Archive for December, 2011

Renewing Patient Centered Care in ASCs

December 20, 2011 Leave a comment

While preparing for a talk I gave recently at the Wyoming State ASC meeting, I happened upon an article where the authors discussed Medicare’s commitment to “patient centered care” the new “buzz” words.  I was somewhat astounded at this assertion having been involved in the ASC industry since 1979…this is not a new initiative…


During the beginning days of ASC business, it was all about creating “high tech, high touch, patient centered care in a warm, home-like environment.”  The largest impetus physicians’ cited when asked why they were building their own surgery center was not about making money, rather it was about “returning the control of the patient back to their physician” …and then curbing the outlandish hospital bills their patients were presenting to them for simple procedures.

I am reminded of one physician telling me of a patient of his who needed a culposcopy, so he scheduled it at the hospital. He did not have the equipment to do this procedure in his office and believed the anxiety the patient was exhibiting warranted the services of an anesthesia provider.  A few weeks after the procedure was performed the patient brought him a copy of her bill from the hospital for $7,500 for a procedure that took minutes to do.  He bought the equipment, got an anesthesia provider to agree to come to his office to do conscious sedation and charged his patients $1,200 which not only covered his expenses but paid the anesthesiologist.

Concept #1: Reduce High Deductibles and Charges

Hospitals were being reimbursed $5,000 and more for a cataract procedure that physicians were getting a pittance for performing in their tiny “surgery centers.”  Patients were complaining of the high deductibles to their physicians who were embarrassed for having taken the patient to the hospital, where he experienced “financial rape.”  Patients were being charged not only for the rent of the OR, but equipment fees and fees for every sponge and widget used AND the charges for these were not small!

Concept #2 Eliminate Excessive Testing

Physicians also were disgruntled that patients whom they scheduled for surgery at the hospital were forced to undergo a battery of tests.  A full panel of lab work was required, a chest x-ray, an EKG, a UA.  This required an additional visit, if not more than one, to the hospital to have these tests performed.  Many of the patients were elderly, had transportation difficulties or worked, thus these extra visits posed a hardship on the patients.  In addition, of course, the costs of these tests were passed on to the patient, at least in part, thus adding to his financial burden.  Surgeons, endoscopists, and anesthesia providers loudly proclaimed and argued that these tests were excessive for the vast majority of their patients and that the preoperative lab requirements needed to be customized/individualized to the patient, the procedure and the type of anesthesia to be delivered.  Hospitals replied that these were their requirements and that was just what was so!  The physicians were left thwarted in their efforts to reduce the inconvenience and cost to their patients.

Concept #3: Improve Patient’s Health Esteem 

Physicians and their staffs committed to providing the best outpatient surgery care possible to recognized that a huge part of this process had to deal with promoting the patient’s image of himself as an otherwise healthy human being.  Studies conducted at that time showed that patients going to the hospital, even for outpatient labs, assumed a sick role.  Everyone knew someone who had gone to the hospital, and even if not VERY sick when they were admitted, got infected and died, or just went to the hospital and died.  Hospitals were strange, mysterious places where patients were “done unto” with little input into their care.  Once they were in the system they were just a number shuttled from one area, from one department to another following the proper colored tape on the floor (in place of a conveyor belt) to the proper department!  This process most certainly did not promote the patients image of himself as “otherwise healthy.”  In addition, many hospitals used the emergency room entrance as the intake entrance for their outpatients.

Concept #4: Eliminate Long Waits and Improve Patient/Physician Communication

Physicians and their patients were also disgruntled that on the day of the surgical procedure patients were told to come to the hospital hours before their surgical appointment time resulting in very long preoperative wait times.  In addition, rather than building a “surgery center” or even remodeling a space inside the hospital to incorporate the visual concepts of an ambulatory surgery environment, hospitals were just taking a deserted wing and putting a sign up that said “Day Surgery.”  The inpatient ORs were used with the outpatients scheduled in amongst the inpatients resulting in long delays, and the outpatient frequently being “bumped” for an emergency.

