The monthly publication for OR decision makers

December 2007 Vol 23, No 12

Leadership Lateral violence: Why it’s serious ASC section on page 23. and what OR managers can do

In this issue nurse hides a surgeon’s favorite nection between nurse-to-nurse bullying instrument when a substitute fills and the behavior of oppressed groups. Ain as the scrub. A circulator does The thinking is that health care organiza- Senate bill seeks to air not tell a new nurse who is scrubbed that tions tend to be hierarchies headed by implant pricing ...... 5 she knows the shunt the surgeon selected physicians and administrators. A hierar- has fallen on the floor. A newly hired RN chy places power in the hands of a few LEADERSHIP. who was previously a scrub tech is people at the top and disempowers nurs- Opening managers’ eyes shunned by both camps. Is this just life in es, who take out their aggressions on one to lateral violence ...... 10 the OR? Is it part of a nurse’s rite of pas- another. sage? Or is it something more insidious— Bullying is especially serious for newly Counts off in 1 in 8 bullying? licensed nurses, says researcher Martha general surgery cases ...... 11 Research suggests these behaviors are Griffin, RN, PhD, because it keeps them prevalent and drive nurses away. The from asking questions, validating their MANAGING PEOPLE. behaviors go by several names: lateral or knowledge, and feeling like they fit in— Which candidates are horizontal violence, nurse-to-nurse bully- all necessary for them to build their the keepers? ...... 14 ing, sabotage, or the popular phrase, knowledge and become part of the orga- “nurses eating their young.” nization. PATIENT SAFETY. The nursing literature over the past 20 She has cataloged 10 behaviors that A time-out tool helps to years has documented lateral violence characterize lateral violence (sidebar, p 7). improve compliance at the and its effects. Some researchers see a con- patient’s bedside ...... 15 Continued on page 7 Managing people OR THROUGHPUT. Are your operating rooms ‘efficient’? ...... 16 Mastering a steep learning curve: MANAGING TODAY’S Trends in perioperative orientation OR SUITE. Managing people a theme solid orientation is a cornerstone right qualities to become successful peri- at conference ...... 21 for successful perioperative nurs- operative nurses (page 14). Aing. Choosing the right candidates Among the challenges: AMBULATORY SURGERY and giving them the knowledge and skills • balancing the need for classroom edu- CENTERS. to adapt to the surgical environment are cation with an introduction to clinical CMS sets final 2008 ASC essential to safe practice and to retaining practice payment rates ...... 23 staff. The learning curve for perioperative • getting orientees up to speed as quick- nursing is steeper than ever— 83% of hos- AMBULATORY SURGERY ly as possible while still giving them a pitals are hiring RNs without OR experi- CENTERS. grounding in the specialties ence, and 55% are hiring new graduates, Tips for a successful hire • building a bridge to practice by com- according to this year’s OR Manager in your ASC ...... 25 bining practical skills with adult learn- Salary/Career Survey. We interviewed ing and nursing theories perioperative directors and educators OR Manager subject • collaborating across a hospital system from 5 organizations about orientation index 2007 ...... 27 for perioperative orientation and how they prepare new recruits. And • seeking solutions for orienting nurses because they often don’t have OR experi- AT A GLANCE ...... 32 to constantly changing technology. ence to go by, we also asked how they select candidates they believe have the Continued on page 12 2

Please see the ad for MEGADYNE in the OR Manager print version. Upcoming Publisher’s Note

Periop process for he ringing was persistent. Santa put anticoagulant therapy down his sudoku puzzle and Tpicked up his new iPhone. What’s needed to meet the Joint Commission’s new patient safety goal “Don’t forget that you were going to requirement? cut the grass today,” reminded Mrs. MRSA protocols for surgery Claus. “Mow the what?” Santa exclaimed. Should preoperative patients be “Remember, with global warm- screened for MRSA? What other steps ing, our snow has disappeared, and should be taken? we’ve replaced it with grass. The snow blower makes a lovely con- tainer for my herb garden; I do The monthly publication love the smell of basil.” for OR decision makers Santa mused: ‘The reindeer like to nibble the grass, but it is tough to get the big sled up in the air without December 2007 Vol 23, No 12 snow.” “You could take the helicopter,” sug- OR Manager is a monthly publication for personnel in decision-making positions in gested Mrs. Claus. the operating room. “No, it is worse than a Hummer with all the fuel it uses. Besides, it wakes up “As you know, since we both had Elinor S. Schrader: Publisher everyone in the neighborhood when I bariatric surgery a number of years ago, Patricia Patterson: Editor land on the roof.” we have been admirers and friends of the Judith M. Mathias, RN, MA: “Well, let me see if I can find some nurses and doctors that work in the OR. Clinical editor snow on eBay for Christmas Eve so that That procedure made a great deal of dif- Kathy Shaneberger, RN, MSN, CNOR: you and the reindeer can go on your ference in our lives. Consulting editor appointed rounds,” responded Mrs. “I hope that my friends in health care, Karen Y. Gerhardt: Art director Claus. “Do you have your list ready?” she especially those in the OR, will be OR Manager (USPS 743-010), (ISSN 8756-8047) asked. informed and help their friends and col- is published monthly by OR Manager, Inc, “Yes,” responded Santa. “And I have leagues understand the health care reform 1807 Second St, Suite 61, Santa Fe, NM some terrific new presents. issues and the solutions that will be dis- 87505-3499. Periodicals postage paid at “For parents, I am bringing lead-testing cussed. So I am giving them this high-tech Santa Fe, NM and additional post offices. kits for the toys under the tree that may false-information detection device. When POSTMASTER: Send address changes to have been made in China. All parents will it detects false information, misleading OR Manager, PO Box 5303, Santa Fe, NM want to test the toys their children receive statements, and other nonsense, a red light 87502-5303. to make sure they are lead-free and safe. starts flashing, and it emits a loud noise OR Manager is indexed in the Cumulative “As a stocking stuffer, I am giving all consisting of blah, blah, blah that over- Index to Nursing and Allied Health the children gift-wrapped alcohol-based rides the speaker or other source.” Literature and MEDLINE/PubMed. sanitizers (no triclosan) to tuck in their “That’s probably illegal, too,” sighed Copyright © 2007 OR Manager, Inc. All rights backpacks to help avoid MRSA. Even Mrs Claus. “But what is that large box that reserved. No part of this publication may be though the concern about MRSA in you are wrapping?” reproduced without written permission. schools is probably overblown, the scare “This is a special present for our leader- Subscription rates: $86 per year. Super sub- can help to reinforce the many benefits of ship in Washington. It contains wisdom scriptions (electronic) $129 per year. good handwashing. and compassion that I hope they will use Canadian, $98. Foreign, $115. Single issues “For those who must share public as they move forward on health care $10. Address subscription requests to PO space with loud incessant cell-phone talk- reform as well as other issues that we are Box 5303, Santa Fe, NM 87502-5303. Tele: 800/442-9918 or 505/982-0510. ers, I have special cell-phone jammers that concerned about. Website: www.ormanager.com silence those calls.” “Like precious jewels, the holidays are E-mail: [email protected] “They are illegal, you know,” com- many-faceted. For some it is a very reli- mented Mrs Claus, who reads The New gious time, for others it means gathering Editorial Office: PO Box 5303, Santa Fe, NM 87502-5303. Tel: 800/442-9918. York Times every day. with families, giving (and receiving) gifts, Fax: 505/983-0790. Santa reviewed his list. “With health or joining with friends for social gatherings. E-mail: [email protected] care reform coming up as the hottest elec- “For me, I enjoy bringing fun and tion issue, there is going to be a great deal laughter to children and adults alike.” Advertising Manager: Anthony J. Jannetti, Inc, East Holly Ave/Box 56, Pitman, NJ of false information bandied about by From Santa . . . and those of us at OR 08071. Telephone: 856/256-2300; Fax: 856/ politicians, interest groups, and people Manager, enjoy the holidays and welcome 589-7463. John R. Schmus, national adver- who are not well informed or who have the New Year. tising manager. E-mail: [email protected] their agendas. —Ellie Schrader

December 2007 OR Manager Vol 23, No 12 3 4

Please see the ad for SKYTRON INC. in the OR Manager print version. Senate bill seeks to air implant pricing

edical device companies would ters from hospitals, consumer groups, have to file reports with the gov- employers, and journalists about the secre- Mernment on prices for all implants cy of pricing for products like hip and sold, under a bill (S 2221) introduced Oct Hospitals“ have knee implants and pacemakers. 23. The sponsors, Senators Arlen Specter of A challenge to implement Pennsylvania and Charles Grassley of no idea what is Iowa, both Republicans, say their aim is to A New York hospital wrote him that make transparent the prices manufacturers a fair price. it spends about $300 million a year on charge hospitals participating in public pro- supplies. Though pacemakers and joint grams like Medicare and Medicaid. implants account for only 3% of the “The device makers actually prohibit items the hospital buys, these devices hospitals from disclosing the price of a account for about 40% of the total medical device to others. So hospitals have “ spending. no idea what is a fair price,” Senator such as pacemakers and internal defibril- An analyst for Wachovia told Grassley said. “This is a major reason why lators, as part of a service to subscribers. investors in October that a Washington, many hospitals pay absurdly more than Guidant countersued, saying ECRI DC, consultant gave the bill about 50% others for the same medical device.” Institute had “tortiously interfered” with odds of passing, noting that Senator Grassley said he is concerned because its contracts with customers and had mis- Grassley is powerful and works across device costs, which are rising 8% to 15% a appropriated “trade secrets” in obtaining party lines. (There is no Democratic year, are taking up more of the Medicare Guidant prices, which it considers confi- cosponsor.) payment, which means hospitals have less dential, from hospitals. Court-mandated Though he could not comment on to spend on other aspects of care such as settlement discussions were underway in the pending litigation, Jeffrey Lerner, staffing. It’s also causing Medicare spend- early November. If the discussions fall PhD, president and CEO of ECRI ing to rise “faster than it should” if hospi- through, the case will proceed to trial. Institute, says he thinks the legislation tals pay more than the fair market price Earlier in 2006, Aspen Healthcare is promising. for implants. Metrics, a consulting unit of the group “For almost any other major pur- Whether hospitals may compare purchasing organization MedAssets, set- chase, like a house, customers are able implant prices has led to lawsuits. Last tled a lawsuit by Guidant alleging that to compare prices to help them make a year, the nonprofit ECRI Institute sued Aspen illegally induced hospitals to vio- decision. It would be very beneficial to Guidant Corporation, whose cardiac late the company’s confidential pricing bring that same shopping power into rhythm business has since merged with agreements for use in its consulting health care purchasing.” Boston Scientific, over the right to publish engagements. If passed, the bill would be challeng- price comparisons of Guidant devices, Senator Specter said he’d received let- ing to implement. Implants have many components, with different parts used for individual patients, making it diffi- Advisory Board cult to compare prices for constructs. The government would need to deter- William R. Anton, RRT Marion L. Freehan, RN, MPA/HA, CNOR mine how to classify the parts. Business director, surgical services; Director, Nurse director, main operating rooms, Under the bill, pricing would be value analysis, University of Washington Massachusetts General Hospital, Boston posted on the Internet. Manufacturers Medical Center, Seattle Jo Harbaugh, RN, BS, CGRN Amy Bethel, RN, MPA, CNA EndoSite advisor, Olympus America Inc who failed to report or misrepresented Executive director, surgical services, Iowa Normal, Illinois price data would be assessed penalties O Health, Des Moines Kenneth Larson, MD of $10,000 to $100,000. Mark E. Bruley, EIT, CCE Trauma surgeon, burn unit director, Vice president of accident & forensic Mercy St John’s Health Center, investigation, ECRI, Plymouth Meeting, Springfield, Missouri Writing to Congress Pennsylvania William J. Mazzei, MD Ramon Berguer, MD Medical director, perioperative services, To comment on S 2221, the Chief of surgery, Contra Costa Regional Medical University of California, San Diego Transparency in Medical Device Center, Martinez, California Mary M. Murphy, RN, BSN, CNOR Pricing Act of 2007, you can send Helen K. Crouch, RN, MPH, CIC Director, surgical services, Munson Medical Director, infection control & epidemio-logy Center, Traverse City, Michigan an e-mail through your Congress services; Infection control consultant for Army, Susan Nielsen, RN, MSA, CNOR member’s website. Senators are Great Plains Regional Command, Brooke Army Director, Central Processing Department, William listed at www.senate.gov. House Medical Center, San Antonio, Texas Beaumont Hospital, Royal Oak, Michigan members are at www.house.gov. Franklin Dexter, MD, PhD Barbara Pankratz, RN, MSN Associate professor, Department of Director, surgical services, University of To download the bill and check its Anesthesia, University of Iowa, Iowa City Wisconsin Hospital & Clinics, Madison status, enter the bill number at the Mary Diamond, RN, MBA, CNOR Ena M. Williams, RN, BS government’s website, Thomas, at Director of surgical services, Tri-City Medical Nursing director, perioperative services, Center, Oceanside, California Yale-New Haven Hospital, New Haven, http://thomas.loc.gov. Connecticut

December 2007 OR Manager Vol 23, No 12 5 6

Please see the ad for ADVANCED STERILIZATION PRODUCTS in the OR Manager print version. Leadership

