Archive for the ‘Quality Improvement’ Category

Where Was The Detour? Turning ORs in 7 to 10 Minutes

November 12, 2012 Leave a comment

An article was recently published regarding the possibility of turning operating rooms in ambulatory surgery centers in 7-10 minutes.  In this article the author talked about the fact that turning the rooms inside this time frame is still a possibility.

I was left struck with, yet again, that we in the ambulatory surgery business took another detour somewhere.  I recently responded to a previous article calling for surgery centers to consider moving toward a patient-centered environment.

As someone who has been involved in the development of ambulatory surgery centers since 1979, I simply had to respond because back in the ‘old days’ this was what ASCs were all about.  In reviewing the article about room turnover times, I was, once again, stuck with the fact that back in the early days of ambulatory surgery, we pledged to turn all our operating rooms over in 7-10 minutes—-patient to patient.  Should the turnover time exceed 10 minutes, a QI study was immediately conducted to identify the problem/area for improvement.  And yet, over the last twenty years, I have begun observing that these times are being extended.

Some of the reasons put forth by ASC leaders for this extended time include the fact that more complex surgeries are being performed in the ASCs.  Another issue presented during QA/PI studies is that our patients are more challenging.  More and more centers are admitting ASA class III and more patients who require a great deal more attention.  Care of the morbidly obese has become a big issue.

The question arises, however, if these are valid reasons for longer turnover times, or is it just that we need to better plan for those challenges?  The second question that arises is that if the condition of those patients validate the longer room turnover times, then what is going on that room turnover times, in general, are increasing?  One could make an assertion that the industry, in its proliferation, has lost track of its roots—its initial commitments.  Is it that more and more centers popping up means more and more hospital trained nurses being put in leadership roles with no distinctions from the freestanding ambulatory surgery center culture.

As long ago as the early 1990s a study was done documenting room turnover times in hospitals.  Understanding that the turnover times were being measured from patient out to next patient in, these times ranged from 45 minutes to 1 ½ hours.  During this same study, it was observed that the average freestanding ASC was able to turn their rooms within the 7-10 minute time frame.  Outlier times were identified for procedures where there were excessive irrigation fluids used, or in shoulder joint replacement surgeries.  It was further documented that turnover times in hospital owned ASCs were primarily in line with hospital turnover times.

In reviewing practices within 36 different ASCs, it has been noted that turnover times have been increasing exponentially with the exception of, universally, cataract surgery.  However, even in this surgery, in multi-specialty centers, turnover times of 15 minutes has become acceptable.  It was cataract surgery centers that perfected the ability to turn rooms in seven minutes with patients commenting that they knew they were on a conveyor belt kind of schedule, but that the personalization of their care was such that had they not observed this, they would not have known.  It was further observed that turnover times for GU and GI procedures generally were far shorter than in other specialties, but still exceeded the 10 minute goal.

So, what happened? 

We have to first look at the commitments of the staff and physicians.  Are they aware that with the turnover times being inside the declared goal of 7-10 minutes,  more procedures/cases could be performed and that this results in happier surgeons who are more likely to utilize their center more and more?   Are they aware that greater utilization increases profitability and, thus, increases their chances of getting a raise or a bonus at year’s end?  Are they aware that faster turnover times, means that patients get out of the center faster and aren’t left with long waiting room times?  This makes for happier patients reporting back to their physicians.  It is a ‘win-win’ all the way around.  The staff has to be gotten on board with the possibility of faster room turnover times.  You need to enroll them 100%! And this includes those physicians who like to hit the staff lounge to gossip, make calls, etc. Or who like to go to their office next door between patients.  Educate them into what is possible in coming right back to the OR after they have seen their patient in recovery and the care person in attendance.

It is impossible to experience rapid room turnovers without assessing the layout of your ORs and procedure rooms.  Hospital operating rooms are typically equipped with large banks of storage cupboards which are usually stuffed full of supplies.  In the ambulatory surgery industry it was quickly recognized that if the procedures were to be reimbursed on a ‘flat fee’ basis, rather than for every widget used, then it was imperative that supplies be strongly controlled.  The basis materials management premise that supplies sitting on shelves have a powerful intrinsic cost become paramount in cost containment practices.  Supplies were moved out of the ORs and were centrally located such that turning them and reducing PAR levels could be easily controlled.  All supplies for the center were treated in this manner with the exception of those supplies only used in certain areas such as peel packs for the sterile processing area.  Thus, all inventories were conducted out of the bulk and sterile storage areas excepting those specialized items stored in those specialized areas.  This kept supply costs down significantly and reduced manpower hours in conducting weekly inventory and re-ordering of supplies.

Operating rooms were equipped with one supply cupboard and one “case cupboard.”  The inventory for the supply cupboards was limited to only those items that were essential as back up for items already pulled for the cases to be conducted in that room.  These included two each of the various sized, most commonly used gloves, one package of sterile 2x2s, 4x4s, etc.  Again, thought was put into what kind of cases were being performed in the center, what would be pulled from the two different storerooms to perform the procedure and what else might be needed because a glove was punctured or ripped, a gown sleeve contaminated, or additional sponges might be needed.