In one instance a young woman was admitted for a cervical conization.  She was told to be at the hospital at 6:30 am even though her procedure was not scheduled until 10:30 am.  When she questioned the lengthy time, she was told there was lots of paper work to get done and other preparations.  (In fact, this particular hospital scheduled all their outpatients for surgery that day to arrive at the same time.)  This young woman arrived at the admitting desk as instructed and sat in the lobby with other obviously sick patients waiting for her name to be called out loudly to come to the desk.  Now understand, this young lady was already highly anxious about her procedure and how it would impact her future child bearing.  Finally, after waiting for an hour, she was admitted and sent to the second floor of the hospital.  On her arrival she was given a patient gown and told to “get into bed”.  Someone would be with her shortly.  She waited another hour for one of the nurses to arrive, take her vital signs and review her history.  That being done, the nurse left the room and shut the door.  This person was left there, with her caretaker alone.  No one came near.  10:30 came and went.  The caretaker went to the door several times and peered out looking for someone, anyone!   When noon came, the caretaker walked down the corridor and found the staff sitting at the nurse’s station eating pizza.  She asked about the delay and was told by a “not too pleased” staff person she would call the OR to check.  Soon after the door to the woman’s room swung open and an orderly pushed in a rickety old gurney telling the patient to get on there while the nurse came running with her “pre-op” shot.  Upon return to her room following the procedure the nurse gave the young woman another shot.  This time it was 50 mg. of Demerol which left her sound asleep in the hospital bed until nearly 7:30 pm that night—-13 hours after she first appeared for her appointment at the admitting desk for a 30 minute procedure.  The average stay in an ambulatory surgery center would not have exceeded 3 hours at the most!

Concept #5: Give Patients a Voice

Physicians believed, rightfully so, that they had very little control over the care of their patients once they were admitted into the system.  They knew that their patients were becoming more sophisticated.  They were watching medical shows on television.  The news media was full of medical information.  The patients were making demands and were questioning.  They were no longer willing to be that person who was “done unto”.  Rather, they wanted to have a say in their care—to be a part of the healthcare team.

Concept #6:  Reduce Infection Risk

Physicians further believed that the safest place for their patients to undergo their procedures would be in their surgery center, where they would not be mixed in with sick hospitalized patients who were potentially infectious.

Concept #7: Hire Competent Staffing and Create Effective, Efficient Staffing Patterns

Physicians were very much aware that they could individually select their staff—their experienced staff—and provide any additional training these staff persons needed thus ensuring the most experienced, most qualified staff in the preoperative, OR, Procedure and recovery areas as well as the sterile processing.  They knew that in the hospital, even though there were nurses who were assigned, say, to the orthopedic or gynecologic operating room and who were in charge of taking care of the equipment and instrumentation for those areas, these nurses were not always available.  There were call ins, vacations, staffing shortages, etc., all of which impacted the availability of these “specialty trained” nurses and technicians for the surgeon,  This left the physician, not infrequently, performing surgery with staff who, sometimes, were minimally trained in the physician’s particular procedures.  This delayed cases and resulted in a high degree of frustration for the physician.  We knew in the industry that we could cross train our staff and provide this physician with the trained staff he needed to care for his patient throughout the patient’s stay.

Concept #8: Develop Efficient Surgery Scheduling

Physicians were also frustrated for both themselves and their patients at the delays in the surgery schedule that left their patients either waiting in their hospital beds, in the Surgery Suite corridors or in the preoperative area where they were, once again, mixed in with hospital inpatients.  This left physicians sitting in the doctors’ lounge waiting for a room to do their procedure.  Another contributing issue was that room turnover times in the hospital surgery suites were running any where from 45 minutes to an hour.  In an ambulatory surgery center at that time they were running 7-10 minutes.  These delays caused the physicians’ office schedules to back up and resulted in the lengthy disruption of the patient’s lives.