Continued from page 1 The 10 most “No other area in the hospital has a Nurses frequent forms of higher probability of lateral violence than “ lateral violence the operating room,” says Griffin, who is need skills director of nursing professional develop- in nursing ment at Brigham & Women’s Hospital in to address Boston and was a certified perioperative Listed by frequency. nurse early in her career. “People from the conflict. 1. Nonverbal innuendo (raising of eye- operating room call me the most, and I brows, making faces) understand it because I’ve lived it.” 2. Verbal affront (covert or overt snide There’s consensus that lateral violence remarks, lack of openness, abrupt needs to be stopped. It’s not just inhu- “ responses) mane—it has a corrosive effect on nurse out after work. They have less chance to recruitment and socialize and bond. 3. Undermining activities (turning retention. It also Coupled with social changes like more away, not available) affects patient single parents, more people working 4. Withholding information (practice safety. Experts longer hours each a week, and longer or patient) agree commu- commutes, people are carrying a heavier 5. Sabotage (deliberately setting up a nication break- load of stress. negative situation) downs and lack A role for nurse leaders 6. Infighting (bickering with peers) of teamwork Though nurse managers and directors 7. Scapegoating (attributing all that are a root cause are stretched themselves, Bartholomew goes wrong to one individual) of errors. If urges them to realize “this is not small 8. Backbiting (complaining to others nurses are afraid to speak up because they stuff—the camaraderie and ability to com- about an individual and not speak- fear being bullied by fellow nurses and municate on your unit are mandatory for ing directly to that individual) physicians, patients can be harmed. teamwork.” 9. Failure to respect privacy Nurse directors and managers play a To address lateral violence, managers 10. Broken confidences pivotal role in defusing lateral violence. need training to make sure they have the “Directors carry the culture code of needed skills, according to Karen M. Stanley, Source: Reprinted with permission from the organization. They are responsible by MS, APRN, BC, and Mary M. Martin, DNS, Griffin M. J Contin Educ Nurs. what they ignore or what they pay atten- ARNP, of the Medical University of South 2004;35(6):257-163. Adapted from Duffy tion to—they set the standard.” says Carolina (MUSC) in Charleston, who are E. Collegian: J Royal Coll of Nurs Kathleen Bartholomew, RN, MN, author also studying lateral violence. Australia. 1995;2(2):5-17; Farrell G A, of Ending Nurse-to-Nurse Hostility: Why “Participants reported over and over J Adv Nurs.1997; 25:501-508; McCall E. Nurses Eat Their Young and Each Other that they believed their nurse manager Lamp.1996;53(3):28-29; McKenna B G, (HCPro, 2006). was aware of the behavior but did not take et al, J Adv Nurs. 2003;42:90-96. Is lateral violence increasing? action to stop it,” they say. They have There are no studies documenting developed a survey to measure lateral vio- newly licensed nurses in that year was whether bullying is increasing, but “if you lence, which is slated for publication in 91%, compared to a national rate of 40% Issues in Mental Health Nursing. ask nurses about it compared with 10 or to 60% in other studies. 15 years ago, they will say it is more com- What we know works For the past 3 or 4 years, education on mon,” says Bartholomew. She became Griffin published a well-known study lateral violence has been included in the interested in lateral violence after she on lateral violence in 2004 in which 26 orientation of all nurses new to Brigham & entered nursing at age 38 and experienced newly licensed nurses were taught about Women’s. Nursing staff also receive 1 hour it herself and later observed it as nurse lateral violence. They learned about ways of education during annual “competency manager of a 57-bed orthopedic unit in a to respond to common forms of lateral days” given by nursing units. The educa- large hospital. violence, with laminated cue cards as tion includes a short video illustrating inci- She thinks the cost cutting that began reminders. dents that have actually happened at the in hospitals in the late 1990s is a factor. A year later, in focus groups, they hospital followed by a 10- to 15-minute Shrinking resources, inefficient systems, were asked about their experience with discussion. and managers’ broader span of control lateral violence, use of the cue cards, and Griffin is conducting a 2-year study have fueled stress, she believes. their socialization. Almost all (96%) had designed to measure the perception of nurs- “Nurses are the last line of defense seen lateral violence during the year, and es’ workplace behavior and the perceived between patients and the system, and they 46% said it was directed at them. All had impact of education on lateral violence. take more on themselves because we’re responded to the incidents, though they What can managers do? never going to say no,” she says. said it was difficult. But the outcome was This is advice from experts on lateral Plus, with more nurses working 12- that the lateral violence stopped. hour shifts, they no longer have time to go Retention for the whole group of 62 Continued on page 9

December 2007 OR Manager Vol 23, No 12 7 8

Please see the ad for SPECTRUM SURGICAL INSTRUMENTS in the OR Manager print version. Leadership

Lateral violence in the OR

Examples from OR Manager readers: I was working for a supplemental The main lounge/break room was used by I worked with a nurse who actually once staffing agency. My first assignment the OR nurses. No one explained the idio- risked the patient to make herself look good allowed me to experience lateral violence syncrasies of the OR setup to me during and me look bad. We were doing a carotid, first-hand while in the scrubbing role. The my orientation. and I was scrubbed. I had a set of Javid surgeon had 2 favorite instruments that My preceptor introduced me to everyone shunts on my field, and before the incision, were essential for him to complete his as a scrub tech turned circulator. After the surgeon looked at all of them and tied a planned surgery—diamond jaw Metzen- those introductions, I was even more dis- suture around the one he wanted. He told baum scissors and a diamond jaw needle placed. I was never made to feel welcome in us he didn’t think he would need it, but if holder. His favorite circulating nurse was the “nurses’” lounge. When I would enter, he did, he would need it fast and didn’t gone for the day. I made a request for the all conversation would quickly become a want to have to wait for me to find it. instruments, but they were nowhere to be low simmer rather than the previous bois- The case started, then, yes, he needed the found. The case was completed with an terous engagements. I was constantly whis- shunt. I reached on my back table, but it unhappy surgeon who voiced my incompe- pered about in that lounge, pointed to, and wasn’t there. As I was frantically search- tence to the rest of the team and the super- my name was often brought up loudly dur- ing, with the surgeon pretty angry with visors. Two weeks later, I was in the same ing those whispering conversations. me, my circulator buddy reached into her scenario, except this time his favorite circu- I tried to use the “scrub” lounge a few pocket, pulled out the shunt with the string lator was there. I again requested the dia- times and found that when I entered the around it, dangled it in front of all of us mond jaw instruments. The circulator room, most of the scrubs either ignored me and said,”Oh, doctor, look what I found on retrieved both, the surgeon was happy, and or fled to other areas of the OR. the floor after you draped!” the procedure was completed. Then the sur- My preceptor never took the opportunity All that time she knew the shunt had geon explained to the circulator that during to show me how things should be done or fallen off my table; she was present and lis- his last case, the instruments were nowhere how to prep correctly. Instead, she took tening when the surgeon explained why he to be found. The circulator stated she didn’t every opportunity to throw me into a situa- would need it fast. Yet she didn’t bother to understand the problem because the instru- tion where I was not totally comfortable, let us know she found it on the floor. ments were right where they belonged. and then scold me when I didn’t do things My manager was in the room. While this Where they had really been was in her locker. the “right way.” She would often tell me nurse was dangling the shunt in front of all —Former perioperative director that since our room or case was delayed, I of us, my manager went to the vascular should take a break. As soon as I would take cart, grabbed another shunt and got it on Shortly after graduating in 1999, I took a a 5- to 10-minute break, she would stand in the field pronto, so thankfully, the patient job as a circulator in the OR. This seemed the hall upon my return and scold me by was okay. to be a natural extension of my previous 9 saying loudly, “Where have you been?“ The surgeon didn’t stop fussing at me for years of experience as a scrub tech. What I When I approached my director, she said the rest of the case because I had dropped didn’t understand going into the job is that that she preferred for the staff to handle the shunt and didn’t realize it. As the circu- the hospital had an unwritten hierarchy. their own difficulties. lator knew would happen, the surgeon did The OR had a locker/lounge area that —Nurse manager, outpatient not hold her responsible at all. was used by all female personnel at the endoscopy center —Director of surgical services beginning of the shift, but only scrub techs used it during the day as a lounge area.

Continued from page 7 nurses bad-mouth other nurses,” she says. include accountability, respect, excellence, “Gossiping can’t exist without an audience.” and adaptability. Each value has expected violence and on ways managers can inter- Examine your own leadership style behaviors, and all are reviewed with each vene to help their staffs. employee. Employees are asked to sign a Educate yourself Adopt a style of leadership that moves commitment to uphold the standards, away from top-down authority toward which is included in their personnel “Educate yourself about lateral vio- consensus building, Griffin advises. Give record, says Stanley. They are evaluated on lence and why it exists,” Bartholomew nurses more autonomy over their practice adherence to the standards and rewarded advises. through structures such as shared gover- by merit pay. Employees can choose not to “As a manager or director, you are nance. “The more you empower them, the sign, but the manager explains they will charged to see that your key people, your less victimization there will be,” she says. still be held to the standards. managers or your charge nurses, are edu- Set behavior standards Educate managers cated, can handle conflict, and can set a standard of professional behavior.” Griffin outlines expected professional Stanley recommends including educa- One thing every nurse can do: Never behaviors in her 2004 article. tion about lateral violence in regular edu- be a silent witness. The Medical University of South cational offerings for charge nurses and “If you can do only one thing to lower Carolina has standards of behavior for all preceptors. the hostility, you should stop listening to employees based on core values. These Continued on page 10

December 2007 OR Manager Vol 23, No 12 9 Leadership Opening managers’ eyes to lateral violence

workshop using real clinical nar- Nurses tell their stories ratives helps nurse managers Alearn about lateral violence at a Actual incidents from Westerly not assessed all my patients, so I said it community hospital in the Northeast. Hospital, Westerly, Rhode Island. could be me (I had 6 patients that night). The hospital has also adopted a policy on The supervisor said, “Was a sign for tests lateral violence, which is in the early I I am a nurse on evenings. I noted on a put on the door?” I said, “Yes, I did that stages of implementation. patient’s MAR [medication administra- because the secretary asked me to if I was Donna DeRobbio, RN, MSN, collected tion record] that there was a 5 am blood walking that way, which I was.” I was the narratives as part of a research study sugar that was not covered with sliding scolded in front of everybody. After I got she conducted on lateral violence at scale insulin, and no notation had been scolded, the supervisor left and never Westerly Hospital, Westerly, Rhode Island, made. As per hospital policy, I filled out asked what I had done toward the under a grant from the University of a variance. Several days later, the per patient’s care, which I thought was Rhode Island. diem nurse who had made the error cor- important and substantial. “Because these are real incidents, it’s an nered me in the med room where several I effective way to introduce the subject of I was assigned an admission from the other nurses were working and scolded lateral violence,” she says. ER, and I took report from the ER nurse me in a loud voice for filling out a vari- The goal of the workshop is to raise and admitted the patient. After my ini- ance, saying I was trying to make her consciousness, assist managers in identify- tial assessment, I found that the fen- look bad. She told me the whole thing ing lateral violence, and encourage them tanyl patch that was supposed to be on was not necessary and I was wrong to to think about the problem. the patient wasn’t on the patient. I have filled out the report. I remember “You want managers to learn to see asked the charge nurse to look with me one nurse quit what she was doing and patterns of behavior. This is not judging but she told me to look again. I did look left the room. again, but no patch. So I asked the someone on a personal level for having a I bad day,” she says. “It’s about the impact I had been on duty for an hour or a bit charge nurse a second time to help me on patient care.” longer, when the supervisor entered the with this, and she told me she guessed if Managers discuss narratives med room where I was. She said to all I wasn’t capable of doing this alone, staff in the room that she had just received she’d have no choice but to see the The workshop is typically conducted a call from a patient who was crying. The patient. Still no patch. As we left the for a group of 8 nurse managers, who are patient stated she didn’t know what was room, the charge nurse said to figure out divided into small groups, preferably with going on with her condition, and her what happened, document it, get anoth- others they don’t know. Each group is nurse was nowhere to be found. The er patch from pharmacy, and not bother assigned one of the narratives (sidebar). supervisor continued to say it was wrong her again. I told my manager about the The group reads the narrative, and mem- not to talk to your patients and who exchange, and she said there was noth- bers discuss them. They then respond to would be doing this? At that point, I had ing she could do. the following questions: • What questions must the nurse have Continued from page 9 “Nurses need to learn how to go to a had at this moment? How did the peer and say, ‘I heard you said something other person(s) present influence the “I’ve found that sessions that allow about me,’ or, ‘I was worried when you nurse’s understanding of what hap- coworkers to learn about lateral violence rolled your eyes after something I did,’” pened? and practice dealing with it together to be she says. “The reality is that we are not • Who was there to help the nurse? the most effective,” she says. having these crucial conversations and • What would you hope the nurse A community hospital in Rhode Island lack the assertiveness skills to deal with learned from this experience? holds workshops for nurse managers where these conflicts effectively. Learning these Each group appoints a leader to report they discuss clinical narratives about lateral skills is critical to professional relations, its findings. Each participant is also asked violence incidents that have actually hap- quality of care, and patient safety.” to reflect on the following questions on his pened to nurses at the hospital (sidebar). Give new nurses a shield or her own: Provide nurses with skills Teach newly hired nurses how to shield • How did this exercise influence your Nurses need skills to be able to address themselves from lateral violence. As understanding of what it means to be a conflict with peers, such as conflict man- Griffin illustrated in her study, coaching nurse? agement and assertiveness. Bartholomew nurses on methods for deflecting lateral 1 • How does it make you feel about your said it took about 2 ⁄2 years of coaching violence, along with cues, can be effective. practice? before she saw a true cultural change on Give new nurses a chance to bond The clinical narratives have been more her unit. But the changes are long lasting effective in educating managers than a lec- Provide support for orientees to help O once the staff can recognize lateral vio- ture would be, DeRobbio observes. lence, see the damage it is causing, and keep them from feeling isolated. have the skills to handle it. “Never hire just one nurse—always

