanced notice allows need for ORs after 3 pm, and re- other procedures to be booked critical. duce overtime. The project was into the unused time. part of an effort to smooth patient Is there a physician flow throughout the hospital. (See 3. champion? November 2003 and January 2005 OR Manager.) Blocks are best managed by an approach to communication.“ For executive committee made up of example: Is the schedule the OR director, the administrator • A letter of congratulation is sent 8. accurate? responsible for surgery, the chief of to surgeons with a block utiliza- Are your OR analyst and sched- surgery, and the chief of anesthesia. tion rate of 70% or greater. ulers making sure the schedule is “Everyone on the committee has • Surgeons with utilization of 70% accurate so utilization reports will a vested interest in making block to 50% are informed they have reflect accurately each surgeon’s scheduling work,” Davis notes. not met the threshold and asked block use? Accurate data is critical The physician champion helps to decrease the time blocked or to when reporting block utilization to to monitor and enforce the block consider changing their day or surgeons. schedule and communicate with time to improve usage. the surgeons. • Surgeons whose utilization falls Are you willing to enforce the block scheduling policy fairly? “Communication goes over bet- below 50% are informed they are 9. ter if the surgeon receives it from a well below the threshold, and if Effective block scheduling re- peer,” she notes. they do not bring their utilization quires maintenance and enforce- The physician champion, with to 70% or above by the end of the ment of rules, Davis says. The the OR director, should be willing to next quarter, they will lose the HCA Inc toolkit provides a sample sign letters to the surgeons inform- privilege of having a block. policy for block scheduling. ing them of their block utilization. Are at least 1 or 2 ORs Will the administration Is there a 6. reserved for first-come, 10. support the block sched- 4. grace period? first-served booking? uling policy? The block scheduling policy al- “Having open rooms allows Effective block scheduling allows surgeons a 3-month grace pe- new surgeons to book occasional ways comes back to good gover- riod to improve their block utiliza- cases in your OR and allows for re- nance. The administration must tion once informed of their utiliza- cruitment of new business,” Davis support the surgical executive tion rates, the toolkit advises. notes. committee that reviews the block “Our plan is to inform surgeons Do you have 1 OR for add- allocations and not overturn their of their block utilization once a 7. ons, emergencies, and flip- decisions. quarter but to tell them we will flopping of cases? wait one more quarter before References doing anything to their block to “In small ORs, this might not be Hospital moves to smooth surgery allow for variances,” Davis says. possible, but in medium to large schedule. OR Manager. 2003; ORs, it is effective,” Davis says. 19(11):11. How is the utilization rate Open rooms provide flexibility communicated? Questions managers ask about pa- 5. to move cases and add cases. There tient flow. OR Manager. 2005; “It’s important to communicate may be exceptions for facilities 21(1):20-21. with every surgeon. If they have a such as eye centers where routines Smoothing OR schedule can ease block, you communicate with them are well established. The rule is not capacity crunches, researchers once a quarter, regardless of their rigid; the point is to have flexibility. say. OR Manager. 2003;19(11):1, 9- utilization,” Davis says. Providing an add-on room for ur- 10. The toolkit recommends a tiered gent and emergent cases enabled St

10 OR Manager Vol 25, No 7 July 2009 OR throughput The research on OR time allocation hat criteria should be 2. Utilization is poorly related to used to make decisions contribution margin. A surgeon Wabout adjusting block or service with high utilization time? Traditionally, OR committees Making“ can still lose the hospital money if have used surgeons’ utilization of decisions on reimbursement for these cases blocks. But OR utilization isn’t the doesn’t cover costs. best way to make this decision, the adjusting time. 3. Efforts to increase utilization can research shows. actually reduce margins. For ex- The method to use depends on ample, the hospital signs an in- why block time is being adjusted, surance contract hoping to increase surgical volume, but not notes Franklin Dexter, MD, PhD: nancial goals, “Dr Dexter says. The many of the patients have Are blocks being adjusted for oper- OR committee might, for example, surgery, and the contracted rates ational reasons; that is, to match look at the contribution margin for are too low to cover costs. staffing to the existing OR work- spinal surgery to decide if giving the 4. Utilization is poorly related to load? Or are blocks being adjusted neurosurgeons more block time variable costs. Surgeons with for tactical reasons, such as to pro- would help the hospital financially. equal utilizations can have differ- vide more convenient access to OR (Contribution margin = revenue – ent variable costs. For example, 2 time for some surgeons? variable costs.) More spinal surgery surgeons have 70% block utiliza- Consider these scenarios: might or might not be a good idea, tion. The first surgeon performs depending on the implant costs and Scenario 1: Tactical outpatient breast surgery, which the reimbursement. decision has low variable costs per OR Tactical decisions also include A group of neurosurgeons has hour. The second surgeon per- strategic issues. Dr Dexter says 91% utilization of their block time. forms joint replacements, which “revenue” should be considered They’re recruiting a new spine sur- have high variable costs per OR from a long-term perspective and geon and need more OR time. hour. should include not only reimburse- Dr Jenkins, a vascular surgeon, 5. For surgeons with low utiliza- ment but also the intangible value has 60% utilization of his block. It tion, it is questionable whether of adding more cases in a focused seems that he could use less time. utilization can be estimated suffi- strategic area. For example, execu- Should the OR committee take ciently precisely for this purpose. tives decide your hospital is going some of Dr Jenkins’s block time A 2003 study found, for example, to be a regional pediatric center. Of and give it to the neurosurgeons? that if during 1 quarter, Surgeon course, you will give your pedi- This is a tactical decision. 1 had a block utilization of 65%, atric surgeon a great deal of block and Surgeon 2 had a block uti- Scenario 2: Operational time, the cost and reimbursement lization of 80%, statistically, the decision issues aside. In this case, each addi- difference may be due to random The neuro service has a block al- tional pediatric patient has an in- chance. For surgeons with low location of 3 ORs on Mondays tangible value, known in econom- utilization, the study found it from 7:15 am to 3:30 pm. They ics as utility, Dr Dexter explains. have little underutilized time and would take more than 10 years of often have overutilized time (ie, Utilization not best choice data to measure block utilization run late). How many nursing staff for tactical decisions accurately enough to be of practi- should be assigned for 8 hours and Utilization is not the best choice cal value in making block-time how many for 10 hours? This is an for making tactical decisions on decisions. block time, Dr Dexter says, citing 5 operational decision. Operational decisions reasons from the literature: Operational decisions should be Tactical decisions 1. Utilization does not help to reduce made to improve OR efficiency, ac- For tactical decisions like Sce- patient waiting times, which is cording to research findings. For nario 1, decisions increasingly are usually a goal of patients as well as being made at least partly to meet fi- clinicians and administrators. Continued on page 12

July 2009 OR Manager Vol 25, No 7 11 OR throughput

Continued from page 11 neurosurgery because the neuro- Dexter F, Macario A, Traub R D, et surgeons are already getting their al. Operating room utilization this purpose, OR efficiency is de- cases on the schedule. Rather, the alone is not an accurate metric fined as a balance between under- for the allocation of operating purpose is to achieve a better bal- utilized and overutilized OR time. room block time to individual ance between underutilized and surgeons with low caseloads. If time is underutilized, revenue overutilized time. Anesthesiology. May 2003;98: isn’t coming in while the OR is in- “Generally, what surgeons care 1243-1249. curring labor costs. Overutilized about are tactical decisions: ‘How McIntosh C, Dexter F, Epstein R H. time means clinicians have to work can I grow my practice?’” Dr Dex- Impact of service-specific late, which is a dissatisfier and can ter says. “What anesthesiologists staffing, case scheduling, be costly if overtime is needed. and nurses generally care about are turnovers, and first-case starts Achieving OR efficiency in- on anesthesia group and operat- decisions on the day of surgery: volves matching the staffing alloca- ing room productivity: A tutorial ‘Will I finish on time?’” tion as closely as possible to the ex- using data from an Australian hospital. Anesth Analg. isting workload. More information on Dr Dexter’s 2006;103:1499-1516. In Scenario 2, depending on the research and consulting is at details of the neuro service work- O’Neill L, Dexter F. Tactical in- www.FranklinDexter.net creases in operating room block load, a decision based on OR effi- time based on financial data and ciency might be to increase the market growth estimates from neuro service’s OR allocation (or References data envelopment analysis. Anesth Analg. 2007;104:355-368. block) from 7:15 am to 6 pm in 2 of Dexter F, Blake J T, Penning D H, et the 3 ORs. The anesthesia providers al. Use of linear programming to Wachter R E, Dexter F. Tactical in- and nurses gain by having more estimate impact of changes in a creases in operating room block predictable work hours (ie, fewer hospital’s operating room time time for capacity planning overutilized hours). allocation on perioperative vari- should not be based on utiliza- able costs. Anesthesiology. March tion. Anesth Analg. 2008;106:215- The purpose of this block ad- 2002;96:718-724. 226. justment is not to encourage more