However, staff considered what eventualities would drive them to tap into the back-up supplies.  They considered the most common eventualities, rather than those that might be rare.  Consideration was given that emergency supplies would most likely be found in anesthesia carts, but also considered what surgical supplies like drains, hemmorrhagic sponges, etc. should be stored in limited numbers in the room. The supply cupboard was never considered to provide everything needed to perform a case.  Limits to the number of items stored there relied heavily on the concept that these were only ‘back-up’ supplies.  The inventory stored in this cupboard was listed on an inventory sheet kept in the cupboard.  The cupboard was restocked at the end of each operating day from the bulk or sterile storage areas.  The restocking of this cupboard was identified on the duty list for each or staff to complete each day.  This list required a date, a ‘completion’ check mark and the initials of the staff.

A second cupboard was dedicated as a case cupboard.  In cataract surgery, GI and GU rooms, two case cupboards were installed to allow for the increased volume.  Each cupboard contained 6-7 shelves representing one shelf for each case scheduled for that room for that day.

In looking at what it would take to get turnover times to that magical 7-10 minutes, staff met in one of the ORs and looked at every task performed in turning a room from the circulating nurse going with the anesthesia provider to take the patient to PACU, to delivering the soiled instruments to the soiled receiving area for processing, to mopping the room, cleaning the or bed…the whole gamut.

AORN recommended practices and the center’s policies were reviewed and implemented for housekeeping and cleaning between cases.

Job functions were reviewed and assigned.  Who was to do what to turn the rooms was not only identified but embraced.  Who was to grab the mop?  Thrown out the window was any conversation about ‘not my job’.  The OR Supervisor and the Executive Director both pitched in with the mop when needed, as did the physician.  All kept the agreed upon goal clearly in mind.  Mopping was not done during non-invasive procedures.  Surgical team areas were identified for mopping between invasive procedures.

It was agreed upon that at the end of the case the RN would take the patient to the PACU with anesthesia, give the hand off communication, visit the next patient scheduled for that room then return to the or to assist in the turnover.

The organization employed a sterile processing technician to wash and process instruments.  Any surgical technician not working a room was assigned to assist in the sterile processing and soiled receiving areas.

At the end of the procedure the surgical technician removed the soiled instrumentation from the room to the soiled receiving area for processing and returned to the room to begin the turnover process.

When the page for turnover was heard, any available staff reported to that room.  The staff lounge was reserved for assigned breaks and lunches.  The organization also employed an orderly, receiving, housekeeping, maintenance person who helped as available turn rooms in this seven-OR facility.  However, whoever was available either grabbed a mop or begin wiping off the flat surfaces and or bed with the germicidal solution.

The OR was equipped with a soiled linen hamper, a biohazardous waste hamper, a general waste hamper and two kick buckets—one for anesthesia and one for sponges.  At the end of the case, these were emptied and disposed according to recommended practices and standards.

In identifying all the elements involved in turning a room the staff noted the hamper liners, kick bucket liners and the linen needed for the or bed as routine.

Physician procedure cards were scrutinized and updated as necessary. Staff met and agreed to follow these rigorously in pulling cases.

It was decided that all cases would be pulled the afternoon prior to the procedure.  All supplies would be put on the shelves in the close cupboard designated as the case cupboard.  Each shelf would be labeled; e.g., #1, #2, etc.  The cupboard shelves were equipped with a lip around the entire shelf and pulled out of the cupboard allowing it to be used as a transporting tray.

The organization approached the local grocery store and were able to get, free of charge, grocery carts with those irritating wobbly wheels.  These carts were cleaned up and the wheels were changed out transfiguring them from grocery carts to supply carts.  Staff used these to transport supplies from the bulk and sterile storage areas and to pick their cases.

Staff, following their procedure cards, pulled every item needed for each case and placed those on the assigned shelf in the case cupboard.

As part of the process for rapid room turnovers, the staff developed a system for “room turnover packs.”  These consisted of the OR table/bed sheet, the draw sheet, the kick bucket liners, and the various hamper liners.  Staff were assigned daily to make these packs by gathering all the items and making rolls that were held in place with a strip of masking tape.  These were kept at the OR control desk.  When pulling cases the staff person would pull however many of these rolls needed based on the number of cases scheduled for that room for the next day.  One of the rolls was placed on each shelf with the supplies for the case.

Once the room was cleaned, the RN or other staff person, as agreed in their assignment meeting, would pull the roll, make the table/bed and place the liners in the appropriate spot.  The surgical technician would pull the pack and place it on the back table and begin draping the instrument table and mayo stand . The RN Circulator began assisting in the opening of sterile supplies and dropping them onto the sterile field while the surgical technician scrubbed.  The RN then would set up the prep table, then leave the room to collect the patient with the anesthesia, provider.  Upon re-entering the room, the RN finishes gowning the tech and physician and turns to assist anesthesia in sedating the patient as needed.