Concept #9: Identify Opportunities to Deliver Personable Care

We in the early infancy of ambulatory surgery recognized that this was as much a specialty as surgery, radiology, emergency, intensive care, etc.  We recognized that the patient presenting for ambulatory surgery had special needs just as those presenting for in-patient surgery, radiographic studies, cardiac caths or were admitted to an emergency department or intensive care.  We recognized that this person coming to our surgery center had a CHOICE in where to have his procedure performed.  We recognized he was our “guest”.  His concept of himself as an otherwise healthy person needed to be promoted, for we were going to return him to his normal environment with as little disruption and in as short a time as  possible.  We recognized that his care person was a critical member of his team and that he was the center of this team.  We recognized that our “barking” his name out in the waiting room didn’t support his dignity.

Concept #10: Maintain High Touch, High Tech Patient Centered Care

In some surgery centers, the pre-op nurse actually came into the waiting room and went  directly to the patient, touching his shoulder and saying, “Mr. Jones, we are ready for you.”  These centers kept a seating chart much like restaurants at the reception desk, so when the receptionist called pre-op to advise them that their patient had arrived (one hour before their scheduled procedure, or thirty minutes if a local),  she told the nurse where the patient was seated and any identifying information.  This set the tone for the patient for how he could expect to be treated throughout his stay.   “High Touch, High Tech, Patient Centered Care” became the mantra in ambulatory surgery.  The tone was efficient, warm and friendly.  The staff were highly trained and all CPR trained with most ACLS and where pediatrics were performed PALS trained.

Concept #11: Develop a Staffing and Patient Family

There was a team environment of patient, physician and staff.  We built one staff lounge where, for sometimes for the first time, the staff mingled with the physicians.  The high volume surgeon of the month got a t-shirt embossed with “I’m # 1”.  Cakes were baked for birthdays.  Pot-luck dinners once a month were the norm.  QI studies were done when room turnovers exceeded the allowable time.

Patients walked into the ORs whenever possible. Parents occasionally came in with the little children until they were asleep.  Morning reports before surgery involved a discussion of each patient’s special needs.  Surgery centers were staffed “skinny” but with highly skilled, experienced nurses who were flocking to work there.  None were hired who didn’t say in their interviews that they “wanted more patient contact”.


Somehow these concepts have become eroded as the years have gone by.  Something has shifted in the ambulatory surgery industry.

Eighty percent of all surgery is being performed outpatient.  There are over 5,000 surgery centers in theUSwith more being built every day.  We are doing sicker patients than ever before—more acute.  Our infection rate is up.  Our complications are up!  CMS asserts physicians are hiring unqualified and inexperienced staff to work in their centers and that this is a contributing factor. One could argue that infections and complications are up because we are doing more surgery in the surgery centers than ever before…except that CMS says they are up, too, because not only are physicians hiring unqualified and inexperienced staff, but they are not being rigorous in adhering to patient admitting qualifications to include ASA status.  I am afraid in many instances that this is so.

CMS is surveying surgery centers all across the country and closing them down for failure to adhere to regulations.  H&Ps are older than 30 days and aren’t updated on the day of surgery.  Physicians are arguing that a history and physical performed a year ago is valid. At times this argument includes patients over the age of 80!  Physicians don’t want to update the H&P on the day of surgery or to assess the patient at the bedside in pre-op stating it will slow him down!  Surgeons and endoscopists are arguing they shouldn’t have to assess their patient in post-op for the same reason stating, too, that anesthesia can do it!  They are complaining about having to sign, date and time their orders, the H&P and the consent.  They are complaining about having to have an interim OP report on the patient’s chart prior to their leaving the center.