Block scheduling Infection prevention funding is cut Continued from page 8 ospitals are cutting staff, re- decreased. Nearly 40% had layoffs blocks, do lots of cases during the sources, and education for or reduced hours, and a third had day, and have limited overtime and Hinfection prevention, a sur- hiring freezes. limited nights and weekends,” he vey by the Association for Profes- “At a time when the federal gov- says. “They find this is a win-win sionals in Infection Control and ernment will be requiring hospitals situation.” That may not be obvious Epidemiology (APIC) shows. to meet national targets for HAI re- to people in systems that have had Of about 2,000 respondents, 41% duction, infection prevention depart- the same underutilized block times reported their budgets had been cut ments need to be growing, not for 20 years, he adds. Today’s envi- primarily because of the economic shrinking,” APIC’s president said. ronment may create the opportu- downturn. Of these, 75% said edu- HAI are health care-associated in- nity to change that situation. cation on infection prevention had fections. —Pat Patterson

Stephanie Davis will speak on block group and operating room pro- Patterson P. Is your OR’s governing scheduling at the Managing Today’s OR ductivity: A tutorial using data structure up to today’s intense de- Suite Conference Oct 7 to 9 in Las Vegas. from an Australian hospital. mands? OR Manager. 2008;24(7):1, Anesth Analg. 2006;103:1499-1516. 6-7. References Patterson P. A few simple rules for Wachter R E, Dexter F. Tactical in- McIntosh C, Dexter F, Epstein R H. managing block time in the oper- creases in operating room block Impact of service-specific staffing, ating room. OR Manager. 2004; time for capacity planning should case scheduling, turnovers, and 20(11):1, 9-12. not be based on utilization. Anesth first-case starts on anesthesia Analg, 2008:106:215-226.

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

With the AORN Leadership Specialty Assembly

For a conference brochure and to register online, go to www.ormanager.com. OR business management

expectations, and infection control Joint practices differently. Commission’s “Some hospitals ask for vaccina- perspective More“ is tions, and some don’t ask for any,” needed to reduce says John Wills, founder and presi- On April 15, 2009, the Joint dent of Status Blue, LLC, a third- Commission posted a response confusion. party credentialing verification or- on its website to a question about ganization (CVO). Companies like standards that address vendor Status Blue use databases and soft- representatives in clinical areas. ware to manage sales rep credentialing; vendors pay an annual pro- The commission says it does not took another step“ toward consis- cessing fee to be included. have specific standards or cre- tency, releasing Joint Best Practices dentialing requirements in this Recommendations for Clinical Health Reciprocity needed area because accepted national Care Industry Representative Creden- “In a perfect world, you do the standards on competence for tialing at the AORN Congress in paperwork once and be squared vendor reps are lacking. March 2009. The recommendations away for all the hospitals,” says But the commission notes, “… include credentialing criteria repre- Wills. In essence, there would be reci- some organizations are recom- senting best practices from 11 orga- procity. Variations in hospital require- mending general credentialing nizations and are designed to pro- ments make reciprocity difficult. requirements for these individu- vide guidance for streamlining “The notion of there being a ‘one als” and refers readers to Ad- vendor credentialing. size fits all’ industry guideline and vaMed’s website (www.ad- Perner says the organizations documentation repository sounds vamed.org). hope the recommendations will good in principle but is difficult to The commission also cites sev- help OR managers establish a ven- conceptualize in real-world prac- eral standards relevant to any dor credentialing policy. tice,” says Wills. “Best practices and person who enters a health care “It’s also important to deter- industry guidelines are important, organization and affects the qual- mine how to implement the policy and we need more consistency with ity and safety of patient care. and communicate it to others so vendor credentialing, but if clini- —www.jointcommission.org/ it’s followed,” he adds. cians have to meet different require- AccreditationPrograms/Hospitals/ Some hospitals have used med- ments and medical staff expecta- Standards/09_FAQs/HR/ ical credentialing as a template for tions for each facility so they can be hc_industry_vendor_ vendor credentialing, but Terry on staff or have privileges, why representatives.htm Chang, MD, director of legal and would the industry operate differ- medical affairs for AdvaMed, says Continued from page 1 ently for vendors?” there’s a difference. “With physi- The good news is most third- tals they service, and costs of the cians, it makes sense to have pri- party CVOs allow sales representa- process all play a role. mary source verification such as tives access to all the hospitals in a In 2006, SMI took a step to help graduation from medical school. single system rather than charging end the patchwork quilt of creden- That kind of rigor makes sense be- the system for each hospital. tialing requirements by publishing cause of the risk. But the risk [from “Reps can log on and send their Management Guidelines for Vendor Ac- what a vendor does] is not the profile with their credentials at- cess (www.smisupplychain.com). same as practicing medicine.” tached to whomever they want,” “We identified the need for ven- Who’s on first? says Wills. “It’s the equivalent of dor management from a safety and sending an email with a link.” That More is needed to reduce confu- quality standpoint,” says Hughes. includes other CVOs the vendor sion. “Suppliers are asking who’s might want to register with. on first, who’s on second,” says New joint best practices The AORN recommendation en- Hughes. “What are we supposed AORN and the Advanced Med- courages hospitals to “institute a to be doing for each system?” ical Technology Association (Ad- policy of reciprocity,” which, along Vendor credentialing require- vaMed), which represents medical with a coordinated credentialing ments vary because individual device manufacturers, recently process, could save resources. CVOs hospitals interpret risk, industry

14 OR Manager Vol 25, No 7 July 2009 OR business management

bership model, defined as “a single Credentialing annual fee good for all installations verification of the same branded service solu- organizations Who“ tion,” in which a vendor represen- bears the tative’s membership grants access to unlimited hospitals for one fee. REPtrax cost? CVOs deny fees are out of line, 214/222-7484 citing costs of annual updates www.reptrax.com needed to meet hospital requirements for TB testing and liability Status Blue insurance, adding new hospitals, 866/383-2583 not efficient,” given“ the amount of and technology costs. www.status-blue.com work involved. He says hospitals “Nearly all vendors find our typically charge $100 to $250 per business model to be fair and equi- Vendor Credentialing sales rep, although one system table compared to alternative busi- Service charges $400 per rep. ness models or hospitals charging 281/ 863-9500 The second option is for ven- individually,” says Wills. www.vcsdatabase.com dors to pay CVOs. Wills sees his Hughes proposes a novel third and other companies as time option: funding by group purchas- VendorClear savers for the hospital. ing organizations (GPOs) such as 888/850-7484 “Everyone is busy enough so Novation, Premier, MedAssets, and https://secure.vendorclear.com why not log into a system that others. The cost to fund credential- other hospitals in your area are Vendormate ing would come from the adminis- using?” he says. “You can monitor 877/483-6368 trative fee (typically up to 3% of and track visitors. It’s apparent to www.vendormate.com total volume) GPOs can charge. He the staff this person isn’t an em- believes this option would lower the ployee. If they have the badge on, typically provide an option in case number of credentialing companies then it’s thumbs up.” of emergencies. For example, a pa- down to “3 or 4,” also reducing the Hughes says the drawback of tient who arrives in the ED has a number of companies a vendor this option for vendors is, “an an- pacemaker from a manufacturer the must register with. nual fee, even though 90% of work hospital doesn’t have a contract is done in the first year. It’s like the with, and the manufacturer’s repre- What’s next? Energizer Bunny for cash flow.” He sentative needs access. In cases like Perner says the recent joint rec- also worries that larger manufac- this, hospitals can allow the vendor ommendations are, “a living docu- turers, which can better afford the entry into the OR. ment. More organizations can join, fees, have an unfair advantage “The system then badges the and we welcome input.” over smaller companies. rep as a vendor visitor and records Hughes at SMI also welcomes “Of 3,000 manufacturers, about the visits,” says Wills. AORN’s involvement, saying, 20 make up 60% to 70% of busi- “Their involvement is powerful. Who pays? ness,” Hughes says. “But you’re They cast a large net.” He also cau- Who bears the cost of vendor still dealing with nearly 3,000 man- tions, “Guidelines are not standard; credentialing? There are 3 options. ufacturers who deserve access to there will always be variation.” The Hughes opposes the first option, present their products. It needs to goal is to cut down on the variation, where hospitals charge suppliers. be managed carefully.” He also while still moving forward. “In “It’s like selling shelf space. I’ll wonders if antitrust charges by health care everyone wants it to be give you 3 feet of shelf space if you smaller companies could be a pos- perfect so they don’t do anything. give me a certain amount of sibility in the future. No matter what the solution, it money,” he says, adding, “I get Fee structure varies won’t solve everything.” very nervous when I see money —Cynthia Saver, RN, MS The fee structure for CVOs can going from suppliers to providers vary. The Independent Medical not for goods sold.” Cynthia Saver is a freelance writer in Distributors Association (IMDA) Wills adds that this system “is Columbia, Maryland. recommends the universal mem-