Many larger organizations are turning to developing and/or hiring an anesthesia technician.  Certification for this person is available on the internet, but in-house training on the part of the anesthesia providers is acceptable.  This person can be quite valuable in assisting in room turnovers, too.  In the absence of an anesthesia technician the anesthesia providers have to assume an “assistive” position in turning rooms.  Include them in your training.  In the absence of an AT, the medication management nurse should be assigned the job of keeping the anesthesia carts fully stocked.

The system/process described above will absolutely allow you to turn rooms within the identified national standard of 7-10 minutes.  However, it is crucial to this process, that each staff person remember that every time someone leaves a room to go fetch something, it is manpower hours that translate to increased room turnover times.  Plan to review your turnover times at least twice a year.  Develop an electronic log and assign a data entry person the task of documenting times patients enter and leave rooms to facilitate your study.

Housekeeping…The Backbone Of The ASC

November 7, 2012 Leave a comment

The patient’s car pulls into the parking lot of the ASC.  He is here for his pre-anesthesia/surgery assessment and education visit.  He can’t help but notice that there is trash here and there around the lot.  A nagging little thought enters his mind about the apparent disregard for tidiness.  He approaches the front door of the Center and, again, notices some pieces of napkins and a styrofoam coffee cup lodge in the corner by the entrance.  There is a sand-filled ashtray near a bench, but the ashtray is overflowing.  That nagging little thought is getting bigger.  When he enters the reception area he notices the wilting—almost dead—plant on the corner of the reception desk.  The carpet shows a clearly defined dark/dirty traffic path.  The upholstery on one of the chairs is badly stained while another is clearly frayed along the front seam.

Does the above scenario sound implausible?  It shouldn’t, for it is a scene CMS surveyors are reporting across the country.  That patient’s nagging thought becomes a roaring symphony to CMS surveyors entering a Center.

Infection Control Surveys

When CMS began the unannounced infection control surveys in the summer of 2009, it became evident that housekeeping practices in ASCs were an urgent issue in the rising rates of infections being reported in the ambulatory surgery Centers.  Surveyors came out of these surveys certain that housekeeping, the training of housekeepers, and the follow-up of the housekeeping practices was not a high priority among the leaders in the ASCs.  Indeed, some surveyors were heard making statements like “it is clear that the leaders of this organization hire incompetent, unskilled and unqualified persons to perform housekeeping (and sterilization) services in this organization.”

In assessing the housekeeping practices in some 36 surgery Centers across the US what was discovered was that the ASC leaders largely hired housekeeping contractors who had “experience” cleaning healthcare facilities.  However, some of this experience was in cleaning doctor’s offices.  Some did list other ASCs.  On occasion, some owners of the housekeeping service had worked, themselves, in the housekeeping department of the hospital.  Several Centers interviewed performed all the housekeeping inservices internally using their RN staff.  In none of the Centers did the organization meet with the housekeeping staff themselves to perform training or to observe their cleaning practices.  And yet, virtually all of the Centers had quite a litany of complaints regarding the services that were being delivered.

In performing inspections of the various ASCs, CMS has reported;

  • Water stained ceiling tiles throughout many Centers.  These stains harbor bacteria.
  • Rust on stretchers, or tables, IV poles, the legs of instrument tables, anesthesia and emergency carts, endoscopic cleaners, in and on sterilizers, medical gas connectors, oxygen tanks and connectors…the list becomes extensive.  Rust harbors bacteria.
  • Dust—everywhere!  Windowsills, blinds, tops of suction canisters, the top of emergency and anesthesia carts, microscope arms, behind equipment on counters, inside drawers in medication rooms and in the OR and sterile processing.  Dust is a large contributor to post-op infections!
  • Chipped and peeling formica throughout the Center on doors, counters, cupboards.  This leaves a surface that is far from ‘seam-free’ and harbors bacteria.
  • Peeling and torn wallpaper—again, not smooth and seam free for washing w/o harboring bacteria.
  • Chipped paint on walls and door frames—same story as above as far as preventing adequate cleaning.
  • Nasty, dirty areas behind sterilizers and open drains that are full of what looks like mold.
  • Mold in air vents—dirty and dusty air vents.
  • Blackened separated floor seams.
  • Separated coving on floors in sensitive areas like the OR
  • Separated back splashes leaving gaping spaces between the back splash and the wall in sterilization and soiled cleaning rooms.
  • Housekeeping closets that either have no or too long black hoses that are touching the bottom of the sink pan.
  • Housekeeping closets that are dirty, cluttered and un-kept.
  • Corners of floors, especially behind doors, that are dirty and appear to have been ‘waxed over’.

In one Center, CMS instructed the ORs/Administrator to demand the housekeepers come in during the day shift in order for CMS to observe their cleaning the ORs.  It was disastrous!  The cleaning crew mopped the OR walls with dripping mops starting at the bottom and working their way up.  In addition, the same mop head was taken into the second OR to use, but, then, so was the same bucket of water!

