The monthly publication for OR decision · PDF fileThe monthly publication for OR decision...

November 2008 Vol 24, No 11

The monthly publication for OR decision makers

In this issueJOINT COMMISSION.What’s needed to address bad behavior? . . . . . . . . . . .7

Spot at-risk behavior, intervene early . . . . . . . . . . . . . . . . . .9

A ‘civility and respect’ policy for surgery . . . . . . . . . . . . . . .10

LEADERSHIP.How to keep shared governance alive . . . . . . . . . . . . . . .11

INNOVATIONS IN SURGERY.Cholecystectomy with no external incisions . . . . . . . . . . . . . . .13

PERFORMANCE IMPROVEMENT.Turning around the culture of an OR . . . . . . . . . . . . . . . .15

MANAGING PEOPLE.When a staff member needs to improve . . . . . . . . . . . . . . .19

Study to focus on OR staffing, relation to patient outcomes . . . . . . . . . . . . . . .23

PERFORMANCE IMPROVEMENT.Hardwiring a process for antibiotics . . . . . . . . . . . . . . . . . .25

AMBULATORY SURGERYCENTERS.A small ASC’s automated supply chain . . . . . . . . . . . . . . . . . . .26

AMBULATORY SURGERYCENTERS.Getting ready for ASC quality reporting . . . . . . . . . . . . . . .28

AT A GLANCE . . . . . . . . . . . . . . . . .32

ASC section on page 26.

Process for addressing disruptivebehavior must be in place by Jan 1

Asurgeon blows up at the staffbecause an instrument is miss-ing from a set. A new nurse is in

tears after a senior RN snaps at her forasking how to set up a piece of equip-ment. A resident won’t respond when anurse asks about a medication order.

Behavior like this used to be consid-ered part of life in health care. Now itis seen as a threat to patient safety anda factor in communication breakdownsthat underlie many health care errors.

Soon ignoring disruptive behaviorcould cost your facility a mark of non-compliance from the Joint Commission.As of Jan 1, 2009, the Joint Commis-sion, under its new Leadership Stand-ards, will expect organizations to have

a code of conduct and a process foraddressing disruptive behavior.

Three articles in this issue can helpyou prepare for the new requirements:• Page 7: Grena Porto, RN, MS, ARM,

CPHRM, who urged the Joint Com-mission to take action, discusses theneed.

• Page 9: Vanderbilt University Schoolof Medicine’s program is used bymore than 30 organizations nation-wide.

• Page 10: A chief of surgery takes thelead in introducing a code of con-duct. v

Joint Commission planning to addmore infection standards for 2010

Joint Commission

Infection control

Special focus: Codes of conduct

Three infection control organizationshave joined with the AmericanHospital Association and the Joint

Commission to publish a compendium ofwhat they say are science-based, user-friendly strategies to prevent 6 types ofhealth care-associated infections (HAIs).

The strategies were developed in theface of rising patient concern about hospi-tal infections and the government’s deci-sion to stop paying for treatment of cer-tain HAIs after Oct 1, 2008.

At least some of the strategies are like-ly to become Joint Commission require-ments in 2010.

The compendium pulls together exist-ing HAI guidelines into a set of recom-mendations that are understandable, easyto use, and stress accountability, saidDavid Classen, MD, the coauthor, repre-

senting the Infectious Diseases Society ofAmerica (IDSA), at an Oct 8 press confer-ence. Also involved were the Society forHealthcare Epidemiology of America(SHEA) and the Association for Profes-sionals in Infection Control and Epide-miology (APIC).

The compendium is supported by 29organizations, including the Centers forDisease Control and Prevention (CDC).

The Joint Commission says it willstudy the compendium in 2009 and plansto adopt at least some of the strategies asrequirements in 2010.