July 2009 OR Manager Vol 25, No 7 15 OR business management A vendor policy for a large system n effective plan to manage Mercy’s legal, risk management, vendors is crucial for any and infection control departments AOR, but designing such a reviewed the courses to be sure system for a large health system is The program“ they provide the necessary infor- complex. Nurse leaders at the Sis- helps manage mation. ters of Mercy Health System, based Vendors covered in St Louis with 19 hospitals in 4 risks. The vendor access program ap- states, have collaborated with their plies to all vendors, except those colleagues to craft a policy that involved in capital construction, works. which is covered by another policy, The policy is at the heart of the by the Strategic“ Marketplace Initia- and vendors who visit physician system’s Vendor Access Program, a tive (SMI), which published Manage- offices and clinics. credentialing process for vendors ment Guidelines for Vendor Access in The program outlines responsi- to manage access in the hospital. 2006 (www.smisupplychain.com). bilities of the director of materials “Our number-one driving force “We used the SMI guidelines as management, the vendor, depart- is a safe environment for patients, a starting point and adapted them ment directors, and medical and coworkers, and vendors,” says to our hospitals,” says Damron. administrative staff. Ruth Damron, RN, BSN, clinical re- This approach gave Mercy the con- During the registration process, source manager for ROi Perfor- sistency it needed while allowing vendors sign off on the required mance Consulting (the operating for some individual approaches to areas as they complete them. division of Sisters of Mercy Health implementation at the hospital “By doing this, they acknowl- System), who coordinated the task level. edge and accept the guidelines es- force charged with developing the For several months, the task tablished in Vendormate,” says program. The program also helps force held a weekly conference call Castleberry. the system manage potential risks to develop the program. “We Vendors who don’t comply face of vendors in the OR and adhere to hashed out what would work for escalating consequences. First vio- professional guidelines such as all of our facilities and different lations are documented, vendors those from AORN and regulatory areas,” says Melissa Castleberry, receive a verbal warning, and the requirements such as the Health RN, BSN, OR supervisor for St Ed- policy is reviewed with them. Insurance Portability and Account- ward Mercy Medical Center, Fort For a second violation, the direc- ability Act (HIPAA). Smith, Arkansas, part of Sisters of tor of materials management or the Unified approach, local Mercy Health System, which aver- applicable department director no- flexibility ages about 5,500 cases per year. tifies the vendor’s regional or cor- “In the past, each hospital had After implementation, the task porate office of his or her company. its own vendor policy. The rules force met biweekly to share issues In the case of a third violation, the were different at different hospi- and best practices and now meets vendor is suspended from further tals, making it confusing for ven- as needed. business with Mercy. Repeated vio- dors,” Damron says. Program details lations by vendors from the same company may result in a ban of all For the task force, she pulled to- Sisters of Mercy Health System the company’s vendors for a speci- gether key stakeholders including classifies vendors as Level 1 (non- fied period or permanently. representatives from materials clinical) or Level 2 (clinical), based management, pharmacy, security, on proximity to patients (sidebar, p Spreading the word clinical engineering, capital man- 18). Level 2 vendors must meet Sisters of Mercy Health System agement, facilities management, more stringent requirements. targeted 3 primary groups for edu- support services, the OR, and any “Most companies already have cation—staff, physicians, and ven- other areas where vendors interact the needed training in place,” says dors—before launching the pro- with staff. Damron. “They either provide it gram. Strategies included webi- The task force tapped into work themselves or use a third party.” nars, e-mails, signs in the physician

16 OR Manager Vol 25, No 7 July 2009 OR business management

and staff lounges and on bulletin culated based on the type and boards, letters to vendors and amount of business each vendor physicians, presentations at meet- conducts with Mercy and an as- ings, education programs, and arti- Reps“ have sessment of each company’s poten- cles in newsletters and on websites. to sign in tial legal risk. The fees, which ven- “The directors of materials man- dor companies pay directly to Ven- agement at the hospitals were the every day. dormate, are assessed per com- champions,” says Damron. She pany, not individual sales repre- provided education kits that in- sentatives. Responsibilities of Ven- cluded a PowerPoint presentation dormate and Mercy are defined in and supporting materials. writing to avoid confusion. cal ancillary services“ supervisor at Mercy’s leaders, including the New vendor representatives re- St Edward Mercy Medical Center. CEOs of each hospital, received ceive a card explaining what they “Some were bucking the system talking points so they could an- need to do for credentialing. The a bit,” agrees Castleberry. “We did swer questions. Damron also pre- vendor creates an online account progressive discipline [for 3 ven- sented to the CEO council. that includes documentation of dors] and ultimately had [2 of] E-mail and phone scripts were training and immunizations. them removed by going to their used to inform vendors. Employ- company.” ees were given a sample script for Checking in As of April 2009, 21% of vendor how to approach a vendor who On-site, the vendor checks in at representatives met all require- did not have a badge. The staff was a kiosk or department computer to ments. Damron attributes the low armed with postcards for vendors receive a daily badge. After the percentage to 2 factors: Some ven- that explained what they needed to visit, the vendor signs out and re- dors only visit a hospital once or do to register. turns the badge holder. Log-ins are twice a year, and it’s more difficult password protected. 3, 2, 1—liftoff! for smaller companies to provide New vendors have a month to The vendor access program was needed training. complete the application. When a launched on July 1, 2008, with an e- The goal is to have 80% of ven- vendor plans to be in an operating mail and letter to vendor compa- dors in compliance in November room room, the physician’s office nies. 2009, with interim goals of 40% by calls to notify the OR inventory “Identifying which reps need to July and 60% by September. staff. be included is a huge undertaking,” “We started at zero, and it takes During normal business hours, says Damron. Some smaller hospi- time to get everyone registered, so vendors sign in through Vendor- tals had vendor information only on we’re pleased with our progress,” mate’s automated system. Damron a card file, so the information had to says Damron. says determining the sign-in points be entered into a database. Daily operations can be eye-opening. “One hospital National account representa- found they had 19 points of entry Sisters of Mercy Health System tives for companies with a Mercy for its new tower.” The hospital chose Vendormate as its partner for contract were asked to disseminate worked to improve security before managing vendor access. “Vendor- the information. Materials manage- implementing the vendor access mate looks at both the sales rep ment had to inform local compa- program. level and the vendor,” says Dam- nies. At St Edward Mercy Medical ron. The company checks vendors By the Sept 1, 2008, deadline, Center, badge readers are located for bankruptcy or anything else only a small number of vendors at all entrances to the OR. If ven- that would affect Medicare reim- were compliant, so Mercy set Nov dors don’t have the appropriate ac- bursement. 1 as a “hard” deadline and started cess code on their badges, they are “We felt we had more control to deny access to vendors without not allowed into the restricted area. because reps have to sign in every the required information. In the case of emergency surgery, day,” adds Sharp. “We liked the “Some vendors were unhappy trauma representatives have “con- services and how they manage with the new system because they tract” badges that allow them access point of entry.” had been doing the same thing for to the OR. Mercy does not pay any fees to years,” says Cynthia Sharp, surgi- Vendormate. Instead, fees are cal- Continued on page 18