While observing housekeepers in another Center, the observation was made that the housekeeper pushed the bucket full of solution out of the one OR, mopped the OR corridor and proceeded into the Pre-op/Recovery area.  When the observer questioned the housekeeper as to when she would change the water/solution in the bucket, the housekeeper replied that she changed it when it got dirty!

In another Center where the RN staff performed all housekeeping duties, it was discovered that counters were never being cleaned, nor was deep cleaning behind equipment, or corners being done.  It appeared that the old ‘a lick and a promise’ was the rule of thumb, as this service was being done at the end of the day’s schedule, and staff were eager to ‘get out of here’.

One cannot assume that these are isolated occurrences.   In the face of increasing numbers of infections in ASCs, we in this industry must cast a disparaging eye toward housekeeping practices in our own ASCs.  ]

We have to carve out the time to address this very serious issue.

  1. Comprehensive Housekeeping Policies.  Surgery Centers should have comprehensive housekeeping policies.  Housekeeping guidelines for hospitals and healthcare facilities can provide the stepping stone for your policies and protocols.  Look at every area beginning with the entry into your Center.  What does it tell the patient about what he can expect from a safety/infection-free environment for him?  What does it tell him about your commitment to cleanliness?  Patients know about sterility.  They strongly suspect that the place where they are having their surgery should be above and beyond clean, if their outcome is to be good.  They all have friends or family, or they know someone who got a post-operative infection.  The condition of your Center also has a huge impact on your marketing.  What does it say to your patient community if you have not maintained your Center either physically or through housekeeping?
  2. Orientation.  Develop a housekeeping orientation program and tools.  Include all areas and essential tasks.  Look at your own expectations in each area.  Meet with your key staff members to discuss and explore their expectations, issues and complaints.  Incorporate clear instructions based upon this analysis as part of the housekeeping orientation.
  3. Tools and Recommended Practices. Develop housekeeping checklists for each area.  Look at recommended practices from the AORN.  These checklists should include terminal cleaning of the ORs, the expected schedules for the cleaning of all areas and the contents of all the different rooms.  What pieces of equipment are they to clean, if any.  Also, develop checklists to document what the nurses are expected to clean and how often.
  4. In developing checklists identify those things that are outside of the daily or weekly routine; e.g., carpets, tile, windows, upholstered furniture, stripping and waxing floors, woodwork, doors, inside cupboards, etc.
  5. Housekeeper’s checklists should hang in their closet.  Get in the habit of checking these several times a month.
  6. Put together a housekeeping training packet and meet, not only with the supervisor, but with the housekeepers who are going to be cleaning your Center.
  7. Determine whether or not the housekeepers have had training in both blood-borne pathogens and toxic/hazardous substances, but also HIPAA.  If not, provide them with those policies and demand that the contractor provide further, documented training.
  8. Provide the housekeepers copies of your housekeeping policies and complete the orientation tool.  Observe their cleaning practices.
  9. During the orientation and training period there should be a conversation regarding the ability of the housekeeping staff to read and speak English.  If the staff is unable to do so, you are expected to provide instructions, checksheets, MSDS in their language!  There are sources for this available on the internet, or contract with an interpreter to make these changes.  You can also have the interpreter provide all the instructions verbally.  Document this in the contract workbook with their contract.
  10. Orient the ASC staff to housekeeping practices.  This should include not only what can be expected from the housekeepers, but what is expected of them.  It is unfortunate that we still see RNs who drop some piece of paper on the floor and leave it stating that it is not in their job description to clean, or they call the MA to pick it up.  The RN’s job is to provide a safe environment for their patient.  This includes a clean environment.  During a recent survey, the surveyor did the white glove test on the bottom of a drawer in the medication room.  She held up a finger laden with dust and showed the RN who was the medication management nurse.  The RN said, ‘housekeeping doesn’t clean inside drawers.’  The surveyor remarked, ‘and clearly, neither do you, nurse!”…..not a good impression…and this is a room where medications are prepared!
  11. CMS expects that the leaders are periodically observing the housekeeping staff at work.  Schedule a midnight visit at least several times a year to ensure that best practices are being followed.
  12. Lastly, CMS also expects that the leaders of the organization are conducting housekeeping inspection tours.  It makes sense that the infection control coordinator be responsible for monitoring the housekeeping practices in the Center.  However, the leaders should hold this person accountable by reviewing the logs on a regular basis and demanding that the housekeeping practices and results of the weekly housekeeping inspection tours be included in her quarterly infection control report to the QA/PI meeting.

In closing, housekeeping practices are the backbone of the Surgery Center.  Without good, sound and solid housekeeping services, low infection rates are in jeopardy, and, eventually, word is going to get out that your Center is less than an ideal place for patients to have their surgery.  Remember, they do have a choice.

The Pre-Operative Patient Assessment in an Ambulatory Surgery Center

July 4, 2012 Leave a comment

According to The ADA Group Center policies “all patients deemed appropriate for procedures performed at the Center are to be interviewed in order to collect a comprehensive patient history, to include medications, and to identify inherently dangerous patient conditions. Patients are to be counseled and assessed paying particular attention to special needs inherent to the patient’s age, prior historical events and underlying health conditions as they impact the proposed surgical and anesthetic event.  Vigilance will occur especially in regards to the recognition of risks inherent to surgical procedures relating to potential adverse drug reactions and interactions, potential or anticipated critical events and to the potential for surgical site infections.