10 OR Manager Vol 23, No 12 December 2007 Counts off in 1 in 8 general surgery cases

urgical count discrepancies occur surgeon and lead author of the study from The study is a followup to a 2006 surprisingly often, in about 1 in 8 Brigham & Women’s Hospital, Boston, report of observations of 10 complex gen- Sgeneral surgery cases in a new study. told OR Manager in an interview. eral surgery cases that found counting to The counts took an average of 13 minutes Discrepancies increase the risk of “significantly compromise” case progress to resolve. In 60% of cases, the discrepancy retained foreign bodies, she says, “because and patient safety. In that study, 14.5% of was a misplaced item, such as a sponge on every time the count is off, we don’t have the incision time was spent on counting. In the floor or in the trash. an accurate count of what is going on.” contrast, the new study, which involved The study of 148 general surgery cases Is technology, such as bar-coded routine cases, found counting took signifi- is believed to be the first to document sur- sponges, the answer? cantly less time. gical count discrepancies based on direct She and her colleagues have completed The report was presented at the observation. a randomized controlled trial of bar cod- American College of Surgeons meeting in In none of the cases was an item left in ing technology, being reviewed for publi- October in New Orleans. An abstract is in a patient’s body. cation, which will provide some data. The the September 2007 Surgical Forum sup- new study will also help by providing a plement to the Journal of the American Counting took an average of 8.6 min- O utes per case, or about 6% of the operative baseline on how counts are performed College of Surgeons. time. Discrepancies were most often relat- currently. The results can be used as a con- ed to sponges, followed by instruments trol to see how new technologies perform, References and needles. Counts after personnel Dr Greenberg says. changes were more likely to involve a dis- “One thing people need to remember Christian C K, Gustafson M L, Roth E M. A crepancy than if the original personnel when we think about these new technolo- prospective study of patient safety in the were present. gies is, while they’re designed to improve operating room. Surgery. 2006;139:159- “I think people have an idea that these on the current situation, they may or may 173. discrepancies are happening. But I don’t not achieve that goal,” she says. “They Greenberg C C, Diaz-Flores R, Lipsitz S, et al. think anyone would have expected it to be might also introduce new system com- A prospective study of the OR counting 1 per 8 cases, or 1 per 14 hours of operative plexities or unintended consequences that protocol. Abstract. J Am Coll Surg. time,” Caprice Greenberg, MD, MPH, a we need to think about.” 2007;205(3S):S73.

hire a minimum of 2,” suggests Bartholo- organization function?’ We all need to Most technical errors mew. “With every nurse you add, you be looking at that. involve experienced decrease stress for the group and increase You really can’t change the people surgeons, complex patients the chances of them staying.” on the front lines if the leadership does O Give the group time to share stories not support them.” Most technical errors in surgery hap- and bond. And keep an eye on what is —Pat Patterson pen in routine operations with experi- happening during the first week and enced surgeons and involve complex patients and technology or systems fail- first month. Keep in touch with new References hires yourself. Have them come by once ures, a new study shows. a week for a 15-minute chat. Say: Examining 258 malpractice claims Bartholomew K. Ending Nurse-to-Nurse involving injuries due to errors, the “Come into my office. I want to hear Hostility: Why Nurses Eat Their Young and researchers found 52% involved technical about your week.” Each Other. Marblehead, Mass: HCPro, errors. The majority of these cases—73%— Offer two-way feedback 2006. www.hcpro.com. involved experienced surgeons, and 84% Preceptors give feedback to new Farrell G A. Aggression in clinical settings: happened during routine operations. Two- nurses every day. Do you also encour- Nurses’ views. J Adv Nurs. 1997;25:501- thirds (65%) were linked to manual error, 9% 508. age new nurses to give feedback to pre- to judgment, and 26% to both manual and ceptors? Griffin M. Teaching cognitive rehearsal as a judgment errors. In all, 61% of the errors Bartholomew says one preceptor shield for lateral violence: An interven- were attributed to patient complexities, such was shocked when she heard her orien- tion for newly licensed nurses. J Contin as emergencies, difficult or unexpected tee say, “I need to know I’m not in your Educ Nurs. 2004;35(6):257-163. anatomy, or previous surgery. Technology or way, that I am not a bother.” The pre- Stanley K M, Dulaney P, Martin M M. systems failures contributed to 21%. ceptor didn’t understand why the nurse Nurses ‘eating our young’—It has a The authors recommend that surgical felt that way. name: Lateral violence. S Carolina Nurs. research should focus on improving deci- “The preceptor’s body language 2007;14(1): 17-18. sion making and performance for routine operations on complex patients and circum- conveyed what she was thinking, but Stanley K M, Martin M M, Nemeth L S, et al. she had no idea she was communicat- Examining lateral violence in the nursing stances. Common interventions such as ing that,” she notes. workforce. Issues Ment Health Nurs. 2007. having experienced surgeons for complex Practice self-evaluation In press. procedures and increasing supervision for trainees will address only a minority of O “To truly embrace change involves errors, the authors say. self-evaluation,” Griffin says. “You —Regenbogen S E, Greenberg C C, Studdert D need to think about, ‘How does this M, et al. Ann Surg. 2007:246:705-711l.

December 2007 OR Manager Vol 23, No 12 11 Managing people

Continued from page 1 scrub with a dedicated preceptor in one service for 4 weeks, then circulate with a Building enthusiasm dedicated RN preceptor in the same ser- Columbia Hospital The rotation“ vice for 4 weeks. Every week features a West Palm Beach, Florida different competency, such as counting or builds specimens. It sounds elementary, but it 250 beds, 7 ORs works because interns can focus on one Gary G. Reardon, RN, MSN, MS, CNOR, confidence. subject at a time. director of surgical services Following this classroom and clinical segment, we have a graduation party. Just 1 year after graduating from nurs- Then the interns enter a 3-week scrub rota- ing school, I became an OR manager. I tion with surgical technologist preceptors took on the responsibility of opening a “ who have been carefully chosen. They If nurses excel in certain cases, we try new hospital in Canada where I had to scrub for 3 weeks in one service such as to assign them to those cases, but if not, hire and train all the staff. That was where general surgery or gynecology, and follow they understand. Everybody has to be I developed my orientation program. their preceptors’ schedules. Because we able to perform any case on call. Based on that history, it did not bother me are a trauma center, this schedule allows We have no vacancies at the present. when I came to Columbia Hospital 10 the interns to work all shifts and week- We have a high retention rate, with some years ago that nurses weren’t coming ends. Then they move into the circulating staff here for 20 years. through the door prepared for the OR. role and are with RN preceptors for 3 I love what I do, and I like to help get I have been meeting with schools in the weeks, again following their preceptors’ people enthusiastic about what they’re area to help them see the importance of schedules. learning. having a perioperative course for nursing The rotation builds confidence and students. I have told them I am willing to Periop internship pays off solid knowledge of the services. After this develop an OR program for their students, Christiana Care Health System rotation is completed, they begin another such as a 6-week internship. Wilmington, Delaware 6-week rotation in another service. Here at Columbia, I had to work to 4 surgical sites, 52 ORs At the end of this 6-month orientation, remove the fear that staff and administra- the interns leave the internship cost center tion had about hiring nurses without OR Beth Fitzgerald, RN, MSN, CNOR, and move to the OR site to continue spe- experience. I pointed out that I was confi- perioperative nurse internship cialty orientations. dent I could train them to become great manager After completing the program (from 9 OR nurses. to 11 months, depending on the site), we New nurses begin with a general orien- In response to a growing shortage of ask the new graduates to select a first and tation to the hospital and then start the ori- perioperative nurses, Christiana Care second choice of service to specialize in. 1 entation to surgical services. They go over Health System developed a “grow our The interns sign a 2 ⁄2 year contract and policies and procedures. They then spend own” perioperative internship program in are obligated to pay back $7,500 if they time in all the departments that report to 2000. It was costly but has paid off. Our don’t complete it. With our high retention surgical sevices and have relationships internship program has staffed 56% of the rate and having staffed the majority of OR with surgical services, such as admitting, OR positions in 4 facilities in the positions in the system, we think we have the lab, and sterile processing. Christiana system, and we have an 83% been successful. We do it in bite-size pieces. One week retention rate for the orientees. Bridge to practice Our 6-month program starts in they concentrate only on the admission of Northwestern Memorial Hospital the patient to the preop holding area. September and March, and we offer 6 col- Another week they just focus on preop lege credits through Delaware County Chicago preparation and documentation. I want to Community College. We have taken 2 to 16 744 beds, 52 ORs in 3 pavilions make sure they understand the process interns through the program at one time. Christine Bloomfield, RN, MS, CNOR, their patients go through before they see The first 2 weeks begin with classes on program manager for perioperative them in the OR. aseptic technique, policies and procedures, education By the end of the first month, they are and AORN recommended practices. I rotating through the services with their teach scrubbing, gowning, and gloving in Northwestern Memorial Hospital and preceptors—scrubbing and circulating. a simulation lab in the shell of two 2 ORs Northwestern Academy, the teaching arm Once they rotate through all of the ser- that were never finished. of the hospital’s human resources depart- vices, they are placed on call with a back- After the first 2 weeks, we begin to ment, have integrated surgical services up team member. When called in, they practice what has been taught in the lab. with professional education, forming what have the choice to call their backup in or On Mondays and Fridays, we have class- we call a “bridge to practice.” not. If they feel comfortable doing a case room time to review subjects such as elec- The program, created a year ago, com- without a backup person, that’s fine trosurgery, positioning, or malignant bines the expertise and practical knowl- because I believe it gives them self-confi- hyperthermia. On Tuesday, Wednesday, edge of the OR educator with the adult dence and autonomy. The staff also self- and Thursday, we move into the clinical learning theories used by the academy to schedule. setting and begin scrub rotations. Interns

12 OR Manager Vol 23, No 12 December 2007 Managing people

build a new approach for OR orientation. tion. How much can we teach orientees The program is based on the premise that and expect them to maintain competency an orientation program needs to integrate in? We finally decided to organize orienta- practical expertise with adult learning the- What“ is a tion around technology rather than service. ory and nursing theory. We divided the department into 2 parts, We start with 6 weeks of AORN’s realistic or pods, based on the technology used. Periop 101 curriculum, with a half a day in Orthopedic, neuro, plastic, and oral and the classroom and half a day in the OR. orientation? maxillofacial surgery are in 1 pod, and all Two OR educators teach the classes with abdominal and thoracic surgery are in the me, as well as preceptors. other pod. Though there’s huge difference After this phase, new nurses choose a between a head and a hip, a lot of the same service to specialize in and spend 2 weeks instrumentation, power equipment, and scrubbing and 2 weeks circulating in that “ technology are used across services such as classroom instruction followed by 18 specialty. neuro- and orthopedic spinal surgery. weeks of clinical experience in which the We have specialized call teams for each New employees are hired for a particu- interns rotate through the specialties. service, so there is no need for them to lar pod and rotate only through services in Every other Monday for the 18 weeks, ori- learn all services. that pod. We often have 30 nurses in orien- entees return to the classroom to discuss a The bridge-to-practice concept com- tation at one time. specific specialty and share progress. This bines Periop 101 with kinesthetic learning, Orientation begins with 1 month of gives them the opportunity to work in a an adult teaching and learning style in classroom instruction with observation in specialty before hearing the lecture specific which the student learns by actually carry- the OR. The orientation is generic at the to that specialty. We found this to be more ing out a physical activity. That enables beginning. Orientees learn table setups, helpful than including all of the specialty nurses to apply the principles they learn in draping, and scrubbing, although RNs do lectures in the initial 4-week classroom Periop 101. little scrubbing. component. With this approach, we believe orien- After the first month, they begin clini- After the 18 weeks of clinical experi- tees will retain information at a much cal rotations through the services in their ence, the interns are working in the ORs higher rate. pod. For the next 8 weeks, they have full- with their preceptors. Usually, within 6 Our major focus is on evidence-based time preceptors. If all competencies have months from the beginning of the pro- practice. We want nurses to know why been met during this 12- to 13-week phase, gram, interns are taking call with a buddy. they are practicing a certain way and not they move into orientation for the entire The classroom is set up with a mock just do things because that is the way it’s pod. The first 2 to 3 weeks of an 8- to 9- OR in a central location. The classes have always been done. week service rotation is with a preceptor. had 12 to 16 interns each. The interns sign Because we just started this program, For the remaining time, the orientee transi- a 2-year contract to continue working with we don’t know the effect on retention. One tions to a novice level and is expected to the Memorial Hermann system. So far, of my goals is to make our retention rate support staffing numbers independently only one nurse has broken the contract our indicator of success. on identified novice cases. because her husband was transferred. She When they transition to the next ser- System effort did pay the $2,500 fee. vice in the pod, they again have a precep- Memorial Hermann The program is a collaborative effort, tor for 3 weeks and then become novices with education staff from multiple facilities Houston, Texas in that service. When orientees have rotat- working together to plan and teach the 11-hospital system ed through all services (usually 21 to 24 course. As a result, OR education is now weeks), they join a “home team” and con- Deborah Alpers, RN, administrative standardized throughout the system. Hos- tinue to develop their practice. The total director of perioperative services, pitals have participated whether they have core education and service orientation Memorial Hermann Southwest a participant in the program or not. The takes 36 to 38 weeks. system effort has been especially valuable The expectation is that they then can About 5 years ago, the majority of hos- to the smaller hospitals. do any case within their pod. Even then, pitals in the Houston area had stopped Many of us look for nurses within our technology and new procedures present their training programs for OR nurses. As it own facilities who want the opportunity challenges. It is usually a year before a per- became more difficult to fill vacancies, at to become OR nurses. son is able to take call. But we’re staffed Memorial Hermann Southwest we knew Orienting by technology we needed a breakthrough. I convinced the around the clock, plus we have teams for Massachusetts General Hospital administration that my part-time educator night call and weekend call, so they aren’t should be made full time, and we launched Boston called in often. an OR internship program. 900 beds, 42 ORs To me, learning the services has to hap- The program is now part of the pen in orientation. If you don’t give nurses Marion Freehan, RN, MPA/HA, the time they need in orientation, it’s too Memorial Hermann system’s educational CNOR, nurse director, main ORs and recruitment plan. hard to play catch-up when you have them in the staffing numbers and count on Based on AORN’s Periop 101 curricu- O With so much new technology, we had lum, the program consists of 4 weeks of them to staff rooms. to look at what would be a realistic orienta- —Judith M. Mathias, RN, MA