July 2009 OR Manager Vol 25, No 7 17 OR business management

Continued from page 17 Sample vendor access requirements “In the future, we’d like to see Level 1 (nonclinical) vendors the access program set up so these 1. Meet insurance requirements vendors could log in,” says Sharp. 2. Written statement from the company that documents the health care The Vendormate system can gen- industry representative’s competencies: erate an electronic, searchable log of • Company’s products all visitors, including company • General hospital safety training name; vendor’s name and e-mail • Patient confidentiality address; meeting contact, location, • Business ethics and purpose; and sign-in/out dates 3. Picture identification that is time sensitive and times. 4. Disclose any apparent or potential conflict of interest Helpful tips 5. Personnel changes As with most large projects, Level 2 (clinical) vendors communication is key. Meet all the Level 1 access requirements plus: “When you think you’ve com- 1. Undergo a criminal background check municated enough, you’ve forgotten 2. Corporate information including regional and corporate supervisory something. Over-communicate and contacts don’t overlook stakeholders,” says 3. Must be accompanied by hospital-designated staff when in patient care Damron, who also recommends tap- areas ping into the corporate communica- 4. Provide information on company’s products tions department, which can add a 5. Demonstrate FDA approval when requested vendor resource link to a hospital’s 6. Licensing for biologicals (tissue banking & distribution) web page and help disseminate in- 7. Possess evidence of annual instruction in: formation. • Confidentiality, patient rights, and HIPAA The information technology (IT) • Product complaints and medical device reporting (MDR) department is also important. Al- requirements though the Vendormate tool is • Aseptic principles and techniques web-based, IT has to supply print- • Infection control ers so reps can print their badges. • Bloodborne pathogens Damron recommends starting the • Fire, electrical, and other safety and emergency protocols process as soon as possible because • Appropriate conduct in the clinical environment of the many priorities facing IT de- • Hospital vendor rules and visitation policy partments. • The medical system, device, product, procedure, or service they will be delivering and/or operating Worth the effort 8. Business ethics, including disclosure of any financial relationships with Creating a systemwide vendor the institution, physicians, or other staff; and code of conduct access system is worth the effort. expectations “It has proven to be an efficient 9. Education and training documents and helpful tool to help the entire 10. Hospital product standardization program system to track who is in our facil- 11. New product introduction processes ity,” says Sharp. “It has helped us 12. Product recall processes to be able to monitor who is follow- 13. Written proof of immunization status: ing the rules and who is not.” • TB testing Damron adds an unexpected • Hepatitis vaccination benefit. “It helped all of us be bet- • Measles, mumps, and rubella (MMR) vaccine ter collaborators.” • Chicken pox vaccination —Cynthia Saver, RN, MS • State-required vaccinations (varies by state; refer to hospital-specific protocol) Cynthia Saver is a freelance writer in Columbia, Maryland. Source: Sisters of Mercy Health System. Reprinted with permission.

18 OR Manager Vol 25, No 7 July 2009 OR business management RACs: What is the OR’s role in readiness?

fter some delay, Medicare’s day period based on the hospital’s program to have outside volume of patients. Acompanies audit claims is What will happen when a getting underway. The companies, Problems“ deal Q RAC finds a problem? called recovery audit contractors mostly with (RACs), will be checking to see that Siddel: If a problem is found, claims filed by hospitals, physi- coding. such as coding for wound care, cians, and other providers follow where the RAC believes it can re- Medicare policies and procedures. cover money, it may contact all of OR Manager asked Keith Siddel, the hospitals in the area asking for MBA, an expert on health care busi- these types of records. What is “the ness operations, to give readers an If the RAC determines the case is status of RACs? introduction to RACs. Siddel is CEO Q clear-cut, and the hospital shouldn’t of HRM Consulting, Creede, Col- Siddel: The RAC program was have been paid, it will request that orado. held up by a protest over the con- the money be taken back and will not bother requesting the records. Why did the government tract awards. The final protests The hospital will then get a letter decide to go with the RAC were settled in February 2009. The Q from the FI saying it has taken the approach? program is now going forward and is being expanded to all 50 states. money back on a group of claims Siddel: The RAC program was The country has been divided into and explaining the reason. The hos- mandated by Congress in 2006. 4 regions with a RAC for each one. pital then has a certain period of Medicare decided to use third- A map and other information are time to appeal the RAC’s decision. party companies to see if by pay- at www.cms.hhs.gov/RAC What types of surgical ing incentives, the RACs could do Outreach in all 4 regions is Q issues are the RACs a better job of identifying claims being conducted this spring and looking at? problems than fiscal intermediaries summer. About half the states were Siddel: The problems deal (FIs). (FIs are private companies to be phased in by March 1, 2009, mostly with coding. There have that process Medicare claims and with the rest to follow. perform other services.) Over the been some coding issues with in- How will RACs look for years, the FIs have become more patient-only procedures. These are problem claims? focused on adjudicating claims and Q procedures that are supposed to be addressing medical necessity than Siddel: RACs take basically 2 done on an inpatient basis but slip on targeting areas to audit. approaches. The first approach is through and are done in the outpa- RACs, which were selected by to data mine. They take millions of tient setting. Most of the time, the competitive bidding, will be paid a claims and analyze them using FI catches this but not always. contingency fee for finding claims computers to look for trends and Documentation is an area to that were overpaid and underpaid. problem areas. On the basis of the focus on because coding is sup- For the most part, the RACs are not analysis, they will do an audit. ported by documentation. OR health care companies but compa- The second approach is to send managers will want to make sure nies that audit businesses like gro- hospitals a letter asking for copies nursing documentation conforms cery stores or Home Depot. of a certain number of medical with hospital policy and regulatory In a 3-year pilot study of RACs records that the RAC will examine requirements. in 6 states (California, Florida, New for problems. RAC auditors can go It also makes sense to make sure York, Massachusetts, South Car- back only to October 2007. coding guidelines are coordinated olina, and Arizona), the govern- During the pilot study, hospitals between your hospital’s health in- ment says it collected over $900 protested that the record requests formation management (HIM) de- million in overpayments and iden- were burdensome. Medicare has partment and the physicians’ of- tified nearly $38 million in under- now restricted the number of fices. Inconsistent coding between payments. records a RAC can request in a 30- Continued on page 20

July 2009 OR Manager Vol 25, No 7 19 OR business management CDC issues

Continued from page 19 to fight it. There is supposed to be draft UTI education. But it is not really in the hospitals and physician practices RACs’ interest to tell you quickly guideline will become easier to spot as what your problems are. They he Centers for Disease Control Medicare transitions from FIs to make money by taking payments and Prevention (CDC) in June Medicare Administrative Contrac- back when you haven’t solved the 2009 issued the Draft Guideline tors (MACs). The MACs will han- problems. T for Prevention of Catheter-Associated dle claims for both Part A and Part So the education has to come Urinary Tract Infections. Comments B, so there will be an easy place for from within the hospital and the are invited until July 6, 2009. Medicare and RACs to go to see if hospital industry. With the first no- The guideline, which updates and there is consistency between hospi- tice you get from a RAC saying, expands the CDC’s 1981 guideline, tal and physician claims. “We want these 10 accounts,” your addresses prevention of catheter-as- How should we be RAC team should be saying, “Ah sociated UTI for pediatric and adult getting ready? ha. This is what they are looking Q patients needing short-term or long- for.” Then the RAC team should Siddel: Every hospital should term catheterization in any type of gather the forces and tackle the have a RAC team. The team should health-care setting. problem. identify where RACs were success- The guideline addresses 3 key ful in taking payments back during What are the penalties for questions: the pilot study and review claims Q claims problems? 1. Who should receive urinary ca- in those areas. If the team identifies Siddel: The RACs will not per se theters? a problem, let’s say with pneumo- assign penalties. They will just re- 2. What are the best practices for nia coding, the team should do an quest the money back. But the fact those who require urinary cathe- audit and resubmit the claims so that the RAC has identified a prob- ters? the hospital doesn’t have to deal lem area means it would be naïve to 3. What are best practices for pre- with RAC auditors. think that the Health and Human venting infections associated with One caution—there are a lot of Services Office of Inspector General obstructed urinary catheters? vendors trying to sell databases or whistleblowers would not grab The CDC says catheter-associated and tracking software. You have to that issue and perhaps argue for UTI is the second most common be careful where you spend money. penalties. This action would not health care-associated hospital infec- There is software that will track all come specifically from the RACs, tion, accounting for just under one- of your claims and send you a but it certainly is a potential effect third of the more than 28,000 infec- daily report on which claims are at from the RAC process. tions reported to the CDC’s surveil- risk based on the RAC demonstra- lance system in 2006-2007. tion project. What it doesn’t tell More about the RAC program is at The infections are associated with you is that some of the information www.cms.hhs.gov/RAC/ increased morbidity, mortality, hos- from the demonstration may have pital cost, and length of stay. been overturned or shown to be wrong. I would caution about Surgery recommendations Among recommendations per- spending a lot of money on soft- Have a question ware until the RAC program really taining to surgery: gets going, and the hospital can see on the OR • Urinary catheters should be used what best fits its needs. revenue cycle? in surgical patients only as necessary, rather than routinely. Keith Siddel will respond Medicare rules on coding • Indwelling catheters should be and claims are complicated to questions in a regular Q removed as soon as possible after and sometimes unclear. How will column. surgery, preferably within 24 these issues be resolved? Send your questions to hours unless there are indications Pat Patterson, Editor, at Siddel: We saw in the demon- for continued use. [email protected]. strations that in these cases, the RAC would say, “This is our inter- You can reach Siddel at The draft guideline is at pretation.” Then the hospital had [email protected]. www.cdc.gov/ncidod/dhqp/pdf/pc/cauti _GuidelineApx_June09.pdf