During the pre-operative interview, whether conducted on-site or through a telephone call,  the peri-operative staff assess the patient’s ASA status, anxiety level, food and drug allergies, skin issues and integrity,  any potential airway issues such as those identified due to a history of sleep apnea, previous anesthesia issues/susceptibility to malignant hyperthermia, pending lab/radiographic studies and results, pre-operative disease status and those special needs inherent to the patient’s age.

Patient education during this pre-operative interview is crucial.  The time constraints in the ambulatory surgery setting make the collection of comprehensive information and patient education challenging at best.  These time constraints do not, however, serve to provide an excuse to erase the performance of the pre-operative assessment and education process from the organization’s routine activities.

And yet, this seems to be a growing trend, as more and more surgery centers are reporting that staffing constraints have, in fact, negated this activity.

Patient education is one of the primary roles of the peri-operative nurse working in ambulatory surgery.  Research has proven that patient education plays a huge part in successful and positive patient outcomes and in patient outcomes and satisfaction.

Patient education should start with pre-operative brochures either sent to the patient when scheduled, procured by the patient through the organization’s website, or provided to the patient during their pre-operative physician or ASC interview/visit.  This process would be enhanced through on-site tours, group educational meetings, phone calls and education reinforcement conducted on the day of the procedure.

Recently, a licensed risk manager did a trend analysis of patient cancellations in just one of her surgery centers to determine the number of patients being cancelled in the pre-op area on the morning of their scheduled surgical/endoscopic appointment.  Of these, many had either eaten or drank something.  Several had not taken required medication or followed their plastic surgeons pre-operative antibiotic regime.  At least two to three per month had inadequate preps with the same number presenting with incomplete lab work.  Three to four patients each month presented with atrial fibrillation or pulmonary issues.  Top this with a minimum of two to three patients a month presenting with no care person and you have a large number of cancellations occurring after the patients were admitted, and, frequently, had IVs started.  While this number was excessive in this one center, a review of some other centers uncovered similar problems—though not so extensive.  In virtually all of the instances identified, none of the patient’s had received a pre-operative phone call from the center, though all had been sent written instructions.  In all centers staff were queried regarding the breakdown in the performance of pre-operative phone calls/interviews.  New staff members were appalled. Faced with the tight staffing they experienced in the ASC, they could not believe that such a thing would be required of them.  They had no understanding, moreover, of the impact these cancellations had on the organization.  Older staff members often recalled a time when pre-op phone calls and/or interviews were done, and that, oftentimes, there was even a pre-operative coordinator who performed this duty.  None believed there was adequate time allowed in the schedule for this activity to occur.  And yet, this licensed risk manager saw part-time nurses rushing to get out of the center at the end of the schedule, or sitting at the nurses’ station or in the lounge for 20-30 minutes chatting.  This same licensed risk manager witnessed staff gossiping and chatting with one another in different parts of the center throughout the day.  All of this activity added up to a rejection of the staff’s assertion that “there is no time to make these calls”.

Further investigation of center’s performing as many as 7,000 cases a year found that those centers were being successful in completing 85-90% of their calls/interviews. A 100% goal was rejected due to late “add ons” and failure of patient response/inability to connect with the patient preoperatively.  These patients were educated and assessed the morning of their procedure.


Adequate preparation makes a huge difference in the patient’s response to his entire procedure.  A four year old was scheduled for bilateral PE tubes.  The grandmother, an OR trained registered nurse living with the family eagerly awaited the child’s phone call scheduling a time for the child to come in for her tour and to get her sample anesthesia and/or surgical mask and to play with the stuffed animal surgical patient.  No call came, so the grandmother awaited the pre-operative phone call to educate the child on what to expect and to gather information in order to best prepare for the care of the child.  No call came.  The grandmother put all her experience in place and did the teaching for the child.  A trip to the hardware store got a mask and hair cover.  The child was told what to expect on arrival, in the pre-operative area…what the OR would look and sound like…it would be cold…everyone would be dressed the same…the equipment, the noises, the table/bed…the anesthesia mask.  On the day of the procedure, the little girl hopped off the pre-op stretcher taking the OR nurses’ hand and walked right down the OR corridor and into the room.  The ASC staff did make a post operative phone call to the family during which she bragged on how brave the child had been and that they had never had a child do that before “without even a whimper”.


In another case, a 69 year old patient was scheduled for a colonoscopy.  During her pre-operative visit her physician provided her the packet of information from the surgery center.  This particular patient happened to be an ASC registered nurse of nearly 30 years experience.  A week prior to the surgical appointment, the nurse opened the packet and discovered that the first piece of literature advised her that the procedure would be performed at one of two centers, but not which one. She waited a day or two for her pre-operative call to clarify the issue.  None came, so she called her physician the Friday before the surgical appointment to find out where she should go.