One patient complained recently in my hearing that she was being wheeled into the OR but hadn’t seen her physician!  In another instance a 44 year old woman died at a surgery center following an 11 ½ hour surgery for a brow lift, upper and lower blephs, cheek implants, a rhytidectomy and chin liposuction.  She was delivered to the recovery at 7:30 pm on a Friday night.  The surgeon and anesthesiologist left the building immediately.  Her temperature was 94.6.  Her blood pressure was 94/60 but anesthesia didn’t stick around to get these numbers, nor did her surgeon!  She was dismissed two hours later to home after sitting in a wheelchair for one hour during which no vital signs were taken.  When she stepped out of the car in her driveway after complaining of shortness of breath during the drive, she dropped dead from multi-focal pulmonary emboli!  This organization had not followed any of their procedures from controlling the time limits for acceptable procedures to be performed at the center, warming the patient during surgery, or post-operative care!  A good risk management mantra is “whenever there is a medical error, there is a human error!”

This was also true in the case of the much publicized patient death inFt. Myers,Florida.  It always is.  In the case of the plastic surgery patient mentioned above, errors started immediately with allowing the case to be scheduled.  When queried, the Administrator/ORS admitted she didn’t bring it to the Medical Director’s attention that the physician had scheduled all of this for a 5 hour time slot, when she knew he couldn’t do all that in that amount of time.  Her statement was that she knew cash flow was low and that the CEO and the Medical Director would both approve it…and so, a relatively young woman died.

Is CMS wrong in their presumptions?  Have we gotten so enamored of the monies to be made in ambulatory surgery centers that we have lost site of the patient and their safety?  Have we gotten so arrogant in our belief that ambulatory surgery is safe that we have lost site of what is best for the patient?  CMS is correct.  We need to drop back and rediscover the concept of  “patient centered” and get this back into our surgery centers.

Physicians ARE staffing their centers skinnier than ever before.  They are working staff from 7 in the morning to sometimes 10-11:59 pm.  I got a call recently as to how late this particular surgeon could do surgery.  I advised him that “overnight” meant 12 midnight, so he made sure all his patients were dismissed by 11:59pm.  I got another call from an Administrator who was threatening to fire a nurse for making a medication error.  After gathering the facts I discovered this happened at 10:30 at night after she had come on duty at 7 that morning.  Breaks were a quick bite in the staff lounge between cases.  When I advised this Administrator of the labor laws AND that fatigue contributed hugely to medical and medication errors and that they was accountable for not staffing adequately, the Administrator’s response was concern for overhead in hiring more staff and that if physicians time was cut to the designated surgery center closing time that this physician might not come back.  I ask you, “Would you want to be that physician’s patient undergoing your procedure there with a grossly fatigued staff and patient?”

Physicians and Administrators are hiring OR Supervisors with no previous OR experience.  They are hiring oncology nurses to work pre-op and recovery; nurses with no previous experience in either of these arenas.  Experienced nurses aren’t applying in these physician-owned surgery centers citing no benefits, long work hours, and poor pay…AND this isn’t just occurring in physician-owned centers alone, but in those being run by some well known, large and successful management companies, as well as centers where hospitals have a partial ownership.

Staff are NOT being allowed to attend outside training programs on pertinent issues such as sterilization.  Owners are arguing the cost of even electronic webinars for their staff. Owners and Administrators, ever mindful of the bottom line, are citing the cost of the program and the cost of bringing in as-needed staff to cover for the person out attending the seminar.  In some instances, even the Administrators are not being given approval to attend national ASC meetings.  The cost of joining professional organizations such as the AORN, ASCA or APIC as a line item on the budget is being crossed off.  Physicians, and administrators, are hiring previously inexperienced persons to work in sterile processing and soiled receiving washing, processing and sterilizing equipment.  Oftentimes, these persons have a rudimentary understanding of English and are unable to read instructions regarding cleaning agents, the cleaning of the instruments and equipment, policies and the instructions for the use and maintenance of the sterilization equipment.  The same holds true for the housekeeping staff and/or contractors.  CMS is citing housekeeping practices in their surveys as a failure to comply.  Physician owners/management companies/administrators are screaming “Foul!”  …but is it really?

CMS is telling us that patient safety HAS to come first.  You cannot draw the line anywhere in the surgery centers to define where this shouldn’t be in place, and it starts with owners, managers and staff becoming “patient centered” once again.

Categories: Patient Centered Care
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