20 OR Manager Vol 25, No 7 July 2009 Joint Commission Educating patients on SSI prevention

hough the Joint Commission is in the midst of revising its Safety goal TNational Patient Safety requirements for Goals, organizations are expected Patient“ surgical site to continue plans to meet the goals education infection by Jan 1, 2010. Proposed revisions affects safety. were issued May 12 for a 6-week National Patient Safety Goal field review. Final goals are ex- 07.05.01 requires hospitals to im- pected in October. plement best practices to prevent The commission is conducting a surgical site infection (SSI). Eight comprehensive review of the safety • NPSG.07.04.01:“Implement best elements of performance (EPs) re- goals during 2009 and will introduce practices or evidence-based main in the proposed revision to no new goals for 2010. Complying guidelines to prevent central line- the safety goals issued May 12, with some of the goals has been “a associated bloodstream infections. 2009. Briefly, the 8 EPs would be: struggle” for some organizations, the • NPSG.07.05.01: Implement best • Educate health care workers commission acknowledges. practices for preventing surgical involved in surgical proce- ”We want to make sure not only site infections (SSI) (sidebar). dures about SSI prevention. that our guidance is up to date but As a guide to evidence-based • Implement policies and pro- also that [all of the requirements] are practice, Kuhny suggests referring cedures to meet regulatory re- still worthy of that type of focus and to the compendium of strategies for quirements and align with ev- that everything being required truly preventing HAI in hospitals from idence-based standards or adds to patient safety,” Louise the Society for Healthcare Epidemi- guidelines. Kuhny, RN, MPH, MBA, CIC, senior ology of America and other organi- • Conduct risk assessments, se- associate director of the Joint Com- zations (www.shea-online.org/ lect measures, monitor compli- mission’s Standards Interpretations about/compendium.cfm). ance with best practices or evi- Group, told OR Manager. dence-based guidelines, and Educating patients on SSI evaluate prevention efforts. Preventing SSIs One specific element of perfor- Of particular interest to OR • Measure SSI rates for the first mance (EP) under the SSI subgoal is 30 days following procedures leaders, NPSG 7, which focuses on to educate patients who are having a reducing the risk of health care-as- without implants and for 1 surgical procedure and their families year following procedures sociated infections (HAI), is being about SSI prevention. expanded from 1 to 5 subgoals, in- with implants. Kuhny notes the requirement • Provide SSI measures to key cluding surgical site infection (SSI). has a tie-in to other patient educa- There is a 1-year phase-in of the stakeholders. tion standards. • Administer antimicrobial pro- new requirements with full imple- “We have always had a signifi- mentation expected by Jan 1, 2010. phylaxis according to evi- cant patient education require- dence-based standards and In the field review, the Joint Com- ment,” she says. “Patient education mission proposed deleting 1 new guidelines. often affects safety, and we obvi- • Use clippers or depilatories subgoal: NPSG.07.02.01, manage as ously want patients to be as much sentinel events HAI-related deaths when hair removal is neces- a part of their care as they can be.” sary (shaving is inappropriate). or permanent loss of function. In preparing to meet the EP, she Four subgoals remain: advises managers to refer to these www.jointcommission.org • NPSG.07.01.01: Comply with other standards: hand hygiene guidelines. • PC.02.03.01 requires patient ed- • NPSG.07.03.01: Implement evi- Provision of Care ucation and training based on dence-based practices to prevent Two standards in the Provision the patient’s needs and abilities. HAI due to multi-drug resistant of Care chapter are relevant to pa- A key requirement is EP 25: organisms. tient education on SSIs: Continued on page 22

July 2009 OR Manager Vol 25, No 7 21 Joint Commission

in a patient tracer, says Kuhny, Examples of who is also a surveyor. patient education In a tracer, a surveyor selects a material on SSI Education“ patient and using the patient’s might be in a record, traces care the person re- Institute for Healthcare ceived. The purpose is to assess the Improvement. Fact Sheet for tracer. organization’s systems for provid- Patients and Families ing care and services. —www.ihi.org/NR/rdonlyres/ In a tracer involving a surgical 0EE409F4-2F6A-4B55-AB01- patient, for example, Kuhny says she would talk with the patient 16B6D6935EC5/0/SurgicalSite not require that,“ Kuhny says. (Exam- and some of the care providers, ob- InfectionsPtsandFam.pdf ples are in the sidebar.) serve the education process, and JAMA Patient Page: Wound Record of Care ask the patient about the education Infections Documentation is addressed in received. She would also ask care- —http://jama.ama-assn.org the Record of Care chapter: givers about the education chosen /cgi/reprint/294/16/2122 • RC.02.04.01 EP 3 requires docu- for the patient and how they knew mentation in the medical record the patient understood what they Compendium of Strategies of information provided to the were trying to teach. In addition, to Prevent Healthcare- patient and family. she would ask about the organiza- Associated Infections in “There needs to be some indication’s policies on patient education. Acute Care Hospitals. tion in the record that education “I would look at the policies to Patient guides on HAI occurred,” Kuhny says, adding see what the organization would —www.preventinghais.com that the type of documentation “is expect for documentation,” she /index.php?sid=S200905181228114 totally up to the organization.” Ex- notes. Though the approach to pa- Z032S amples are placing a copy of the tient education is up to each orga- education form in the patient’s nization, she adds, the organiza- Surgical Care Improvement chart; making a brief progress note tion needs to define how it will Project. Tips for Safer Surgery such as, “Education provided on document education. In a tracer, “I —www.ofmq.com/Websites/ofmq/ preventing surgical site infection;” would compare the documentation Images/FINALconsumer_tips2.pdf or having a check box in the pain the patient’s record with what tient’s record to say education was the policy required,” she says. Continued from page 21 provided, and the patient verbal- Kuhny encouraged managers to ized understanding. proceed with their plans for meet- “The hospital evaluates the pa- ing the requirements on preventing tient’s understanding of the ed- Rights of the Individual SSIs. Though there may be some ucation and training it pro- The chapter on Rights and Re- revisions, many of the require- vided.” sponsibilities of the Individual ments are in other standards hospi- The intent is to make sure the under RI.01.01.03 requires the hos- tals already are addressing. patient understands the education pital to respect a patient’s right to —Pat Patterson provided, Kuhny says. This can be receive information in a manner he done in a number of ways, such as or she understands. having the patient repeat back That applies to patients who what was heard. speak another language as well as Have an idea? • PC.03.01.03 EP 4 has an obvious to those who have vision, speech, Do you have a topic you’d like link to education on SSIs: “The hearing, or cognitive impair- to see covered in OR Manager? ments. Have you completed a project hospital provides the patient with you think would be of help to preprocedural education, accord- What will surveyors look for? others? We’d be glad to con- ing to his or her plan for care.” sider your suggestions. One way surveyors are likely to It’s up to the organization whether Please e-mail assess compliance is to include pa- Editor Pat Patterson at to use printed patient education infor- tient education on SSI prevention [email protected] mation. The Joint Commission does