A comprehensive pre-operative phone call or interview is crucial to patient safety and satisfaction.  Needless to say, neither the grandmother in the first example or the RN in the second will frequent those two centers again…and…rest assured their dissatisfaction has been loudly shared with family and friends who will also, most assuredly, shy away from those two centers.

Conducting a comprehensive pre-operative patient assessment and teaching interview, whether on site or over the phone, need not erode into staff overtime pay.  How is it possible to get this very important activity done in the face of “staffing skinny”?

Pre-operative assessments can be conducted as near the time the patient is scheduled as possible.  Consider setting up a system identifying those patients who are awaiting surgery/awaiting the pre-operative assessment and education interview.  All pre-operative staff should be trained to conduct these interviews and to recognize Red Flags reported during the interview for referral.  The “Awaiting” files are checked daily.  The goal would be to do the assessment as soon as possible—some may be two weeks out from their surgery date.  Staying ahead is a bonus allowing time to get those patients scheduled closer to the date of their procedure interviewed.

Once the history is collected, cultural diversities identified, special learning needs addressed and general educational

information imparted, the pre-operative nurse monitors the receipt of lab, EKG or radiographic reports, the physician’s H&P and consents which are all added to the patient’s file whether paper or electronic.  Anything missing is identified well in advance of the surgery date and collected at that time.  Continual monitoring identifies “missings” well ahead of the surgical date thus decreasing those nasty surprises that happen on that date when the H&P, lab work, consents, etc. are missing resulting in case cancellations and/or delays to say nothing of the irate patient and physician.

ASCs pride themselves on patient satisfaction.  Cancellations and delays impact patient AND physician satisfaction tremendously to say nothing of the cost incurred by the organization for supplies used in pre-op, staff hours and salaries, supplies opened in the OR and those corresponding staff costs.  Add this to the negative experience by both the patient and physician, and the cost is even higher.  It could be argued that the organization cannot afford to NOT do the pre-operative interview and assessment.

The Joint Commission and CMS urge ASCs to embrace a culture of patient safety.  How could this even remotely be possible without a pre-operative assessment and educational interview conducted by the ASC?

Losing A Patient

April 10, 2012 Leave a comment

As healthcare workers, we always know that there is a possibility that one of our patients will die on us. 

I began my nursing career in surgical intensive care in a very large teaching trauma center in San Antonio, Texas following a critical care internship.  The patients we got in the SICU were major traumas—a woman thrown under a train by a jealous boyfriend or tied to the tracks by an irate pimp—or arms cut off by a husband; a 14 year old boy who dove into a “too shallow” pool to retrieve his baseball hat while horsing around with his cronies and now faces a lifetime as a quadriplegic and so on. One day I came into the unit, looked around and marched straight out and to the DON’s office where I put my application in to work charge nurse recovery.  Those patients were asleep and as soon as they woke up, they were off to their rooms. Minimum exposure to sadness, to trauma (all intensive care patients left the OR and went straight to the SICU). From there I went to the Operating Room.  Those patients were ASLEEP the whole time I took care of them. So after being a trauma junkie I entered the world of wellness nursing in the guise of same day surgery.  And I fell in love with it.


Oh, I have faced death in my beloved world of otherwise healthy patients.  There was the patient we lost—a 46 year old healthy woman who came in for a vein stripping and died because the esophagus was intubated rather than the trachea.  There was the 45 year old woman who came into another center for multiple plastic procedures and after 11 and ½ hours of surgery died upon exiting her car in her driveway of multiple pulmonary emboli. We had the 86 year old who was oxygen dependent, and who wasn’t given oxygen during his stay in the center; consequently exiting the operating room with no vital signs.  Nothing prepares you for such a loss.  You are never fully prepared.  We live in a world of wellness where our patients are, even with all their underlying health issues, truly Class I & II ASAs who consider themselves otherwise healthy.  We see them that way.  We admit them, take their histories, their vital signs, listen to their stories, meet their care persons, laugh with them, get frustrated, give them instructions, put them in the car and wave at them as they leave.  “There we go, another one bites the dust!”, I used to say jokingly as I marked their name off the schedule, did a little jig of happiness and sang a little.  We had returned another patient to his family, to his social world better than when he came in…another success.  We become conditioned that this is the way it IS!  This is the way it SHOULD BE…and it is.  We become, gradually, complacent that it will ALWAYS be that way.  We let down our guard.  We start going on automatic pilot.  We become drones addicted to the routine of everyday life in our busy surgery centers. AND THEN….it happens…and it is catastrophic…a child dies on our table….we work frantically…we do everything we know to do…everything we have learned…everything we have been taught to save this child…to bring him back so we can deliver him safely to his family….but it doesn’t work.  We are left with the horrific impact….the horror of facing the family…the family with…now…empty arms.