December 2007 OR Manager Vol 23, No 12 13 Managing people Which candidates are the keepers?

ow do you know a nurse is a good Interviewing Interviewing fit for the OR—even if the person Hdoesn’t have OR experience? scenarios questions There’s a body of research that shows that the better the fit between an organization Two scenarios used by Christiana Some questions asked at Memorial and an employee, the longer the person is Health Care System, Wilmington, Hermann Southwest in Houston: Delaware: likely to stay. 1. Tell us about a time when you were Scenario 1 Managers often say they have a “gut proud of your decision-making feeling” about who will make it in the OR. You are assigned to a trauma case skills. Pick a problem you have had That’s one piece of the puzzle, but you involving a 15-year-old with multiple life- to solve, give the details involved in need to make sure you have a selection threatening injuries from a motor vehicle it, and tell us what you did in creat- process that is job related, objective, and accident. The patient is not expected to ing the solution to that particular consistent, advises Charles Handler, PhD, survive but is brought to the OR to do problem. an organizational/industrial psychologist everything that can possibly be done. The 2. Give a detailed example of what specializing in employee selection. trauma surgeon is visibly upset and has you do in your current position to You want to ensure every applicant is brought 4 other surgeons with him. This is organize yourself to begin your day evaluated based on the same criteria. going to be a busy case with 5 procedures and throughout your day. That’s also the best way to ensure the taking place at one time (neurosurgery, process can stand up to legal scrutiny, says 3. Tell us about a time when you have orthopedics, general surgery, plastics, and Handler, founder of www.rocket-hire.com, had to deal with a person in a posi- cardiovascular). a website that focuses on employee screen- tion of authority, and you had a dif- ing and assessment. • How will you handle this case emo- ference of opinion. How did you Of course, you will review a candi- tionally? handle this situation? date’s nursing experience and clinical • How will teamwork play a role in this 4. Tell us about a time when you were skills. You will check references to verify procedure? able to achieve something by doing previous employment. But you also want Scenario 2 more than was expected. to know how applicants would handle sit- 5. Describe a situation in which you uations in the OR. Known as “behavioral You have been asked to form a team and were expected to work with an interviewing,” this is based on the premise revise a policy on retained foreign objects. individual you personally disliked. that the best predictor of future behavior is Describe how you would facilitate this What happened? teamwork and encourage participation how a person responded to similar situa- 6. Talk about a time when you made a among the unengaged OR staff. tions in the past. personal sacrifice to reach a work Keys to behavioral interviewing: objective. • Relate the situation directly to the job. personal event.” 7. Pick an example from your current Don’t ask something like, “If you • Average: “I’d do what I can, but my job that would reflect on your abili- were an animal, what would you be?” own life is important, too.” ty to deal with pressure and/or (OR examples in the sidebar.) • Poor: “This is basically just a job. I stress. • To help ensure objectivity, rate would have trouble making last- 8. What types of things make you responses using a scale planned out in minute changes.” angry in the work setting? advance. The scale might outline Be sure to train managers and staff 9. When has a customer or co-worker behaviors that represent excellent, who will be interviewing so they fully been able to make you act less average, or poor responses, Handler understand the process, Handler adds. mature and professional than you suggests. Tips from OR managers normally do? You might have a committee of man- agers and staff develop the scenarios and Deborah Alpers, RN, administrative perioperative nurse internship manager model responses, with input from the director of perioperative services at for Christiana Care Health System, HR department. Memorial Hermann Southwest in Wilmington, Delaware, has applicants One example of a scenario: “This job Houston, says she asks a lot of questions write an essay about why they want to be may require you to work overtime on about difficult scenarios. an OR nurse. short notice. How would you handle “If they tend to blame others and don’t “For one person, it was because a fami- that?” suggest steps they can take to make the ly member had a good experience with Examples of responses: situation better, that turns me off,” she surgery, and the candidate kept talking • Excellent: “There have been times I says. She also finds those who make lists about how wonderful the OR was. For have done this. I have changed my and take notes during the interview tend another, it was the excitement they felt schedule to meet my work commit- to have good organizational skills, a quali- about wanting to work in surgery. I find ment, even though it meant missing a ty she is looking for. Beth Fitzgerald, RN, MSN, CNOR, the new graduates especially refreshing

14 OR Manager Vol 23, No 12 December 2007 Managing people Patient safety

because they are energetic and excited A time-out tool helps to improve about wanting to learn perioperative nurs- ing.” she says. compliance at the patient’s bedside At Columbia Hospital in West Palm Beach, Florida, Gary G. Reardon, RN, he highest priority of any health MSN, MS, CNOR, says he looks past the care provider is to ensure patient lack of OR experience for something Tsafety. The single most important else—potential and energy. tool for preventing errors is the ability to “My first question is: ‘Why do you communicate. According to the Joint want to be an OR nurse?’” Reardon says. Commission, the number one cause of “If they talk about wanting to get away sentinel events is a breakdown in com- from so much shift work, or they have a munication among the surgical team, babysitter problem, or they really like to patient, and family. For wrong surgery, work days, I don’t waste my time. in 2006, communication was second only “But if someone says, ‘I really want to to procedural compliance as a root cause work in the operating room, if someone of these events. would just give me a chance,’ I keep talk- The Joint Commission requires ing. If I see that desire, I hire them. These accredited organizations to adopt the were the characteristics someone saw in Universal Protocol for preventing wrong me years ago and gave me a chance.” surgery. The Universal Protocol has 3 Avoiding inappropriate questions major requirements: • a preoperative verification process Another benefit of a structured, job- related interview is that it helps avoid • marking the operative site To aid site verification for bedside procedures, improper questions. “Asking inappropri- • a time-out immediately before the a time-out document is attached to each pro- ate questions in a job interview is probably procedure. cedure/equipment tray. The wire cart also has the easiest way to get sued,” Handler says. The protocol applies not only for green fluorescent time-out labels. Inappropriate questions are those that operative procedures but also for non- OR procedures performed at the bed- place people in a protected class at a dis- components of the time-out are included. side. (The only advantage. Examples of protected classes In addition to this document, a fluo- exception for are race, ethnicity, religion, national origin, rescent green sticker labeled Time-Out is bedside proce- age, sex, and disability status. visible on the wire cart where the trays dures is that For example, it’s not legal to ask appli- are kept. This green sticker is used by the the site does cants about their plans to bear children, nursing units and the Central Sterile not have to be their date of birth, their marital status, or Processing Department. Implementation marked if the whether they own a car unless these ques- of this standardized process has reduced tions can be shown to be directly related to person per- O the incidence of bedside procedure forming the a person’s ability to do a job. events related to the Universal Protocol. procedure is —Stephanie Landmesser, RN, MSN, Incisionless surgery with the patient from the time of the CNOR decision to perform the procedure until for acid reflux disease Clinical Nurse Educator of the procedure is performed.) Perioperative Services After reviewing the Joint Commis- Surgeons at Ohio State University per- Lankenau Hospital sion’s guidelines for the Universal formed the first incisionless procedures in Wynnewood, Pennsylvania the US for gastroesophageal reflux disease, Protocol and our current policy, we developed a standardized process to be the university reported in October. A copy of the bedside time-out verification used for all surgical procedures that The procedure allows reconstruction of tool is in the OR Manager Toolbox at occur outside the operating room. the valve at the top of the stomach using a www.ormanager.com. new device introduced through the mouth In collaboration with our Central and advanced into the stomach. The Sterile Processing Department, we iden- EsophyX device by Endogastric Solutions tified specific instrument trays that has been cleared by the Food and Drug would be used for bedside procedures. Administration. We attach to the outside of each tray a Check our website Patients are usually in the hospital time-out document, which serves 2 pur- for the latest news, meeting overnight and are symptom free, Ohio poses. The first purpose is to identify the announcements, and other State surgeons report. They say the proce- tray as one that will be used for bedside practical help. dure leaves no external scarring, causes lit- procedures requiring a time-out verifica- www.ormanager.com tle postoperative pain, and reduces recov- tion. The second purpose is for the docu- O ery time. ment to be used as a written verification —www.endogastricsolutions.com of the procedure, ensuring all necessary

December 2007 OR Manager Vol 23, No 12 15 OR throughput Are your operating rooms ‘efficient’?

etting the right case in the right (overtime). Rather, schedule his cases room at the right time is the goal into 12 hours of allocated time (7 am to 7 Gfor every OR director. Often, pm). That way, anesthesia and nursing though, defining how well the OR suite The 8“ metrics staff know they will be there for 12 hours runs depends on whom you ask. when they arrive at work, and overtime The question, “Are my ORs effi- are based on costs (financial and morale) will be cient?” could be could be answered with reduced. The common response to this a qualitative approach by administering the literature. approach is, “No one wants to be there a written survey to OR personnel. A until 7 pm.” The answer is, “You are more quantitative approach has been there now until 7 pm, so why not make published (Macario, 2006) (see table). the scheduled OR time 12 hours long This OR efficiency scoring system could and have a more predictable work day be used as a management tool. For exam- “ duration?” Thus, optimizing staffing ple, statistical process control techniques service (ie, unit of OR allocation such as costs is finding a balance between over- could be used to analyze a dashboard of surgeon, group, department, or special- time and finishing early. these 8 performance indicators to evalu- ty) and then using computer software to There may be concern about the abili- ate baseline performance, identify areas minimize the amount of underutilized ty to flex staffing enough to avoid excess needing improvement, and conduct time and the more expensive overuti- staffing costs. It can be difficult to match prospective monitoring. lized time (Strum, et al, 1999). scheduled cases with staffing perfectly so Poorly managed OR suites may score Underutilized hours reflect how early the staff still get the hours and shifts they 0 to 5 points (on the 0 to 16 scale), while the room finishes. In the example above, need. For example, if Dr Smith needs a high scores of 13 to 16 are achievable if staff were scheduled to work from 7 12-hour block, the manager needs to find with state-of-the-art management sys- am to 3 pm, but instead the room fin- staff who want to work a 12-hour shift tems in place. ished at 11 am, there would be 4 hours of (or part-timers in some combination). The 8 metrics were chosen based on a underutilized time. The excess staffing Staffing is not only an OR efficiency issue review of more than 100 OR manage- cost (Strum, et al, 1999) would be 50% (4 but also a staff satisfaction issue. ment articles published in the literature hrs/8 hrs). Start-time tardiness in the past decade. These performance On the other hand, if 9 hours of cases indicators should be able to be computed are performed in an OR with staff sched- Start-time tardiness is defined as the from data already available in OR infor- uled to work 8 hours, then the excess mean tardiness of start times for elective mation systems. Surgeon satisfaction is staffing cost is 25%. Overutilized hours cases per OR per day. Reducing the time also critical, but no valid and reliable are the hours that ORs run longer than patients have to wait for their surgery instrument to measure this has been the regularly scheduled OR hours, or 1 once they arrive at the hospital (especially developed. hour in this example. The calculation is if the preceding case runs late) is another Excess staffing costs due to OR as follows: 1 hr/8 hr=12.5%, which is important goal. If a case is supposed to allocation not being based on then multiplied by the additional cost of start at 10 am (patient enters OR), but the maximizing OR efficiency staying late, which often is assumed to case starts at 10:30 am, there are 30 min- be a factor of 2 (related to monetary over- utes of tardiness. In computing this metric, Nothing is more important than to first time cost paid to staff, as well as recruit- no credit is given if the 10 am case starts allocate the right amount of OR time to each ment and retention costs related to early (for example at 9:45 am). service on each day of the week for its case unhappy staff because they have to stay The tardiness in starting scheduled scheduling. This is not the same as the late unpredictably). cases should total less than 45 minutes block time! To illustrate, imagine that 2 OR suites can reasonably aim to per 8-hour OR day in well-functioning cases each lasting 2 hours are scheduled achieve a staffing cost that is within 10% OR suites. Facilities with long work days into OR 1 with OR nurses and an anes- of optimal (ie, workload is perfectly will have greater tardiness because the thesiologist scheduled to work an 8-hour matched to staffing). longer the day, the more uncertainty day. The matching of workload to If the key is to allocate appropriate about case start times. Having patients’ staffing has been so poor that little can be time to each service based on historical medical records ready to go with all done the day of surgery to increase the OR use, how do you deal with rooms needed documents is essential for on- efficiency of use of the staff. Neither consistently running late on the day of time starts. awakening patients more quickly nor surgery? The answer: Make the allocated Case cancellation rate on day reducing the turnover time, for example, time into which cases are being sched- of surgery will compensate for the poor initial uled longer. For example, if a surgeon Cancellation rates vary among facili- choice of staffing for OR 1 and/or how does 12 hours worth of cases every day ties, depending partly on the types of the cases were scheduled into OR 1. he is in the OR, don’t plan 8 hours of patients receiving care, ranging from Optimal allocation of OR time should staffing (7 am to 3 pm) and have every- 4.6% for outpatients (van Klei, et al, be based on historical use by a particular one frustrated by having to stay late

16 OR Manager Vol 23, No 12 December 2007 OR throughput

A scoring system for OR efficiency with 8 performance indicators Metric Points 012 Excess staffing costs >10% 5% -10% < 5% Start-time tardiness > 60 mins 45-60 mins < 45 mins (Mean tardiness of start times for elective cases per OR per day) Case cancellation rate > 10% 5% -10% < 5% PACU admission delays > 20% 10%-20% < 10% (% of workdays with at least one delay of 10 mins or greater in PACU admission because PACU is full) Contribution margin (mean) per OR hr < $1,000/hr $1,000/hr-$2,000/hr > $2,000/hr Turnover times > 40 mins 25-40 mins < 25 mins (Mean setup and cleanup turnover times for all cases) Prediction bias > 15 mins 5-15 mins < 5 mins (Bias in case duration estimates per 8 hr of OR time) Prolonged turnovers > 25% 10%-25% < 10% (% of turnovers that are more than 60 mins)

Source: Reprinted with permission from Macario A. Anesthesiology. 2006;1005(2):237-240.