22 OR Manager Vol 25, No 7 July 2009 Process improvement Applying the Surgical Apgar Score his patient is a 10. Every- thing went well.” Or The 10-point Surgical Apgar Score “T“This patient is a 5. She Surgical Apgar Score, No. of points will need close monitoring.” Before 01234 long, physicians and nurses may be Estimated blood loss, mL >1,000 601-1,000 101-600 ≤100 using a numerical score like this Lowest mean arterial when transferring patients from the pressure, mmHg <40 40-54 55-59 ≥70 OR to the next level of care. Lowest heart rate/min >85a 76-85 66-75 56-65 ≤55a Researchers have validated a 10- point Surgical Apgar Score that can Note: The Surgical Apgar Score is calculated at the end of any general or be used to provide a quick report vascular surgical operation from the estimated blood loss, lowest mean arterial on how well a patient fared during pressure, and lowest heart rate entered in the anesthesia record during the surgery and the risk for major operation. The score is the sum of the points from each category. postoperative complications. a. Occurrence of pathologic bradyarrhythmia, including sinus arrest, atrioventricular block or dissociation, junctional or ventricular escape rhythms, Patterned after the familiar and asystole, also receives 0 points for lowest heart rate. Apgar score for newborns, the Sur- gical Apgar Score is derived from 3 Source: Regenbogen S E, Ehrenfeld J M, Lipsitz S R, et al. Arch Surg. intraoperative variables: 2009;144:30-36. • estimated blood loss Copyright © 2009 American Medical Association. All rights reserved. • lowest mean arterial pressure • lowest heart rate. patients with scores of 9 or 10, only Score when transferring a patient “With these 3 pieces of informa- 72 (5%) developed major complica- after surgery. tion, you can make a pretty good tions, and 2(0.1%) died within 30 “It’s a shorthand way of com- guess at how a patient might do in days of surgery. In contrast, of 128 municating the overall stability of the first 30 days after the opera- patients with scores of 4 or less, 72 the patient and success of the oper- tion,” says Scott Regenbogen, MD, (56%) developed major complica- ation,” he says. MPH, of the Harvard Medical tions, and 25 (19.5%) died within 30 The score is being validated for School and Massachusetts General days. The researchers found the 3- other types of surgery, including Hospital, Boston, the lead author of variable Surgical Apgar Score total hip and knee replacement, rad- a report in the Archives of Surgery. achieved C statistics of 0.73 for major ical cystectomy, and colon and rectal Predictors of complications and 0.81 for deaths. resection. A poster presented at the complications American Academy of Orthopaedic Ready to use After evaluating dozens of vari- Surgeons meeting in February 2009 The tool is ready for clinical use, ables, the researchers determined reported the Surgical Apgar Score is Dr Regenbogen says. The article these 3 were the only independent “strongly predictive” of major post- outlines a number of applications. predictors of 30-day major compli- operative complications after total Surgical teams could use the Surgi- cations. The Surgical Apgar Score joint replacements. Data on colon cal Apgar score to give immediate is intended to be a useful tool that and rectal resections presented at feedback on a patient’s condition. can be used in “any setting without the American Society of Colon and The score can aid communication a lot of cost or difficulty,” Dr Re- Rectal Surgeons meeting in May between surgical teams and the genbogen told OR Manager. 2009 shows the score also predicts postanesthesia care unit and nurs- The study involved a sample of which patients are likely to develop ing unit. It could be used to assist 4,119 general and vascular surgery a late complication after they leave in decisions about admitting pa- patients from the National Surgical the hospital. tients to the ICU. Quality Improvement Program At one Boston teaching hospital A quality improvement (NSQIP) database at Massachusetts that participated in the study, Dr tool General. Regenbogen says, residents and The Surgical Apgar score can be An analysis showed that of 1,441 nurses use the Surgical Apgar Continued on page 24

July 2009 OR Manager Vol 25, No 7 23 OR business management Continued from page 23 OR business conference in Chicago used as an outcome measure for quality improvement and safety ef- opportunity for ideas, networking forts, Dr Regenbogen notes. articipants attending the twice what those countries spend, For example, a surgical division 2009 OR Business Manage- Curran said, “We don’t have extra- chair might choose to review every Pment Conference in May in ordinary outcomes. We don’t have elective operation with a score of Chicago heard speakers address is- the highest life expectancy, at least less than 5 to try to understand what sues challenging OR leaders today, 45 million are uninsured, and our is going on with those operations. from implementing Lean princi- infant mortality is number 35 in the Or the chair might look at patients ples in perioperative settings to world.” with scores of 8 or more who go to managing implant costs. Discus- Although Curran said 2007 was a the ICU to see if that was an appro- sions in and out of the sessions “very good year” for hospitals, 2008 priate use of resources. The score supplemented speakers’ presenta- reflected the changing economic does not allow for comparison tions and gave attendees the op- scene. “Charitable gift giving slowed, among institutions, the authors portunity to exchange ideas, opin- elective surgery dropped, credit rat- note. ions, and strategies. ings were downgraded, increased To evaluate its broader applica- OR directors, OR bility, Surgical Apgar Scores were business managers, ma- collected for all patients enrolled in terials managers, and the World Health Organization others interested in the study of the Surgical Safety Check- business side of surgery list in 8 countries. Use of the check- chose among 3 all-day list was shown to be linked to lower seminars and 8 break- patient deaths and complication out sessions and spent rates (March 2009 OR Manager). A time networking with report on the study’s results for the exhibitors. Surgical Apgar Score is being re- The keynote address focused on unemployment resulted in increased viewed for publication. 3 worries—money, patient safety, uncompensated care, and there was “We have always looked at this and talent shortages—keeping declining reimbursement from as a way that hospitals with rela- health care leaders awake at night. Medicare and Medicaid,” she sum- tively low resource availability for “What’s important to the boss med up. quality monitoring might have a drives the agenda,” said Connie Troubles continue in 2009. The useful tool for their ORs,” Dr Regen- Curran, RN, EdD, FAAN, presi- construction boom has ended, and bogen says. “The idea is that it can dent of Curran Associates, a health unionization is a growing force. be used both by surgical teams in care management consulting firm To counteract money concerns, their care and by the administration and editor emeritus of Nursing Curran advised participants to in quality audits or attempts to Economics, in explaining the need “seek out profitable service lines make improvements.” to understand concerns of upper and surgeons. Determine where —Pat Patterson management. Curran noted what you are making money, and where OR leaders could do to address you are losing money.” References each worry. Patient safety worries Haynes A B, Weiser T G, Berry W R, et al. A surgical safety checklist What, me worry? On patient safety, the second to reduce morbidity and mortal- In setting the stage for money worry, OR leaders are especially ity in a global population. N Engl concerns, Curran said US health concerned about wrong-site J Med. Jan 29, 2009;360:491-499. care spending is now 17% of our surgery and what Curran called Regenbogen S E, Ehrenfeld J M, gross domestic product (GDP), “surgical souvenirs”: Items left be- Lipsitz S R, et al. Utility of the with a projected increase to 19.2% hind after surgery in about 1 in Surgical Apgar Score. Arch Surg. by 2013. That compares to the 7% 5,000 cases. 2009;144:30-36. to 8% average in the United King- A retained object is a “never” dom, Canada, Australia, and Ger- event, defined as an identifiable, many. Despite spending more than preventable occurrence with seri-

24 OR Manager Vol 25, No 7 July 2009 OR business management

ous patient consequences. Exam- Kowalski advised working with ples of other never events are all elements of the supply chain, catheter-associated urinary tract in- from evaluating products to charg- fection, pressure ulcer, and surgical Seek“ out ing. “They are interdependent,” he site infection after coronary artery profitable said. “You can create a [negative] bypass graft surgery. The Centers ripple effect by only focusing on for Medicare and Medicaid Ser- service lines. one thing.” vices (CMS) no longer pays for cer- Managing supply chain begins tain never events acquired in the with a strategic plan. Kowalski rec- hospital, and private payers have ommended writing down the steps followed suit. in the chain and analyzing how to and free up their“ future. You can be improve each one. Nurses: A source of picky.” revenue Measure it, manage it Supply chain insights Curran noted the focus on pa- “Focus on opportunities with Jamie Kowalski, MBA, FACHE, tient safety translates into a focus the biggest rewards,” said Kowal- FAAHC, FAHRMM, who has been on nursing. “Nurses can drive ski. That usually means physician in the supply chain field for more money and be a source of rev- preference items, which represent than 35 years, sums up the current enue,” she said and recommended the largest (45%) piece of the sup- state of affairs as, “I’ve never seen nurses get involved in quality ini- ply chain pie. anything like it. It’s like a perfect tiatives. A total supply chain solution storm.” The storm includes eco- “Use a balanced scorecard and should include spend analytics, nomic recession, reduced volumes try to improve every year even if distribution and inventory man- and revenues, proliferation of tech- it’s just 2%.” agement, contract management, nology, and lack of access to capi- Despite recent hospital layoffs, charge capture, and clinical utiliza- tal. Kowalski is vice president of Curran said the shortage of health tion. At the center are metrics. “If business development for Owens care workers, including nurses, you can’t measure it, you can’t & Minor, Inc, a health care distrib- will continue, making it leaders’ manage it,” said Kowalski. utor and supply chain manage- third worry. Both speakers emphasized that ment company. He and Carl The average age of a nurse is 47, OR leaders don’t have to do this Natenstedt, CPA, also of Owens & but an OR nurse’s average age is work in isolation. Minor, discussed how OR leaders even higher at 52 years. “We’re a “Use your partners,” said Kowal- can manage supply chain more ef- chronologically gifted profession,” ski, including, “suppliers, consul- fectively, particularly because the said Curran. Two-thirds of nurses tants, and purchasing companies.” OR has a significant impact on the worked less than full time last year —Cynthia Saver, RN, MS hospital’s bottom line. but enough hours so they qualified “Supplies is the fastest growing for benefits. Cynthia Saver is a freelance writer in expense category in a hospital,” In the current recession, nurses Columbia, Maryland. said Kowalski. “Cardiovascular are staying in the workforce, but as and orthopedic supplies are dri- Curran said, “The recession will ving the spend growth by a big end,” leaving a shortage of nurses amount.” to care for an aging population. Don’t miss out! Another factor affecting workforce Supply chain strategy 2010 is nurses’ exiting hospitals because Unfortunately, the OR supply of dissatisfiers such as inadequate chain is often not optimized; for OR Business compensation and excessive pa- example, the typical OR writes off Management perwork. 30% of charges. Managing the sup- Curran sees a silver lining in the ply chain yields large benefits. For Conference recession cloud. “It’s a good time instance, Natenstedt said, “Increas- to clean house,” she said. “Get rid ing inventory turns from 2 to 4 May 12 to 14, 2010 of [sub-performing personnel]. In- frees up an average $5 million in San Francisco vite them to update their resumes capital.”