I remember once when working recovery having a 3 year old little girl brought to me from the OR wrapped in a pink blanket.  Her long black lashes lay silent on her cold, still body.  A little child with major heart defects whose only chance of living was to try to correct them…but she couldn’t hang on…I believe God wanted her too much.  As I carried her in my arms to the morgue down the back steps I was faced with her parents coming up the stairs from the cafeteria.  I just sat down with them right there and handed them their baby.  We held one another and cried.  There is nothing else that can be done.


Stephanie broke down in tears when she heard of the loss at one of our surgery centers.  I tossed and turned all night.  We had them bring in a grief counselor for the staff.  Stephanie reminded me that every time a patient comes into our centers, holds out their wrists and we affix a wristband, that patient is now “at risk”.  We must never forget that and must stay alert and ever ready.  Go in peace, Little One.

Measuring Patient Satisfaction, Part 3

October 3, 2011 Leave a comment

Conversations with the QI Coordinator in these incidences (in part 2) resulted in significant changes in the entire education of the patients. In all of the centers the decision was made to conduct the postoperative teaching during the preoperative phone call or visit.   The QI Committee met to discuss what additional steps could be taken to enhance patient teaching and in all cases came to the realization that their teaching really had been only to cover the usual basics all patients experience during the first 48 hours postoperatively, but did not include effective discharge planning; i.e., care beyond the basic physical care of the wound, etc.  The next step was to identify the types of procedures where additional education and planning would be warranted.  The groups identified additional information that would be needed.  All of the groups admitted that they always asked if there was a caregiver and stressed that that person, or someone, had to be there to drive the patient home.  However, they never inquired regarding the health of the caretaker or much more beyond the driving the patient home conversation.  “Can your caretaker adequately care for you at home?  Can this person provide your meals?  Change your dressing?  Help you ambulate?”  These questions were added to the preoperative teaching.  Additional questions developed included the home environment; e.g., are there stairs to navigate to the TV?…to the bedroom?  Who will prepare your meals?  Help you bathe?  These questions became very helpful when in the course of interviewing one patient, it was discovered that his “caretaker” would be his wife.  He had planned to take a cab in for his cataract surgery and to return home where his wife would assume his care.  However, it was discovered that his wife was a cardiac patient and was bedridden!

The next step many of the groups made was to contact the various patient care coordinators in some of the physicians’ offices soliciting their help in getting this information from the patient at the time he was scheduled for his surgical appointment.

The pre-op staff in the centers revised their preoperative phone call process to make the call on the average two weeks prior to the scheduled appointment in order to allow adequate time for the patient to make his plans.  One center developed a service of adult care persons to serve as caregivers for their patients.  These persons were all known to the center staff.  Background checks were done on them. CPR certification was a requirement to be placed on the list.  The patients who had no caregivers were given the list and had the option to contract with one of these persons.  The patient paid the caretaker.  These persons were bonded and screened by the center leaders.  This alleviated cancellations at the last minute due to the unavailability of a caretaker, or the confrontation of the patient postoperatively when no caretaker arrived to take him home.  The caretaker brought the patient to the center for his procedure, stayed and participated in the postoperative instructions, drove the patient home, prepared him a meal, stayed the first night and brought him back for his first postoperative visit.  This program has been in place several years at this particular center resulting in high patient satisfaction rates.

Additional centers have begun asking their focus questions through postoperative e-mails to the patients and are reporting very positive results from this process.

Measuring patient satisfaction need not be a hair pulling, frustrating process, but, rather, can result in tremendous satisfaction on the part not only of the patient but of the center leaders and staff.

Categories: Quality Improvement

Measuring Patient Satisfaction, Part 2

September 16, 2011 1 comment

The first step is to review and revise your existing questionnaire.  Turn it into a tri-fold brochure and place a stack of them in your waiting room with a sign that says, “Please tell us how we are doing!”

The goal now becomes to transform the measurement of patient satisfaction/perception of care into focus questions.  These are questions that are identified by the QI Committee and the members of the Medical Advisory/Executive Committee and may be asked of the patient over a designated period of time by the staff during the postoperative phone calls.

Meet with the QIC members and the medical staff on the MAC/MEC.  Advise these persons of the intent to ask the patient questions the outcome of which will make a difference in how you practice.  A topic is selected with 2-4 questions regarding that topic.  These are put into a questionnaire or QI study format and are asked during the post-op phone call.  The callers gather the questionnaires and forward these to the QI Coordinator for analysis.  The QI Committee and/or the MAC/MEC determine if the identified topic will be queried for one, two or three months.  Results are submitted to the various committees when completed for further input.  Some of the questions asked include:

  • Did you observe the staff washing their hands during your stay at the center? How? When?
  • Was your recovery experience what you expected and how could we have improved upon that?
  • Was you pain management adequate?  Did the pain medication you were prescribed work, or did you have to contact your physician for another/different prescription?
  • Did your caretakers ask your name, the type and site of the procedure you were to undergo in pre-op, prior to starting a treatment such as an IV or prior to giving a medication, and in the OR?
  • Did you feel the staff provided you a safe environment?
  • Did you experience any infections postoperatively even if not related directly to the procedure you had done?  Were you on postoperative antibiotics?  How long did you take them?  Did you finish your course of medications?