Joint Commission Vice PresidentRobert Wise, MD, said that though allhospitals are actively working on thesestrategies, such as preventing catheter-associated bloodstream infections, “we

Continued on page 5

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Every patient receives oral and writteninstructions before going home aftersurgery. A nurse goes over the dis-

charge teaching. The surgeon has seen thepatient in the office earlier to explain thesurgery and discuss care at home.

But how well do patients understand?A new study from the emergency depart-ment (ED) suggests there could be a bigcommunication gap. That could be a bigrisk to patient safety.

One surgeon, Michael S. Woods, MD,calls the communication gap “the greatestthreat to patient safety in the US,” greaterthan unbridled technology, adverse drugevents, or lack of an electronic healthrecord. He’s written a new book onimproving communication.

This is an issue that needs more atten-tion, studies suggest.

The ED study found a serious mis-match between instructions and whatpatients understood. In these patients,who spoke English, 42% didn’t accuratelyrecall at least half of what they were told—even though 80% thought they did. Thestudy was in the July 2008 Annals ofEmergency Medicine.

Even patients who stay in the hospitalhave a hard time remembering theirinstructions. In a group of patients overage 70 discharged from an urban academ-ic hospital, more than half (54%) didn’trecall anyone talking with them about careat home.

What do surgical patients understand?A small Australian study of 13 general

surgery patients interviewed a week aftergoing home found some of the samethemes—a “one size fits all” approach,inconsistent instructions, and a lack ofassessment to see how well they couldcare for themselves after discharge.

Health literacy is a huge issue. Aboutone-third of US adults have literacy skillsbelow the high school level. Close to halfof those have trouble with common print-ed material, even a pill bottle label.

Some simple remediesDr Wood in his book, In a Blink:

Awareness, Assessment, and Adapting toPatient Communication Needs from JointCommission Resources, suggests somefairly easy steps for improving communi-cation, even with today’s tight schedules.He practices in Santa Fe, New Mexico,home to a people from a variety of ethnici-ties, education, and socioeconomic levels.

His audience is physicians, but any care-giver could learn from the book.

His approach: Be aware of 6 variablesthat affect communication—ethnicity,socioeconomics, literacy, gender, personal-ity, and time. By being aware, he says aclinician can learn to do a quick “thin-slice” assessment of each patient and dis-cern what communication style will workbest.

Why not ask patients what works best?A nurse and psychologist, Evelyn C.Kemp, did just that. She tested 3 methodsfor communicating with a patient aboutdeep-vein thrombosis:1. Yes-No: “I’ve given you a lot of infor-

mation. Do you understand?”2. Tell back-directive: “It’s really impor-

tant that you do this exactly the way Iexplained. What do you understand?”

3. Tell back-collaborative: “I imagineyou’re really worried about this clot.I’ve given you a lot of information. Ifwould be helpful for me to hear yourunderstanding about your clot and itstreatment.”Patients significantly preferred no. 3.

Kemp’s advice:• Ask patients what they understand in

their own words. • Let them know that you realize med-

ical information is complicated, and it’sOK if they don’t understand every-thing the first time. Her study is in theJournal of the American Board of FamilyMedicine (2008;21:24-30).We suspect many nurses already use

this collaborative method. Having patientstell back may take a little more time. Butit’s worth it to enable a smooth recovery.And it’s certainly less time consumingthan treating a complication that hap-pened because a patient wasn’t clear aboutwhat to do. v

—Pat Patterson

3November 2008

Upcoming

OR Manager Vol 24, No 11

November 2008 Vol 24, No 11OR Manager is a monthly publication forpersonnel in decision-making positions inthe operating room.

Elinor S. Schrader: PublisherPatricia Patterson: EditorJudith M. Mathias, RN, MA:

Clinical editorKathy Shaneberger, RN, MSN, CNOR:

Consulting editorKaren Y. Gerhardt: Art director

OR Manager (USPS 743-010), (ISSN 8756-8047)is published monthly by OR Manager, Inc,1807 Second St, Suite 61, Santa Fe, NM87505-3499. Periodicals postage paid atSanta Fe, NM and additional post offices.POSTMASTER: Send address changes toOR Manager, PO Box 5303, Santa Fe, NM87502-5303.