July 2009 OR Manager Vol 25, No 7 25 ASCs seek to get policy message across

mbulatory surgery centers not face such serious cuts. For ex- (ASC) have been getting ample, the Medicare Payment Ad- Amore attention from regula- visory Commission (MedPAC), the tors and health policymakers over Concern“ advisory panel for Medicare, rec- the past year, and not all of it has about payment ommended an inflation update fac- been welcome. tor of 3.6% for hospitals but only From quality reporting legisla- disparities. 0.6% for ASCs. Bryant noted Med- tion to Medicare payment issues, PAC’s original recommendation ASCs have been under review. was a factor of 0% for ASCs until That is due in part to efforts by intensive industry lobbying suc- hospitals to curtail what they see as ceeded in raising it to a positive she warned. “It’s“ important that unfair competition from physician level. we’re all saying the same thing.” groups with access to the most The reason, she said, is that profitable patients and procedures, Payment disparities MedPAC and other federal agen- without the added strains of emer- Changes in Medicare reimburse- cies have been listening to hospi- gency and uninsured care. ment levels for 2009 show ASCs tals. A MedPAC report to Congress It is time to address these issues, are losing ground on payment for in March defends the lower reim- speakers and attendees agreed high-volume procedures. Pay- bursement rate by claiming advan- during the April annual conference ments will decline up to 22% (for tages that ASCs have. of the Ambulatory Surgery Center paravertebral procedures for pain It states, “Physicians have Association in Nashville, Ten- management). Other declines in- greater control and may be able to nessee. clude: perform more surgeries per day in The association’s president, • cataract surgery: -1% ASCs because they often have cus- Kathy Bryant, urged members to • upper GI endoscopy: -7% tomized surgical environments communicate with legislators, reg- • diagnostic colonoscopy: -6% and specialized staffing.” The ulators, and their own communi- • lesion removal during colono- panel also appeared to conclude ties about the contributions they scopy: -6%. that because volumes and rev- make and the hardships some of Because of differences in the enues had risen in preceding years, the new regulations will cause. way adjustments are calculated, ASCs were thriving. “We have to stay on message,” hospital outpatient departments do Until 2003, according to ASC As-

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 7 July 2009 Ambulatory Surgery Centers

sociation figures, Medicare pay- center because it forces some pa- CMS allows ments to ASCs were about 80% of tients to wait longer than necessary exception on the amounts paid to hospital outpa- for treatment, just to wait out the tient departments. The rate is now notification period (sidebar). advanced notice 59%, and the association says if In response to quality reporting In late May, ASCs celebrated nothing is done, the rate is on track requirements that penalize nonpar- news that Medicare will allow an to drop to 50% within 5 years. ticipants with decreased reim- exception in its new ASC Condi- MedPAC’s argument, according bursement, the association has tions for Coverage (CfCs) that re- to its January meeting transcript, is sponsored a collaboration that gen- flects one of their concerns about that lower rates for ASCs are ap- erated 11 quality measures for the patient notification rule. The propriate because ASCs have surgery centers, of which 6 have CfCs took effect May 18, 2009. lower costs than hospitals, which been approved by the National The exception came in interpre- may be because they have less Quality Forum. tive guidelines for state survey complex patients and fewer regula- As with other requirements, agencies issued May 15 by the tory requirements than hospitals. Bryant says of performance mea- Centers for Medicare and Medic- MedPAC also expressed concern sures, “We want to share our data. aid Services (CMS). The guide- that as the number of ASCs in- But we want to share our data in a lines allow an exception in certain creases, the volume of outpatient fair way.” cases to the rule that a patient surgery will grow and increase must receive written notice of pa- Medicare spending. ‘Playing the charity card’ tient rights and ASC ownership at The ASC Association has argued One of the main reasons regula- least a day in advance of surgery. to MedPAC that one goal should tors have tended to sympathize The exception applies to situa- be to get 60% to 70% of services with hospital protests is that hospi- tions in which the patient is re- now performed at hospitals at a tals play the charity card in what ferred for surgery on the same day higher cost into the “most cost-ef- ASCs believe is a misleading way, the procedure is scheduled, and fective, clinically apt place” where Bryant says. ASCs, especially those the referring physician states in they can be performed. affiliated with hospitals, often pro- writing that the procedure is med- vide charity care as a public service ically necessary that day and is ap- Regulatory hardships or to comply with hospital policy. propriate for an ASC. The changes that took effect this Hospitals, which are required by The ASC Association lobbied year in Medicare Conditions for law to treat all emergency patients, CMS for relaxation of the advance Coverage also cause concern, de- act as if that were a sacrifice, Bryant notice rule, which they say pre- spite some modifications. “Over- noted. sents a hardship in many cases. night stay,” for example, now means She maintained that the physi- Association president Kathy “24 hours,” rather than “continuing cians who provide uncompensated Bryant said of the change, “We ap- past 11:59 pm,” a change that per- care in their own surgery centers preciate CMS’s willingness to re- mits more procedures beginning really do make a personal sacrifice consider its decision. This is a later in the day. Still, Bryant noted, of time and money. great example of the impact ASCs an ASC cannot schedule a proce- Hospitals that say they are los- can have when we work together dure that would include, as a matter ing needed revenues to ASC com- on issues like these.” of treatment protocol, subsequent petition also are misrepresenting She noted the exception is un- transfer to a hospital. “If you do,” the case, Bryant said. likely to occur often because ASCs she says, “you are risking your certi- Between 2003 and 2006, hospital normally perform elective proce- fication, not just the payment.” outpatient volume nationwide dures and rarely schedule them Another sore point is the 24- grew by 2.1%. However, revenues on the same day. hour notice requirement for advis- from outpatient procedures in- More information is at http:// ascassociation.org/coverage/ ing patients of their rights and the creased by 9.3%, meaning those ownership status of the surgery Continued on page 29

July 2009 OR Manager Vol 25, No 7 27 Ambulatory Surgery Centers

Testing practices need a closer look s too much preoperative testing No significant differences being done for ambulatory No significant differences were Isurgery patients? New research found between the groups in rates suggests testing practices may How“ of perioperative adverse events need a close look. necessary within 7 and 30 days after surgery. “If anesthesiologists are just or- Most events were not serious. dering tests as a routine, they need is testing? More patients in the testing group to look at our study and re-exam- returned to the hospital within 7 ine what they’re doing,” advises days. The main reasons were se- Frances Chung, FRCPC, a well- vere pain, infection, and urinary re- known researcher in ambulatory Because the“ new study is small tention. anesthesia. (1,026 patients), Dr Chung says re- In the no-testing group, none of In the new pilot study, Dr Chung sults should be considered prelimi- the adverse events was associated and her colleagues evaluated nary. In addition, the study had with patients not having preopera- whether preoperative testing can be strict exclusion criteria and did not tive testing. eliminated in healthy ambulatory include patients with major med- Cost savings were US $14,800 surgery patients without an increase ical issues, especially related to car- ($30.90 per patient) in the no-test- in adverse events. Savings for the diac and respiratory disease, such ing group. health care system could be signifi- as patients who had a myocardial Little need for testing cant. About 65% to 70% of surgery is infarction within 3 months before outpatient, and preoperative testing Because of the sample size, the surgery. findings aren’t strong enough to in the US is estimated to cost more Still, the findings add another than $18 billion a year. warrant changing preoperative test- important piece of evidence on the ing protocols, notes Dr Chung, who First randomized trial merits of preoperative testing. is professor of anesthesiology at the Though preoperative testing for Study protocol University of Toronto and medical ambulatory surgery has been de- The researchers randomized the director of the ambulatory surgical bated for almost 30 years, the 1,026 patients to 2 groups: unit and combined surgical unit at study is the first prospective, ran- • indicated testing: 527 patients Toronto Western Hospital. domized, controlled trial to assess • no testing: 499 patients. The authors say their findings if such testing can be eliminated The testing group had a com- justify a large multicenter study, for ambulatory surgery patients. plete blood count (CBC), elec- which is not underway at this time. An American Society of Anes- trolytes, blood glucose, creatinine, Because most study patients thesiologists (ASA) 2002 practice electrocardiogram (ECG), and were ASA P1 and P2, the findings advisory states that preoperative chest x-ray, as indicated by the On- apply primarily to those 2 groups, tests should not be ordered rou- tario Preoperative Testing Grid, though Dr Chung says the findings tinely but may be ordered, re- consensus guidelines used by hos- can also apply to stable patients quired, or performed selectively to pitals in Ontario, Canada. with higher ASA classifications. guide or optimize perioperative No tests were ordered for the The testing decision also depends management. no-testing group. Patient age, gen- on the type of surgery. For exam- Case series reports have sug- der, type of surgery, anesthesia, ple, she says testing is not ordered gested that even indicated testing and ASA physical status were simi- for cataract patients even if they may be unnecessary in healthy am- lar for the 2 groups. Most patients are ASA P3 or P4. bulatory surgery patients. An indi- were ASA P1 or P2, and 12% of pa- Toronto Western Hospital has cated test is one ordered for a spe- tients in each group were ASA P3. changed its practice since the cific clinical indication or purpose. study, she notes, though some pre-