2002) to 13% (Pollard, et al, 1999) to 18% efficiently but still lose its financial shirt best performing OR suites average less (Basson, et al) at VA medical centers. if many surgeons are slow, use too many than 25 minutes (Dexter, Epstein, et al, Many cancellations are due to nonmed- instruments or expensive implants, etc. 2005). Cost reduction from reducing ical problems such as a full ICU, surgeon These are all measured by the contribu- turnover times (because OR workload is unavailability, or bad weather. OR can- tion margin per OR hour. The contribu- less) can only be achieved if OR alloca- cellation rates can be monitored statisti- tion margin per hour of OR time is the tions and staffing are reduced (Dexter, cally (Dexter, Marcon, et al, 2005), and hospital revenue generated by a surgical Abouleish, et al, 2003). Despite this, well-functioning OR suites should have case, less all the hospitalization variable turnover time receives lots of attention cancellation rates less than 5%. labor and supply costs. Variable costs, from OR managers because it is a key Monitoring cancellations correctly is not such as implants, vary directly with the satisfier for surgeons. taking the ratio of the number of cancel- volume of cases performed. Sometimes an OR suite reduces lations to the number of scheduled cases This is because fee-for-service hospi- turnover times (by providing more staff (Dexter, Marcon, et al, 2005). tals have a positive contribution margin to clean the room, for example), but new Postanesthesia care unit for almost all elective cases mostly due to problems arise (such as not enough time admission a large percentage of OR costs being for sterilizing instruments for the new fixed. For US hospitals not on a fixed case or not being able to take the patient PACU admission delays are defined annual budget, contribution margin per to the PACU because there are no beds) as the percentage of work days with at OR hour averages $1,000 to $2,000 US that were “hidden” by long turnover least one delay of 10 minutes or greater per OR hour (Dexter, Ledolter et al, 2005; times. in PACU admission because the PACU is Dexter, Blake, et al, 2002; Macario, Times between cases that are longer full. It is important to adjust PACU nurse Dexter, et al, 2001). than a defined interval (eg, 1 hour staffing around the times of OR admis- Turnover times because the to-follow surgeon is unavail- sions. Algorithms exist that use the num- able) should be considered delays, not ber of available nursing hours to find the Turnover time is the time from when turnovers (Dexter, Macario, et al, 1999). staffing solution with the fewest number one patient exits an OR until the next Prediction bias of understaffed days (Dexter, Epstein, patient enters the same OR (Donham, et 2005; Marcon, Dexter, 2006). al, 1999). Turnover times include cleanup Prediction bias is defined as bias in Contribution margin per OR hr times and setup times but not delays case duration estimates per 8 hours of between cases. Based on data collected at OR time. Prediction error equals the An OR suite that puts up with exces- 31 US hospitals, turnover times at the sive surgical times can schedule itself Continued on page 18

December 2007 OR Manager Vol 23, No 12 17 OR throughput

Continued from page 17 ating room efficiency. Anesth Analg. Macario A, Dexter F, Traub R D. Hospital 2003;96:1109-1113. profitability per hour of operating actual duration of the new case minus room time can vary among surgeons. Basson M D, Butler T W, Verma H. Anesth Analg. 2001;93:669–675. the estimated duration of the new case. Predicting patient nonappearance for Bias indicates whether the estimate is surgery as a scheduling strategy to Marcon E, Dexter F. Impact of surgical consistently too high or consistently too optimize operating room utilization in sequencing on post anesthesia care low, and precision reflects the magni- a veterans’ administration hospital. unit staffing. Health Care Manag Sci. tudes of the errors of the estimates. Anesthesiology. 2006;104(4):826-834. 2006; 9:81-92. Efficient OR suites should aim to have a Dexter F, Abouleish A E, Epstein R H, et Pollard J B, Olson L. Early outpatient pre- prediction bias that is less than 15 min- al. Use of operating room information operative anesthesia assessment: Does utes (Dexter, Macario, et al, 2005). A rea- system data to predict the impact of it help to reduce operating room can- son for bias can be surgeons consistently reducing turnover times on staffing cellations? Anesth Analg. 1999;89: shortening their case duration estimates costs. Anesth Analg. 2003;97:1119-1126. 502–505. because they have too little OR time allo- Dexter F, Blake J T, Penning D H, et al. Strum D P, Vargas L G, May J H. Surgical cated and need to “fit” their list of cases Calculating a potential increase in hos- subspecialty block utilization and into the OR time they do have. In con- pital margin for elective surgery by capacity planning: A minimal cost trast, surgeons may purposely overesti- changing operating room time alloca- analysis model. Anesthesiology. mate case durations to keep control of or tions or increasing nursing staffing to 1999;90:1176-1185. access to their allocated OR time so if a permit completion of more cases: A van Klei W A, Moons K G, Rutten C L, et new case appears, their OR time is not case study. Anesth Analg. 2002;94: 138–142. al. The effect of outpatient preopera- given away. tive evaluation of hospital inpatients Remember that lack of historical case Dexter F, Epstein R H, de Matta R, et al. on cancellation of surgery and length duration data for scheduled procedures Strategies to reduce delays in admis- of hospital stay. Anesth Analg. 2002;94: is an important cause of inaccuracy in sion into a postanesthesia care unit 644–649. predicting case durations. In general, from operating rooms. J PeriAnesth Zhou J, Dexter F, Macario A, et al. Relying half of the cases scheduled in your OR Nurs. 2005;20:92-102. solely on historical surgical times to suite tomorrow will have less than 5 pre- Dexter F, Epstein R H, Marcon E, et al. estimate accurately future surgical vious cases of the same procedure type Estimating the incidence of prolonged times is unlikely to reduce the average and same surgeon during the preceding turnover times and delays by time of length of time cases finish late. J Clin year (Zhou, et al, 1999). day. Anesthesiology. 2005;102:1242-1248. Anesth. 1999;11:601-605. It would be nice to have no uncertain- Dexter F, Ledolter J, Wachtel R E. Tactical ty in case duration prediction. But it is decision making for selective expan- present. The problem is looking for a sin- sion of operating room resources Elective ORs better for gle number that is correct most of the incorporating financial criteria and time. You won’t get accurate estimates by uncertainty in sub-specialties’ future emergencies in study using historical case duration data. workloads. Anesth Analg. 2005;100: Rather, from the historical data, you’ll 1425-1432. Emergency patients were operated on get an assessment of the uncertainty. more efficiently by reserving capacity in Dexter F, Macario A, Epstein R H, et al. elective ORs rather than having dedicat- With proper management weeks to Validity and usefulness of a method to ed emergency ORs, in a new study from months ahead of time, the groundwork monitor surgical services’ average bias for an efficient (well-functioning) OR in scheduled case durations. Can J The Netherlands. suite should be in place. Statistical Anesth. 2005;52:935-939. The study used a simulation model to process control could be used to prospec- examine the 2 approaches to reserving Dexter F, Macario A, Qian F, et al. tively monitor a dashboard of items, capacity for emergencies. The outcome O Forecasting surgical groups’ total measures were waiting time, staff over- such as the ones discussed above. hours of elective cases for allocation of time, and OR utilization. —Alex Macario, MD, MBA block time. Anesthesiology. 1999;91: Department of Anesthesia 1501-1508. Results indicated that the policy of Stanford University School of reserving emergency capacity in all elec- Medicine Dexter F, Marcon E, Epstein R H, et al. tive ORs led to improved waiting times Validation of statistical methods to for emergency surgery from 74 minutes Summarized with permission from Macario, compare cancellation rates on the day to 8 minutes. Overtime was reduced by A. Are your hospital operating rooms “effi- of surgery. Anesth Analg. 2005;101(2): 20%, and overall utilization increased by cient”? 2006;105:257-260. 465-473. Anesthesiology. about 3%. Donham R T, Mazzei W J, Jones R L, et al. The results led to the closing of the References Procedural times glossary. Am J emergency OR at the Erasmus University O Anesthesiology. 1999;23,5 Suppl:4. Medical Center in Rotterdam. Abouleish A E, Dexter F, Epstein R H, et —Wullink G, Van Houdenhoven M, al. Labor costs incurred by anesthesiol- Macario A. Are your hospital operating ogy groups because of operating rooms “efficient”? A scoring system Hans E W, et al. J Med Syst. 2007; rooms not being allocated and cases with eight performance indicators. 31:543-546. not being scheduled to maximize oper- Anesthesiology. 2006;105(2):237-240.

18 OR Manager Vol 23, No 12 December 2007 OR Business Management Conference

May 19-21, 2008 Hyatt Regency San Francisco at the Embarcadero Center 20

Please see the ad for MATROX GRAPHICS INC. in the OR Manager print version. Managing Today’s OR Suite Managing people a theme at conference

he power of teams and a culture of collaboration were themes at the TManaging Today’s OR Suite confer- ence Oct 3 to 5 in San Diego. The confer- ence attracted 726 attendees for the 2-day conference and 390 for the preconference seminars. They visited an exhibit featuring 88 companies. Attendees gave the conference high ratings, with 92% rating it as “excellent” or “very good” and 100% saying they thought the content would be valuable in their work settings. Barbara Johnson, RN, BSN, MHA, was honored as OR Manager of the Year. Johnson, director of perioperative nursing at Piedmont Hospital in Atlanta, said she has “the best perioperative team in the universe.” She advised managers, “Don’t think you have to have all the answers— rely on your staff.” Select for talent Match peoples’ talents to their roles, “People will walk through a wall for you How do you build great teams? keynoter Curt Coffman advised. if they believe you care about them,” One answer is to select people who said Annie McKee, PhD. have the right talent, said Curt Coffman in Failure is not final his keynote, sponsored by Kimberly-Clark to move them to do what needs to be done. Health Care. Coffman told of a man who “They are very clear about what is The message from CDR Scott Waddle, asked a circus performer how he trained important to them. And they understand USN (Ret), about his recovery from a dev- his dogs to do amazing tricks. The reply: themselves well enough to talk, walk, and astating error in which the submarine he “I find the ones who can do it, and I pick live what is important to them.” commanded caused the death of 9 people, them.” After McKee’s lecture, the audience struck a cord with the audience during a ”It’s more effective to find the role that gathered poolside for a gala wine-tasting session sponsored by the J2 Group, Inc, fits the person than try to rewire someone reception sponsored by Integrated Perioperative Health Systems Consulting. to fit the role,” he said. “If you can find Medical Systems International, Inc. Waddle, who had had a stellar career someone and reposition them, they can become a great performer.” Coffman is coauthor with Marcus Buckingham of the best seller, First, Break All the Rules: What the World’s Greatest Managers Do Differently (Simon & Schu- ster, 1999). Becoming a resonant leader Great leaders like Nelson Mandela have high emotional intelligence—the ability to manage their emotions and inner potential for positive relation- Barbara Johnson, ships, said Annie McKee, PhD, who RN, BSN, MHA, spoke at a special lecture sponsored by of Atlanta, Cardinal Health, Medical Products and OR Manager of the Services. McKee is author with Richard Year (right), Boyatis of Resonant Leadership, which receives her plaque builds on their work with Daniel from OR Manager Goleman on emotional intelligence. President Ellie Such leaders, she said, “know how to Schrader. manage emotion in themselves and others

December 2007 OR Manager Vol 23, No 12 21 Managing Today’s OR Suite

Attendees sampled California wines at a poolside reception sponsored by IMS.