Periodically, physicians may come forth with a comment like, “You know, I have always wondered if patients (fill in the blank) post-operatively.”  You can use these questions for your focus studies.

From questions like those identified above the committee members can identify two or three additional questions on each subject.

Results of these focus studies can be dramatic; e.g., the question about the recovery experience produced several major issues:

  • One patient had undergone a knee arthroscopy with a inguinal block. He was a professional football player whose caretaker was his 5’4”, 112 lb wife.  It seems he had to climb a series of steps from his driveway to get into his house.  The TV was in a basement media center and the bedroom was on the second floor.  He fell several times while trying to navigate to reach these various areas.
  • Patient # 2 underwent surgery for her bilateral carpal tunnels.   During the postoperative phone call she expressed her upset in that both hands were splinted.  Her husband was the helpless type who couldn’t even” fill the teakettle for a cup of tea”, but she couldn’t help…neither could she perform her own personal, intimate care.  She reported being extremely frustrated and embarrassed.
  • Patient #3 had experienced bilateral bunionectomies to include excision of her Taylor bunionettes with no understanding whatsoever of the amount of pain she would experience.  In this instance, she, too, had to climb stairs to her front door and to her second floor  media room  and bedroom.

In all of the above cases, which occurred at different surgery centers, there was inadequate teaching for the postoperative experience. Obviously the level of satisfaction regarding their experience was very low.

Part 3

Categories: Quality Improvement

Measuring Patient Satisfaction, Part 1 of 3

August 17, 2011 Leave a comment

“There must be a mechanism in place to measure a patient’s satisfaction.  The patient has  the right to express his satisfaction or otherwise.”  

These are the regulations and the standards imposed upon surgery centers by regulatory agencies such as CMS and the different state licensing agencies as well as by the various accreditation organizations.

In the early days of ambulatory surgery we took that to mean that every patient was to be given a copy of our standardized patient satisfaction questionnaire upon his discharge from the center with a request to mail it back at his earliest convenience.  This form was frequently a list of questions put together by the Medical Director, the Administrative Director and the OR Supervisor/QI Coordinator.  We dutifully distributed these forms to our patients and implemented numerous tactics trying to get back more than the usual 20-30%.  We tried giving them a self-addressed, stamped envelope at no small expense.  That helped, and sometimes got us up to a 40% return.  We tried telling our Medicare patients that the form was required to be given to them by Medicare in the hopes they would think that they had to send it in if they wanted Medicare to pay the ASC fees.

These tactics worked to the extent that they worked.  There were centers who reported returns as high as 80-90%.

Research into these reports, however, sometimes uncovered some interesting processes in place to reach those percentages.

In one center that reported nearly a 100% return rate, we found the surgeon was bringing the form into the exam room during the patient’s post-operative visit.  He would ask the patients the questions and duly complete the questionnaire with their responses.  After that, he would have the patients sign and date the form.  He was very proud of his response rate, but one wonders whether his patients felt free to respond openly with any criticisms.

In another center the staff went over the questionnaire with the patients during the post-operative phone call and completed the form.  Again, concerns are raised regarding how free the patients felt in giving their response. Nevertheless the organization was reporting exceptionally high percentage of returns on their surveys.

The passing out of the questionnaires, or the completion of them by the staff, met the absolute requirement that the patient be queried, or be given the opportunity to express his satisfaction or otherwise; however, within three-four months of a center’s opening, it became blaringly obvious that certain questions were problematic.  These questions always resulted in poor ratings; e.g.,

  • Waited too long.
  • Surgery didn’t start on time.
  • The room was too cold.
  • The fees weren’t discussed adequately.

The QI Committee reviewed the comments and implemented everything they could to try to increase satisfaction in these areas.  We did time studies and tried to work with the patients to ensure they didn’t arrive too early at the center on the morning of their procedure.  We met with the medical staff, especially those who were chronically late.  We altered our schedules, but still those complaints persisted.  We let patients wear their street clothes where possible.  We got them socks to wear on their feet.  We bought blanket warmers and wrapped them in toasty blankets.  We bought warming units of various kinds.  We met with surgeons and, where possible, increased the OR temperature as much as allowable.  We developed proposed fee schedules to give to the patients identifying the various fees for which they would be billed along with those of the ASC.  But…in spite of all these efforts these areas continued to be the ones with the ongoing complaints. So….we set up critical thresholds and declared that we would not address those issues unless we got a percentage of complaints greater than our threshold.  We continued, though, to get the complaints even though we had done everything we could think of to remedy those issues.  We even altered the survey forms taking off the offending questions, but what we, again, found was that we were not learning anything new from the questionnaires.  They truly were just an exercise to meet the regulations and standards, as we struggled to get an acceptable return rate.

But wait!  What if there was a better way the results of which could impact the way we deliver our care in our surgery center? This would take the entire process out of being a painful exercise and turn it, instead, into a valuable tool.

In part 2, I’ll share how to make this process  simple, impactful and painless…

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