28 OR Manager Vol 25, No 7 July 2009 Ambulatory Surgery Centers

ASC policy other nondiscretionary services such as diagnostic colonoscopies and Better screening Continued from page 27 needed for ASC cataract removal surgery,” a sample procedures brought in a higher pro- letter to legislators notes. The bill patients portion of income to hospitals. would also modify the patient rights Patients who are not properly As an industry organization, the and ownership notification rule to assessed before procedures in ASC Association said it will step up allow surgery the same day it is ambulatory surgery facilities are lobbying efforts this year but is also scheduled. at risk for postoperative compli- trying to involve individual ASC Stay informed and cations and hospitalization, ac- owners and staff members, begin- speak up cording to the Pennsylvania Pa- ning with a legislative and compli- While making their voices heard, tient Safety Authority. ance seminar in June. Letter-writing ASCs also need to keep their ears Of 467 events submitted to the campaigns are continuing, and the open as broader health care issues Authority from 2004 through association’s staff distributed sam- emerge, ASC Association lobbyist 2008, 43% were serious, most ple letters and talking points to at- Sarah Walters told a conference au- often requiring patients to be tendees with the admonition that dience. “We’re seeing a lot of trac- transferred to a hospital. Half of personal messages from con- tion” on health care reform, she reports involved patients over stituents count with policymakers. said, with the White House letting age 65, and 5% involved a pedi- The ASC Association also is Congress take the lead in drafting atric patient. planning a national open house day specific legislation. More than one-fourth (27%) of August 11, when ASCs around the She predicted it would address de- the facilities showed a need for country will invite community resi- livery systems, such as insurance and improved screening. In 85 re- dents to visit and learn about the Medicare, along with types of cover- ports, the patient had a condition benefits of receiving diagnosis and age. Expect more emphasis on pre- such as an arrhythmia or sleep treatment at local facilities. vention and wellness, she advised. apnea that might have put the pa- It is also rounding up support ASCs can be a part of the national tient at risk during the procedure. for the Ambulatory Surgical Center discussion of health care reform, she “Our data shows many ambu- Access Act of 2009 (HR 2049). The said, as offering cost savings and pa- latory surgical facilities need to bill would tie ASC payments to tient choice. But first, she added, improve their screening and as- hospital outpatient payments and “there’s the problem with payments sessment processes,” said the au- maintain the 59% rate. that we need to address.” thority’s executive director, Mike “ASCs are a critical point of access Doering. for important screening benefits and Continued on page 30 He added that patients can help by telling their providers operative testing is still being done. of need for testing,” she says. about conditions they have, such For example, chest x-rays are not —Judith M. Mathias, RN, MA as heart or respiratory problems. ordered for all patients who are The report offers risk reduction heavy smokers and have pul- References strategies. Two sample preopera- monary disease. ECGs aren’t or- Chung F, Yuan H, Yin L, et al. Elimi- tive screening tools are posted on dered for all patients over age 45 nation of preoperative testing in the authority’s website: with a cardiac history or hyperten- ambulatory surgery. Anesth • a health history sample Analg. February 2009;108:467- sion. • a nursing preoperative screen- 475. Accompanying editorial, “We should encourage anesthe- 393-394. ing sample form. siologists to consider changing —www.patientsafetyauthority Roizen M F. More preoperative as- their practice in preoperative test- .org/NewsAndInformation/PressRe- sessment by physicians and less ing. This study helps them in un- by laboratory tests. N Engl J Med. leases/Pages/pr_2009_March_31.aspx derstanding that there is not a lot 2000;342:204-205.

July 2009 OR Manager Vol 25, No 7 29 ASC policy Continued from page 29

Both listen and speak up, she urged. “It is criti- cally important for ASCs to be informed, and don’t hesitate to write your members of Congress. I think the challenge is to make sure our voice is heard.” Time to speak up The association’s chair, Alsie Sydness-Fitzgerald, CASC, agreed that ASCs need to speak up more. “Speaking as a nurse, I don’t understand, if we perform, say, an arthroscopy, why we get paid less for it than a hospital.” She noted that when the first ASCs emerged during the 1970s, they were seen as a source of more personalized care but faced little controversy. It has been their success in recent years that led to greater regulatory scrutiny, and she said it now is time to confront the misconceptions that have arisen. “We’ve been around a long time,” Sydness- Fitzgerald said. “The reason people don’t know about us is we’ve been very quiet.” —Paula DeJohn

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30 OR Manager Vol 25, No 7 July 2009 Perioperative Textbooks A Little Outdated?

a new edition has dawned! The highly anticipated update to the well-known text Patient Safety During Operative and Invasive Procedures has arrived. Updated Title and Content “Many references in this text are from 2008. This is impressive in a textbook that may take several years to produce. This allows the nurse to have the most up to date information and be able to apply it directly to current practice”*. Theodore J. Walker, RN, BSN, MSN, CNOR, ACNS, BC Major USAF, NC On Sale Now Individual Copies for Only $95.00 Up to a 20% Discount for Bulk Orders

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P O Box 5303 Santa Fe, NM 87502-5303

At a Glance

Surge in nurse employment ing prevents 82% of retained sponges. generally are covered by private —but it won’t last Bar-coded sponges and radiofre- insurance and Medicare. With the recession, the RN short- quency-tagged sponges prevented —www.wsj.com age has eased or even ended in 97% of retained sponges. X-rays were many parts of the country, a new most costly but less effective than bar- Las Vegas hepatitis C study finds. Older nurses have de- coded sponges. Bar-coded sponges outbreaks spur 5 new layed retirement or returned to were the most cost-effective of the state laws work, and part-time nurses have be- methods studied. come full time in response to the — Regenbogen S E, Greenberg C C, Nevada has passed 5 new state economy. The increase has been Resch S C, et al. Surgery. May laws in response to hepatitis C out- stunning—in 2007-2008, RN em- 2009;145:527-535. breaks in 2 Las Vegas endoscopy ployment in hospitals increased by centers last year, the Associated 243,000, or 18%. Press reports. The outbreaks led to Doubts raised over hip But the relief will be temporary. the largest patient notification in resurfacing A new shortage will loom in the US history. More than 50,000 pa- next decade, with a shortfall devel- Enthusiasm is waning for hip tients may have been exposed to oping about 2018 and growing to resurfacing after recent studies bloodborne diseases because of about 260,000 by 2025. The data is show the procedure is no better reuse of syringes and vials of anes- from Peter Buerhaus of Vanderbilt than the newest types of total hips thetic drugs. Nine patients con- University. at helping patients resume an ac- tracted hepatitis C, and more than —Buerhaus P, Auerbach D I, Staiger tive lifestyle, according to the June 100 cases may be linked to the D O. H Affairs. 2009;28(4):w657- 4 Wall Street Journal. Studies also now-closed centers. w668. http://content.healthaffairs.org show women are more likely to One law requires ASCs to have suffer complications after resurfac- unannounced inspections yearly. ing compared with total hip. Another requires that a nurse ac- Cost-effectiveness of Hip resurfacing has been touted company all inspection teams. A preventing retained sponges as an alternative to total hip re- third law puts more teeth in pro- New technologies can substan- placement for younger, more active tections for whistleblowers because tially reduce the incidence of re- patients. The surgeon replaces the some nurses reportedly were tained sponges at an acceptable socket but preserves the femoral afraid to step forward about the cost, researchers have found. They head after smoothing away the problems for fear of losing their compared standard sponge count- arthritic damage. jobs. Two other laws are intended ing with new technologies for pre- Hip resurfacing is more difficult, to bridge gaps in communication venting retained sponges using a takes more OR time, and requires during a public health crisis. model they developed to compare longer incisions than total hips, ac- —www.mercurynews.com/news/ cost-effectiveness of the methods. cording to the Journal. Both proce- ci_12490632?nclick_check=1 Findings showed standard count- dures cost $30,000 to $50,000 and

32 OR Manager Vol 25, No 7 July 2009