Creating a just culture How can you hold people accountable without finger pointing? One answer is the Just Culture Model. A just culture creates a fair and open David Marx, JD, president of Outcome atmosphere, David Marx explained. Engineering, LLC, Plano, Texas, who developed the model, explained that just culture falls in the middle of the continu- um from a blame-free culture to a punitive with the Navy, commanded the nuclear culture. submarine USS Greeneville. On Feb 9, “We are fallible creatures,” Marx said. 2001, during a visit to the submarine by a “Rules that say we can’t make mistakes group of civilians, he ordered a maneuver will fail.” Instead, a just culture balances 3 that caused the submarine to rise to the duties—avoid causing unjustified risk or surface in seconds, crashing into a harm, produce an outcome, and follow a Japanese fishing trawler, thought to be procedural rule—with organizational and miles away. The trawler sank in less than 3 individual values such as safety, cost effec- minutes, killing 9 people, including 4 17- tiveness, equity, and dignity. year-old students. Creating a just culture takes time, he Waddle emotionally described his dev- said, because managers’ and staffs’ expec- astation. “How did we miss this?” he kept tations must change. Managers must asking himself right after the crash. After understand risk, design safe systems, and being relieved of command, he told his facilitate safe choices by staff. The staff crew to tell the truth. Waddle spiraled into should be expected to look for risks, report Elvis returned to sing at deep despair, even briefly thinking about errors and hazards, help design safe sys- the IMS reception. taking the lives of his family and himself. tems, and make safe choices. The staff But he turned to his long-held tenets: needs to learn to ask, “What is the risk not integrity, accountability, and responsibility. worth taking?” which Marx said is the produced the best seller The Carrot At the court of inquiry, Waddle told the most important question. Principle, a book based on the simple con- truth and took responsibility for the inci- A carrot a day keeps your staff cept that recognizing employees generates dent. He testified and sent letters of apolo- commitment and leads to high-level per- Closing the conference was Max gy to the families, whom he was not formance. The luncheon was sponsored Brown, of the Carrot Culture Group, a allowed to meet. He was allowed to retire by Advanced Sterilization Products. division of OC Tanner Company, which and retain his pension. Conveying his message with humor, He finally wrote a book, The Right Managing Today’s OR Suite Brown had volunteers toss stuffed carrots Thing, and in 2002, was able to travel to Oct 29-31, 2008 into the audience to make his point that Japan to apologize in person. Gaylord National recognition is what keeps top employ- He encouraged the audience, which ees—“88% cite lack of recognition as the Washington, DC, metropolitan area responded with a standing ovation, to number 1 reason they leave,” he said. think about what they would do if tested A brochure will be posted in March For recognition to be authentic and by something like a sentinel event, advis- at www.ormanager.com and successful, Brown said it must be frequent, included in the April OR Manager. O ing, “Keep your character and integrity timely, and specific. intact.”

22 OR Manager Vol 23, No 12 December 2007 CMS sets final 2008 ASC payment rates

or 2008, ambulatory surgery centers (CPT 35473 and 35476) but to exclude (ASCs) generally will be paid at 65% femoral-popliteal angioplasty (CPT Fof hospital outpatient department 35474) for safety reasons. (HOPD) payments, under a final rule Medicare“ will A list of the excluded procedures is at issued Nov 1 by the Centers for Medicare www.cms.hhs.gov/ASCPayment. On and Medicaid Services (CMS). The rule, pay for lap the left, look for CMS-1392-FC. Scroll effective Jan 1, 2008, sets rates for the first down to Appendix EE. year of the new ASC payment system, the chole in ASCs. Four-year phase-in most significant change in Medicare ASC reimbursement in 20 years. Payment rates under the new ASC The same rule updates the hospital system will be phased in over 4 years for outpatient payment system, resulting in procedures currently on the ASC list, giv- ing ASCs time to adjust. Procedures an average overall outpatient payment As part of the“ new payment system, added to the list will transition immedi- increase of 3.8%. From now on, ASC pay- CMS adopted a new policy that will ately to full payments under the new ments will be updated jointly with the allow ASC payments for any procedure system. hospital outpatient payments. not specifically excluded from the list. FASA said it would post on its web The new rule does not make changes Excluded procedures, in general, are site the national 2008 ASC payments plus in the ASC payment system itself; those those that are on the CMS inpatient list, what rates would be if the rates were rules were final in August. typically require active medical monitor- fully adopted in 2008. FASA will also The new payment system patterns ing and care after midnight on the day of post a rate calculator ASCs can use to ASC payments after the hospital outpa- the procedure, or are deemed to pose a determine what their local payments will tient system. As such, ASCs will be paid safety risk for Medicare patients in ASCs. be. according to rates set for APCs (ambula- Under the new policy, Medicare will tory payment classifications) rather than now pay for laparoscopic cholecystecto- Why will ASCs be paid 65%? the groupers ASCs are used to. But CMS my in ASCs. FASA argues that lap chole CMS says the 65% amount was set to will report payment rates by CPT code should have been included on the list keep the ASC payment system budget so ASCs will not need to determine even under the old system. neutral. FASA explains how this was which APC a CPT code belongs to, FASA In response to public comments ques- determined: CMS sets payments for each notes in an overview of the rule on its tioning the safety of some procedures in APC based on the APC’s relative weight, website (www.fasa.org). ASCs, such as balloon angioplasty of the a measure CMS uses to rank the costs of The Nov 1 rule also finalizes at 3,390 peripheral vessels, CMS says its medical performing procedures in one APC com- the list of procedures payable in the ASC experts did a comprehensive review. As pared with the costs of other APCs, plus setting in 2008, which is 819 more than a result, CMS decided to leave on the a uniform conversion factor that applies the current list. ASC list iliac and venous angioplasty Continued on page 24

Ambulatory Surgery Advisory Board

Lee Anne Blackwell, RN, BSN, EMBA, CNOR Rebecca Craig, RN, BA, CNOR, CASC Rosemary Lambie, RN, MEd, CNOR National director, clinical education, Administrator, Harmony Ambulatory Nurse administrator, SurgiCenter of ambulatory surgery division, HealthSouth Surgery Center, LLC, Fort Collins, Baltimore, Owings Mills, Maryland Corporation, Birmingham, Alabama Colorado LeeAnn Puckett Nancy Burden, RN, MS, CAPA, CPAN Stephanie Ellis, RN, CPC Materials manager, Evansville Surgery Director, Ambulatory Surgery, BayCare Ellis Medical Consulting, Inc Center, Evansville, Indiana Health System, Clearwater, Florida Brentwood, Tennessee Donna DeFazio Quinn, RN, BSN, MBA, Lisa Cooper, RN, BSN, BA, CNOR Ann Geier, RN, MS, CNOR, CASC CPAN, CAPA Executive director, El Camino Surgery Vice president of operations Director, Orthopaedic Surgery Center Center, Mountain View, California Ambulatory Surgery Centers of America Concord, New Hampshire Norwell, Massachusetts

December 2007 OR Manager Vol 23, No 12 23 Ambulatory Surgery Centers

Bill seeks higher Key facts on ASC pay rate for 2008 payment rule ambulatory surgery New“ bill • For 2008, ASCs will generally be centers seeks to set ASC paid 65% of hospital outpatient pay at 75%. department (HOPD) payments. A new bill (S 2250) introduced by • A total of 3,390 procedures will be Sen Mike Crapo (R-ID) on Oct 26 seeks payable in the ASC setting in 2008, to improve the reimbursement system up by 819 from the current list. for ambulatory surgery centers. The • There is a 4-year phase-in to the bill, a companion to House Bill 1823, new payment system for proce- would continue to link ASC payments payments at 75%“ of HOPD payments. dures currently on the ASC list. to the hospital outpatient rate, as in the ASCs maintain this would allow them to • New procedures added to the list current CMS rule. But the bill seeks to provide more services at a lower cost to set ASC payments at 75% of what hos- will be paid under the new pay- Medicare patients than what hospitals ment system immediately. pital outpatient departments receive provide. • Some procedures are not affected by rather than the 65% provided for ASCs Procedures not paid at 65% in 2008. the 65% ASC discount: from HOPD Sen Crapo said the bill would allow There are some procedures that will payments: ASCs to provide more services, encour- not be paid at 65% of the HOPD rate, —Procedures requiring a device age competition, and generate savings FASA notes. These include the following: that costs more than 50% of total for Medicare and its beneficiaries. Device-intensive procedures APC reimbursement. For more, visit the FASA website at —Procedures frequently performed www.fasa.org. ASCs will be paid more for proce- in physician offices, for which the dures that require use of a device that ASC payment will be the lesser of Continued from page 23 costs more than 50% of the total APC the payment rate determined using reimbursement. For these, ASCs will be the 65% methodology or the cost of to all APCs. The relative weights for each paid the same as HOPDs for the device, the physician's office expense for APC are determined using hospital cost with the 65% discount for ASCs applied the procedure when performed in reports. The relative weight is then mul- to the rest of the APC reimbursement. In the office. tiplied by a uniform dollar conversion all, 45 procedures are designated as factor to get the national HOPD rate. device intensive for 2008. Examples are Sources: Centers for Medicare and In 2008, the relative weights for calcu- insertion of pacemakers, pulse genera- Medicaid Services, FASA. lating ASC payments for each APC will tors, and pacing or defibrillator leads; be the same as the relative weights used insertion of male slings; cryoablation of office. CMS set these limits to discourage for HOPDs. The process for calculating the prostate; implant of spinal infusion procedures performed most of the time the payment rates will also be the same, in the less expensive office setting from pumps; and implant of cochlear devices. O except different conversion factors will Some commenters asked CMS to migrating to the ASC. be used for ASCs and HOPDs. In 2008, include other procedures with expensive the ASC conversion factor will be 65% of implants in this category. One is injecting FASA and AAASC have information and the hospital conversion factor. Local implant material into urethral or bladder tools for gauging the impact of the new pay- adjustments are also applied. tissues for incontinence (CPT 51715). But ments on your ASC at www.fasa.org and This is the percentage CMS believes is CMS declined, saying its payment policy www.aaasc.org. budget neutral, meaning that even if the is final for 2008. new ASC payment system was not Procedures frequently performed The final payment update rule is at implemented for 2008, CMS figures the in physician offices www.cms.hhs.gov/ASCPayment. The rule overall ASC payment rates would still was scheduled to appear in the Nov 27 total 65% of the HOPD rates. ASC payments for 365 procedures Federal Register, which will be posted at Because of differences in the annual performed more than 50% of the time in www.gpoaccess.gov/fr. updates, ASCs believe payments physician offices will be less than 65% of between surgery centers and HOPDs HOPD payments. For those, CMS limits will continue to diverge over time. The payment to the lesser of the payment ASC community is seeking legislation to rate determined using the 65% method- remedy that. A Senate bill was intro- ology or to the cost of the physician’s duced in October that would set ASC practice expense when performed in the

24 OR Manager Vol 23, No 12 December 2007 Ambulatory Surgery Centers

Tips for a successful hire in your ASC

he temporary staffing agency you tered a difficult situation with a cowork- An offer of employment is made contin- use for your ASC assures you it con- er.” gent on the results of screening, back- Tducts thorough background checks. Honesty is a 2-way street between the ground checks, and reference checks. You decide to hire the accounts receivable manager and the candidate. It’s not unusual for these checks to clerk sent from the agency. Your prehire “Be clear about the negatives, too, come back positive. Hardin estimates that background check reveals the clerk spent because every place has good and bad,” about 25% reveal misdemeanors such as time in prison for embezzlement. You says Cooper. “If there will be a lot of over- possession of marijuana, writing bad escort the clerk out the door. time, don’t hide it; be upfront about it.” checks, reckless driving, driving without a Most managers have some kind of hor- Otherwise, the staff member may leave, license, and driving under the influence ror story about a seemingly good hire putting you back where you started. (DUI) without injury to another person. gone bad. Hiring in an ASC is often chal- Overlooked but vital Felonies such as rape or burglary are “few lenging. The ASC administrator may dou- and far between.” ble as the human resource (HR) manager, “I’ve seen it over and over again,” says Cooper counsels manager to be careful or the HR resource may be off-site and not Hardin. “Hiring managers don’t check ref- when hiring a company to conduct back- readily available. erences. So many problems could have ground checks. She recommends contact- “You don’t necessarily have a lot of been prevented if only a thorough refer- ing local hospitals and major businesses to backup,” says Lisa Cooper, RN, BSN, ence check was done.” obtain recommendations. “I would not CNOR, chief executive officer of El Hardin recommends using only super- just look on the Internet,” she says. Cooper Camino Surgery Center in Mountain visors, not coworkers, for references and adds that managers should also evaluate View, California. How can you enhance remembering that if the candidate gives the company a staffing agency uses for your chances of making a smart hire? you the name, chances are the reference checks to ensure it’s doing a good job. Heed this advice from the experts. will be positive. She calls the candidate’s How does a history of drug use or a Common mistakes immediate supervisor first because he or criminal record factor into the hiring deci- she will frequently provide more informa- sion? Hardin recommends considering if it The most common mistake managers tion than the human resources depart- was a misdemeanor, how long ago it make is talking first and too much, says ment, which often gives only dates of occurred, how old the person was at the Susie Hardin, vice president of human employment. time of the infraction, and whether it was resources for Symbion in Nashville, Even limited information can be help- an isolated incident or part of a pattern. Tennessee. “People explain the company ful, particularly when evaluating the “Consistency is very important, in case and job up front, then ask the candidate length of employment listed on the you are ever challenged in court.” about themselves, but you’ve already resume, especially for those candidates Another factor is how forthcoming the given them the answers. It’s better to let who list only years. For example, a nurse candidate is. During the interview Cooper the candidate speak first.” lists her tenure at a previous job as 2005- likes to ask, “We run an extensive back- Another common mistake is basing a 2007, implying she was employed for 2 ground check. Is there anything you’d like decision to hire on a person’s credentials years. However, further research reveals to tell me before we do that?” or past jobs, assuming he or she will know she started in December 2005 and left in “If they don’t say anything, and some- the clinical procedures performed in the January 2007, closer to 1 year and half the thing comes up on the check, that’s proba- ASC. Hardin suggests asking candidates experience, a significant difference. bly reason enough not to hire them,” she to explain the steps of a procedure rather Cooper is particularly interested in the says. than asking for a yes or no as to whether tenure of candidates for jobs in lower Take time now, not later they know how to do it. salary brackets. “Those positions are a lit- Ann Bures, RN, MA, CHCR, past pres- tle easier to fill, so if they are moving Making the right hire takes time. It’s ident of the National Association of Health around, it likely means they are job hop- not easy being patient when you’re faced Care Recruiters (NAHCR), reminds man- ping.” with open positions. agers they need to understand their work With these candidates, Cooper also “People get desperate,” says Cooper, environment and work group dynamics. focuses more on the details of getting to “they make a quick decision and don’t “What kind of person will fit with the work on time because people with lower wait until the fit is right.” But not taking group? If you have an assertive group, can incomes often have fewer resources to fall time during the hiring process can cause a candidate stand up to that?” Bures sug- back on. problems down the road and more time gests asking the candidate, “How do you Screening for secrets on the manager’s part. introduce yourself to a new work group?” To avoid the hasty hire, “managers and “Describe a time when you encoun- Criminal background checks and drug screens have become routine in job hiring. Continued on page 26

December 2007 OR Manager Vol 23, No 12 25 Ambulatory Surgery Centers

Continued from page 25 More questions to hire by must be prepared,” says Bures. She recom- mends a structured approach, including Most of these interview questions handle nurse-surgeon friction,” says reviewing the application, having a set of fall into “behavioral interviewing,” a Ann Bures, RN, MA, CHCR, past probing questions, and using a question- technique predicated on the idea that a president of the National naire related to ambulatory surgery. person’s past performance indicates Association of Health Care Bures uses the Healthcare Selection future performance. It emphasizes Recruiters. Inventory (HSI) from TestSource, a compa- questions that elicit descriptions of spe- 4. Describe your personality to me. ny in Grand Rapids, Michigan, that special- cific behaviors in response to various “Usually they’ll say they are a ‘peo- izes in assessment and retention in health situations. ple person,’” says Hardin. “But I’ve care (http://testsource.com). The HSI had people tell me they were selfish, Feedback Report provides an overview of 1. What do you want from a job and a company? opinionated, or self-centered.” She the candidate’s potential for success on the recommends doing this before you job and includes three scales: Overall 2. Why did you leave your previous share what kind of employee you Performance Index, Retention Index, and position? are seeking. Service Excellence Index. The tool takes a Susie Hardin of Symbion, Nashville, candidate about 20 to 30 minutes to com- 5. What would your current manager Tennessee, says to match the answer say about you? How would he or plete and can be done before the interview. against the resume. “If they say it Similar tools are available from other com- she describe you as far as your was for more money, but there’s a work ethic and reliability? panies. gap in employment, they didn’t Bures credits the inventory, face-to- leave for more money.” 6. Describe some of the typical aspects face interview, and time in the OR of your day. shadowing another employee as a com- 3. Tell me about a time you had a “This tells you about their abilities bination that’s worked well for her. She physician throw an instrument or to set priorities and delegate,” says prepares the staff with questions they engage in another act of conflict. Bures. can ask the candidate during the shad- “You need to ask about how they owing experience. Shadowing helps ensure a good fit and gives peers a chance to ask questions. Partnership and processes Surgeon faulted in wrong-site case Bures recommends working closely neurosurgeon, J. Frederick Har- successfully on the correct side. The with your HR contact to ensure an effi- rington, MD, bears most of the patient later died. Results of the investi- cient, effective interview process. That Ablame for operating on the wrong gation into the cause of death had not will help save time and lessen the side of the patient’s head in July at been reported at press time. chances of making a poor decision. Rhode Island Hospital, the state’s health After employees have been on the The state found Dr Harrington failed department concluded in October, the job for about a month, Hardin likes to to check the CT scan images of the Providence Journal reported. ask them if the job turned out to be brain but relied on his memory and what they expected and if it matched The surgeon was allowed to resume failed to pause before the procedure with what they heard in the interview. surgery in October without restrictions. began when someone in the OR ques- That step will help fine-tune your hir- He stopped operating voluntarily short- tioned him. ing process. ly after the error. The state said systems issues at the You have to be an investigator, a crit- Though wrong-site operations often hospital contributed to the error. The ical thinker, and a good listener to involve a cascade of errors, in this case, hospital has been studying the issues match the right person to the right job. most of the blame lies with the surgeon, and making changes to prevent similar It can be a challenge, but the reward is a events in the future, an administrator O said Robert S. Crausman, MD, head of satisfied, long-term employee. the state’s medical board. from the hospital’s parent company —Cynthia Saver, RN, MS The case involved an 86-year-old told the Journal. Among these are new man with a subdural hematoma who procedures for emergency cases. Cynthia Saver is a freelance writer in was admitted through the emergency Access the article on the Journal web- Columbia, Maryland. site at www.projo.com. Enter search department and had the wrong side of O his head treated. When the error was term “Frederick Harrington.” discovered, treatment was performed

26 OR Manager Vol 23, No 12 December 2007 OR Manager Subject Index 2007

VOLUME 23 CMS ASC payment overhaul coming, Hiring tips for ASCs, Dec: 25 — Index by Mary Walsh, MLS Jul: 25 Interviewing candidates, Dec: 14 CMS guideline changes, Jan: 1 National shortage snapshot, Sep: 14 ACCREDITATION CMS revises rules, Jan: 9 Opportunities in interim management, CMS updates ASC coverage rule, Oct: 32 Apr: 1 Bariatric accreditation options, Jan: 14 Informed consent guidelines revised, Orientation trends, Dec: 1 Ready for bariatric surgery?, Apr: 23 ERRORS - SEE TREATMENT ERRORS AMBULATORY SURGERY Jun: 5 Outpatient quality reporting slated, Sep: 5 ETHICS 2007 ASC Salary/Career Survey, Oct: 27 Some errors no longer paid for, Oct: 5 2007 ASC Salary/Career Survey, Sep: 12 CODING DNR in the OR, Nov: 17 AAASC and FASA to merge, Nov: 28 Donation after cardiac death, Oct: 18 CMS ASC payment overhaul coming, Advanced spine surgery center, Nov: 29 Physician conflicts of interest, May: 1 Jul: 25 ASC financial benchmarking, Jan: 26 COMMUNICATION Policies on disclosure of MD conflicts, ASC focuses on savings, Aug: 29 May: 24 ASC payment rates, 2008: Dec: 23 Accurate surgeon preference lists, Nov: 1 EVIDENCE-BASED PRACTICE ASC pay plan still falls short, Sep: 25 JCAHO Hot Spot, Jan: 21 EBP steps for CABG, Aug: 9 ASC salary/compensation, Oct: 29 Lateral violence, Dec: 1 Interspinous process decompression, Jul: ASC Supply cost data stories, Jun: 27 Lateral violence & managers, Dec: 10 (suppl) CMS ASC payment overhaul coming, Make the break from 5x7 cards, Nov: 9 Intervertebral disc replacement, Sep: Jul: 25 Military team training (TeamSTEPPS), (suppl) CMS updates ASC coverage rule, Oct: 32 Jun: 22 EYE SURGERY GOA agrees on ASC pay, Jan: 30 Postop debriefing for early-warning, Hiring tips for ASCs, Dec: 25 Jul: 10 Preventing TASS: expert advice, Aug: 25 Improving ASC revenue, part 1, Apr: 28 Preop briefings boost safety, Jul: 1 HOSPITALS Improving ASC revenue, part 2, May: 27 Preop briefings for patient safety, Mar: 1 Are infections inevitable?, Feb: 5 Patient discharge: quick and safe, Mar: 23 Support for when things go wrong, Jul: 17 Most Wired hospitals lessons, Jan: 5 Plan an ASC open house, Jul: 29 Timeout: it’s apple pie, Jul: 14 COMPETENCE PA reporting infections, Jan: 25 Plans reward peak performers, Feb: 23 Policies on disclosure of MD conflicts, Preventing TASS: expert advice, Aug: 25 Competencies for OR management, Jun: 9 May: 24 Ready for bariatric surgery?, Apr: 23 Retained objects reduction, Apr: 8 INFECTION CONTROL Risk management vulnerability, Feb: 27 CONFLICT RESOLUTION Spine surgery in the ASC, Nov: 25 Are infections inevitable?, Feb: 5 Stronger supply chain: 7-steps, May: 25 Lateral violence, Dec 1 Biological indicators FAQs, Oct: 23 AORN Lateral violence & managers, Dec: 10 Chemical indicators FAQs, Jun: 20 CONSENT – SEE INFORMED CONSENT Editorial, Feb: 3 Weight of instrument sets, May: 5 BARIATRIC SURGERY COSTS & COST CONTROLS Major study on surgical outcomes, Aug: 21 Bariatric accreditation options, Jan: 14 ASC focuses on savings, Aug: 29 Preventing TASS: expert advice, Aug: 25 Becoming a bariatric center of excellence, ASC pay plan still falls short, Sep: 25 INFORMATION SYSTEMS ASC supply cost data stories, Jun: 27 Jan: 1 Adding instrument tracking?, Aug: 14 Get more from value analysis, Jun: 18 Ready for bariatric surgery?, Apr: 23 Information systems ratings, Apr: 12 BENCHMARKING Implant costs sway MDs, May: 21 More wired OR supply chain, Aug: 13 Physician-led value analysis, Jun: 16 ASC financial benchmarking, Jan: 26 Most Wired hospitals lessons, Jan: 5 Questions re: ortho navigation, Sep: 1 GI endoscope benchmarking, Nov: 19 DESIGN & CONSTRUCTION Moving to online charting, Apr: 11 BUSINESS OR analyst: support periop leaders, OR construction track, Feb: 7 Aug: 17 ASC focuses on savings, Aug: 29 DEVICES - SEE SUPPLIES & EQUIPMENT Perfect OR inventory quest, May: 16 ‘Diamond standard’ for supply chain, RFP for software, Apr: 14 Jul: 20 DISASTER PLANNING RFP sample, Apr: 15 Editorial, Aug: 3 Disaster preparedness checklist, Aug: 12 INFORMED CONSENT Get more from value analysis, Jun: 18 Planning for the worst, Aug: 1 Improving ASC revenue, part 1, Apr: 28 DISCHARGE PLANNING CMS consent guidelines, Jan: 7 Improving ASC revenue, part 2, May: 27 CMS guideline changes, Jan: 1 OR analyst: support periop leaders, Minimizing discharge risks, Mar: 27 Informed consent guidelines revised, Aug: 17 Patient discharge: quick and safe, Mar: 23 Jun: 5 OR business manager roles, Aug: 19 Revised PADSS, Mar: 25 INNOVATION DOCUMENTATION Physician conflicts of interest, May: 1 Atul Gawande on safer surgery, May: 9 Physician-led value analysis, Jun: 16 Good data to guide decisions, Sep: 19 Five-way kidney swap, Feb: 8 Plan an ASC open house, Jul: 29 Moving to online charting, Apr: 11 Managing OR inventory, May: 1 Warranty for CABG?, Aug: 1 EDUCATION NOTES surgery innovation, Jul: 1 CHANGE INSTRUMENTS - SEE SUPPLIES & Military team training (TeamSTEPPS), EQUIPMENT Atul Gawande on safer surgery, May: 9 Jun: 22 Manage with positive redirection, Jun: 23 Simulation labs aid staff education, Jan: 16 JOB SATISFACTION CMS (CENTER FOR MEDICARE & EFFICIENCY - SEE PRODUCTIVITY MEDICAID SERVICES) Job satisfaction, Oct: 14 EMPLOYMENT JOINT COMMISSION ASC payment rates, 2008: Dec: 23 ASC pay plan still falls short, Sep: 25 2007 ASC Salary/Career Survey, Sep: 12 Editorial, Jun: 3 ASCs lobby on pay plan, Apr: 21 2007 Salary/Career Survey, Sep: 1 Continued on page 28

December 2007 OR Manager Vol 23, No 12 27 OR Manager Subject Index 2007

PROGRAM PLANNING Continued from page 27 Barbara Johnson, Manager of the Year, Oct: 7 Make the break from 5x7 cards, Nov: 9 Flash sterilization readiness, Mar: 17 (cor- Competencies for OR management, Jun: 9 PURCHASING Opportunities in interim management, rection, May: 18) Accurate surgeon preference lists, Nov: 1 Apr: 1 JCAHO survey readiness, Jan: 20 ASC supply cost data stories, Jun: 27 Joint Commission’s 2008 safety goals, OR director’s duties expand, Oct: 1 ORTHOPEDICS ‘Diamond standard’ for supply chain, Aug: 16 Jul: 20 Tissue standard, Feb: 15 Bone cement complication, Feb: 30 Get more from value analysis, Jun: 18 Tissue tracking requirements, Feb: 1 Implant makers craft legal deal, Nov: 5 Make the break from 5x7 cards, Nov: 9 Universal Protocol same for now, Aug: 5 Implant pricing bill, Dec: 5 Managing OR inventory, May: 1 LAW & LEGISLATION Questions re: ortho navigation, Sep: 1 OR inventory like a grocery store?, FMLA and staffing, Apr: 17 OUTCOMES - SEE QUALITY May: 14 FMLA facts, Apr: 18 PAIN Perfect OR inventory quest, May: 16 Implant pricing bill, Dec: 5 Physician-led value analysis, Jun: 16 LEADERSHIP New findings on postop pain, Nov: 16 Selecting a GPO: checklist, May: 26 PATIENT RIGHTS Stronger supply chain: 7-steps, May: 25 Good data to guide decisions, Sep: 19 QUALITY Governance success factors, Jan: 11 DNR in the OR, Nov: 17 PATIENT SAFETY Mentoring new leaders, Jun: 11 ‘5S’: lean method to cut clutter, Mar: 15 Nurse leader programs list, Jun: 8 Atul Gawande on safer surgery, May: 9 Becoming a bariatric center of excellence, OR director’s duties expand, Oct: 1 Counts in general surgery, Dec: 11 Jan: 1 OR governance models, Jan: 10 Editorial, May: 3 Lean thinking: OR processes, Mar: 1 Planning for future leaders, Jun: 1 Error reporting helps patient safety, Apr: 1 Magnet status aids staffing, Jun: 1 MANAGEMENT Joint Commission’s 2008 safety goals, Major study on surgical outcomes, Aug: 16 Aug: 21 FMLA and staffing, Apr: 17 Postop protection from VAP, Jul: 15 Interviewing candidates, Dec: 14 Kids at highest med error risk, May: 11 OR medication safety, Jan: 17 Six practices for a lean OR, Mar: 10 Lateral violence & managers, Dec: 10 Warranty for CABG?, Aug: 1 Manage with positive redirection, Jun: 23 Preop briefings boost safety, Jul: 1 Preop briefings for patient safety, Mar: 1 ‘Wasteology’ in the OR, Mar: 11 OR governance models, Jan: 10 What works to smooth preop?, Feb: 10 Planning for future leaders, Jun: 1 Preventing wrong surgery, Aug: 7 RECRUITMENT & RETENTION – SEE Support for when things go wrong, Jul: 17 Retained objects reduction, Apr: 8 PERSONNEL RETENTION MEDICARE – SEE CMS Sleep apnea risk assessment, Mar: 21 Timeout: bedside, Dec: 14 RESUSCITATION ORDERS MEDICATION ERRORS – SEE TREAT- Timeout: it’s apple pie, Jul: 14 MENT ERRORS DNR in the OR, Nov: 17 Tissue tracking requirements, Feb: 1 PATIENT SATISFACTION DNR policy elements, Nov: 18 MEETINGS REVENUE – SEE BUSINESS Accountability key to survival, Jun: 15 Warranty for CABG?, Aug: 1 RISK MANAGEMENT Business management topics, Mar: 7 PEER SUPPORT Risk management vulnerability, Feb: 27 ‘Carrot Principle’ as motivator, Aug: 10 Support for when things go wrong, Jul: 17 Great leaders keep great staff, Apr: 5 PERSONNEL RETENTION Sleep apnea risk assessment, Mar: 21 ‘Just culture’ for patient safety, Jul: 5 RULES AND REGULATIONS Magnet status aids staffing, Jun: 1 Managing Today’s OR Suite, Dec: 21 CMS guideline changes, Jan: 1 Managing Today’s OR Suite program, Mentoring new leaders, Jun: 11 PHYSICIANS CMS revises rules, Jan: 9 Apr: insert Outpatient quality reporting slated, Sep: 5 OR construction track, Feb: 7 MDs/Hospitals manage surgical services, SAFETY – SEE ALSO PATIENT SAFETY Power of teams conference theme, Jan: 22 Nov: 1 Joint Commission’s 2008 safety goals, ‘Resonant Leaders’, May: 7 Physician conflicts of interest, May: 1 NURSING SHORTAGE POLICY Aug: 16 SALARIES & BENEFITS – SEE ALSO SUR- 2007 Salary/Career Survey, Sep: 1 Donation after cardiac death, Oct: 18 VEYS National shortage snapshot, Sep: 14 Policies on disclosure of MD conflicts, 2007 ASC Salary/Career Survey, Oct: 27 OPERATING ROOMS May: 24 PREOPERATIVE CARE 2007 Salary/Career Survey, Oct: 1 Are your ORs ‘efficient’?, Dec: 16 Annual salary/compensation, Oct: 9 Lean thinking: OR processes, Mar: 1 Cardiac screening revised, Nov: 23 Plans reward peak performers, Feb: 23 MDs/Hospitals manage surgical services, Preop prep strategies, Feb: 1 Salaries for high pressure work, Oct: 16 Nov: 1 Role of preop clinic, Feb: 14 SCHEDULING & UTILIZATION OR governance models, Jan: 10 Sleep apnea risk assessment, Mar: 21 Logistics: learning from FedEx, Nov: 12 Six practices for a lean OR, Mar: 10 VHA improves OR processes, Nov: 14 MDs/Hospitals manage surgical services, ‘Wasteology’ in the OR, Mar: 11 What works to smooth preop?, Feb: 10 ORGAN TRANSPLANTATION PRODUCTIVITY Nov: 1 VHA improves OR processes, Nov: 14 Donation after cardiac death, Oct: 18 Are your ORs ‘efficient’?, Dec: 16 SENTINEL EVENTS - SEE TREATMENT Editorial, Oct: 3 Lean thinking: OR processes, Mar: 1 ERRORS Five-way kidney swap, Feb: 8 Logistics: learning from FedEx, Nov: 12 SKILL MIX OR MANAGERS Parallel processing reduces OR time, 2007 Salary/Career Survey, Oct: 1 Feb: 18 OR skill mix holds steady, Sep: 11 SPINAL SURGERY 2007 Salary/Career Survey, Sep: 1 Preop prep strategies, Feb: 1 Role of preop clinic, Feb: 14 Advanced spine surgery center, Nov: 29 VHA improves OR processes, Nov: 14

28 OR Manager Vol 23, No 12 December 2007 OR Manager Subject Index 2007

SURVEYS Editorial, Nov: 3 More wired OR supply chain, Aug: 13 Fusion evidence sparse, Mar: 5 2007 ASC Salary/Career Survey, Oct: 27 OR inventory like a grocery store?, Spine surgery in the ASC, Nov: 25 2007 ASC Salary/Career Survey, Sep: 12 May: 14 STAFFING 2007 Salary/Career Survey, Oct: 1 Questions re: ortho navigation, Sep: 1 2007 Salary/Career Survey, Sep: 1 TISSUE BANKS 2007 ASC Salary/Career Survey, Sep: 12 Annual salary/compensation, Oct: 9 2007 Salary/Career Survey, Sep: 1 Tissue tracking requirements, Feb: 1 ASC recruiting difficulty, Sep: 13 Editorial, Sep: 3 TREATMENT ERRORS JCAHO survey readiness, Jan: 20 FMLA and staffing, Apr: 17 Job satisfaction, Oct: 14 Editorial, Jan: 3 Interviewing candidates, Dec: 14 National shortage snapshot, Sep: 14 Editorial, Mar: 3 Magnet status aids staffing, Jun: 1 Open staff positions, Sep: 9 Error reporting helps patient safety, Apr: 1 Orientation trends, Dec: 1 OR annual budgets, Oct: 13 Kids at highest med error risk, May: 11 Planning for future leaders, Jun: 1 STERILIZATION & DISINFECTION OR ratings on SCIP measures, Oct: 11 OR medication safety, Jan: 17 OR skill mix holds steady, Sep: 11 Preventing wrong surgery, Aug: 7 Adding instrument tracking?, Aug: 14 OR staff hiring, Sep: 10 Root causes of surgical events, Apr: 8 Biological indicators FAQs, Oct: 23 OR staffing trends, Sep: 9 Some errors no longer paid for, Oct: 5 Chemical indicators FAQs, Jun: 20 Recruiting difficulty, Sep: 7 TURNOVER TIME – SEE PRODUCTIVITY Flash sterilization readiness, Mar: 17 (cor- Salaries for high pressure work, Oct: 16 VENDORS rection, May: 18) Scope of job/title, Oct: 11 SUPPLIES & EQUIPMENT Use of overtime, Sep: 7 Physician conflicts of interest, May: 1 RFP for software, Apr: 14 Adding instrument tracking?, Aug: 14 Use of travel/agency nurses, Sep: 7 WASTE DISPOSAL ‘Diamond standard’ for supply chain, Value analysis, Oct: 12 Jul: 20 Who owns ASCs?, Feb: 29 ‘Wasteology’ in the OR, Mar: 11 TEAMS & TEAMBUILDING WORK REDESIGN GI endoscope benchmarking, Nov: 19 Managing OR inventory, May: 1 Editorial, Jul: 3 ‘5S’: lean method to cut clutter, Mar: 15 More wired OR supply chain, Aug: 13 Military team training (TeamSTEPPS), Logistics: learning from FedEx, Nov: 12 OR inventory like a grocery store?, Jun: 22 Parallel processing reduces OR time, May: 14 Retained objects reduction, Apr: 8 Feb: 18 Perfect OR inventory quest, May: 16 VHA improves OR processes, Nov: 14 Planning for the worst, Aug: 1 Stronger supply chain: 7-steps, May: 25 TECHNOLOGY Six practices for a lean OR, Mar: 10 Used equipment ‘Remedy’, Sep: 23 WRONG SITE - SEE SURGICAL SITE ECRI advises on cell phone use, May: 13 Weight of instrument sets, May: 5 SURGERY Five-way kidney swap, Feb: 8 NOTES surgery innovation, Jul: 1 Surgical ‘Apgar score’, Mar: 9 SURGICAL CARE IMPROVEMENT PRO- JECT Creating culture of teamwork, Mar (suppl): 7 DVT prophylaxis, Mar (suppl): 26 Hair removal case study, Mar (suppl): 14 Hair removal changes, Mar (suppl): 13 Keeping OR patients warm, Mar (suppl): 16 OR ratings on SCIP measures, Oct: 11 Please see the ad Postop protection from VAP, Jul: 15 for Preventing VTE, Mar (suppl): 23 Quality reporting, Mar (suppl): 12 VHA, INC. Right antibiotic at right time, Mar (suppl): 8 in the OR Manager SCIP overview, Mar (suppl): 4 print version. SCIP: periop leader’s role, Mar (suppl): 5 Setting up beta-blocker protocol, Mar (suppl): 20 Tighter glucose control, Mar (suppl): 10 VTE risk levels, Mar (suppl): 25 Warming protocols at two hospitals, Mar (suppl): 19 SURGICAL SITE Preventing wrong surgery, Aug: 7 Timeout: bedside, Dec:14 Timeout: it’s apple pie, Jul: 14 Universal Protocol same for now, Aug: 5 SURGICAL TECHNOLOGIST OR skill mix holds steady, Sep: 11

December 2007 OR Manager Vol 23, No 12 29 Please see the ad Please see the ad for for BAYLOR HEALTH YALE NEW CARE SYSTEM HAVEN HEALTH in the OR Manager SYSTEM print version. in the OR Manager print version.

Please see the ad for AORN MANAGEMENT SYSTEMS in the OR Manager print version.

30 OR Manager Vol 23, No 12 December 2007 31

Please see the ad for INTEGRATED MEDICAL SYSTEMS in the OR Manager print version. At a Glance

Eye surgery errors rare but serious how the companies have agreed to han- In the study: dle consulting. • 58% of invasive MRSA infections Errors in eye surgery are rare, happen- The lists of consultants and payments occurred outside the hospital but ing in an estimated 69 cases out of 1 mil- are on websites of Zimmer, Smith & among persons with risk factors for lion. But consequences can be serious, a Nephew, Biomet, DePuy Orthopaedics, MRSA, such as hospitalization within new study finds. The most common error and Stryker. the past year was implant of the wrong lens, accounting • 27% were hospital-onset for 63% of mistakes. These errors most Excess disinfectants harm • 14% were community associated (had often happened because lens specifica- electronic equipment no documented health care risk fac- tions weren’t checked before the case. tor). The remaining 1% could not be Four federal agencies issued a public The Universal Protocol, if followed, classified. health notice Nov 2 cautioning about would have prevented 85% of the errors, The researchers estimate 94,360 hazards associated with inappropriate say the authors, from Albany Medical MRSA infections occurred in the US in use of liquid disinfectants and cleaners College, Albany, New York. The proto- 2005, and 18,650 were associated with on electronic medical equipment. col, mandated by the Joint Commission, death—exceeding deaths from AIDS, In the past 2 years, the agencies have requires steps to verify the surgical site. Parkinson’s disease, emphysema, or learned of equipment fires and malfunc- In the analysis of 106 cases occurring homicide. tions and health care worker burns due between 1982 and 2005, the wrong eye MRSA infections and deaths were to corrosion of circuits caused by disin- was injected with anesthesia in 14 cases higher for the elderly, African-Americans, fectants or cleaners that penetrated (13%), and the wrong eye was operated and men. equipment housings. Examples of affect- on in 15 cases (14%). In 8 cases, confu- —Klevens R M, Morrison M A, Nadle J. ed equipment are infusion pumps, venti- sion involved the wrong patient or pro- JAMA. 2007:298:1763-1771. cedure. In 2 cases, the wrong tissue was lators, and sequential compression implanted. device pumps. The notice includes rec- The most severe injuries involved the ommendations. First certification for wrong implant or tissue. The notice was issued by the Food and bariatric nurses Drug Administration, Centers for Disease The study led by John W. Simon, MD, The first certification program for Control and Prevention, Environmental was reported in the November Archives bariatric nurses has been established by Protection Agency, and Occupational of Ophthalmology. the American Society for Metabolic & Safety and Health Administration. —www.fda.gov/cdrh Bariatric Surgery (ASMBS). To be eligible Orthopedic implant makers for the certified bariatric nurse (CBN) post MD consulting fees examination, an RN must have at least 2 Most invasive MRSA infections years of experience in caring for morbid- Orthopedic implant makers have related to health care, CDC ly obese and bariatric surgery patients. posted on their websites lists of the reports Exams are offered twice a year through a physicians to whom they are paying con- week-long computer-based testing pro- sulting fees and the amounts. The post- Invasive infections caused by gram. ings are part of an agreement by the Methicillin-resistant Staphylococcus aureus Information and registration for the companies with federal prosecutors in (MRSA) may be twice as common as exam are available on the ASMBS web- September related to alleged kickbacks thought, and most—85%—are associated O site. to surgeons. Also posted are the agree- with health care, according to a report by —www.asbs.org ments with prosecutors, which spell out the CDC:

The monthly publication for OR decision makers Periodicals

P O Box 5303 Santa Fe, NM 87502-5303

32 OR Manager Vol 23, No 12 December 2007