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Copyright © 2008 OR Manager, Inc. All rightsreserved. No part of this publication may bereproduced without written permission.

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Where’s that lost specimen?How ORs are improving safety in this

crucial area. They are analyzing theirprocesses and closing the loopholes.

New imaging technologyPortable CT scanners, intraoperative

MRI—new imaging technology may becoming to your OR sooner than youthink.

Editorial

“

“How well do patientsunderstand?

4

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see lots of variation in practice. All arepartly effective, but none are completelyeffective.

“The Joint Commission knows hospi-tals already are using some of the strate-gies in the compendium. Most could domore.”

In 2009, he said, the Joint Commissionexpects hospitals to review the compendi-um and their current practices to seewhich strategies they need to add. Also in2009, the commission will gather a groupof stakeholders to consider which prac-tices should be immediately required foraccreditation. In 2010, those will becomerequirements, he said.

Strategies for SSI preventionMany of the strategies recommended

for preventing SSIs are already in the JointCommission’s 2009 National PatientSafety Goal 7, which must be fully imple-mented by Jan 1, 2010.

The strategies cover surveillance, prac-tices, special approaches, education, andapproaches that should not be consideredroutine. They are rated A, B, or C, basedon the strength of the recommendation,and I, II, and III, based on the quality ofthe evidence.

SSI prevention practicesThe SSI prevention practices will be

familiar to OR leaders:• Administer antimicrobial prophylaxis

in accord with evidence-based stan-dards and guidelines (A-I).

• Do not remove hair at the operative siteunless the presence of hair will inter-fere with the operation. Do not userazors (A-II).

• Control blood glucose level during theimmediate postoperative period forpatients having cardiac surgery (A-I).

• Measure and provide feedback toproviders on rates of compliance withprocess measures, including antimicro-bial prophylaxis, proper hair removal,and glucose control (for cardiacsurgery) (A-III).

• Implement policies and practicesaimed at reducing the risk of SSI thatmeet regulatory and accreditationrequirements and are aligned with evi-dence-based standards (eg, CDC andprofessional organization guidelines)(A-II).

SSI surveillanceThe compendium includes these sur-

veillance strategies:• Perform surveillance for SSI (A-II). • Provide ongoing feedback on SSI sur-

veillance and process measures to sur-gical and perioperative personnel andleadership (A-II).

• Increase the efficiency of surveillancethrough use of automated data (A-II).

Education• Educate surgeons and perioperative

personnel about SSI prevention (A-III).• Educate patients and families about SSI

prevention, as appropriate (A-III).

Approaches not considered routine for SSIprevention• Do not routinely use vancomycin for

antimicrobial prophylaxis; however, itcan be appropriate for specific clinicalcircumstances (B-II).

• Do not routinely delay surgery to pro-vide parenteral nutrition (A-I).

The Compendium of Strategies toPrevent Healthcare-Associated Infectionsin Acute Care Hospitals is in a supplementto the October 2008 Infection Control andHospital Epidemiology (Vol 29, Suppl 1).Access for free at www.preventingHAIs.com. v

5OR Manager Vol 24, No 11November 2008

William R. Anton, RRTBusiness director, surgical services; Director,value analysis, University of WashingtonMedical Center, Seattle

Renae Battié, RN, MN, CNORDirector, intraoperative services, SwedishMedical Center, Seattle

Ramon Berguer, MDChief of surgery, Contra Costa Regional MedicalCenter, Martinez, California

Mark E. Bruley, EIT, CCEVice president of accident & forensic investigation, ECRI, Plymouth Meeting,Pennsylvania

Jayne Byrd, RN, MSNAssociate vice president, surgical services, Rex Healthcare, Raleigh, North Carolina

Robert G. Cline, MDMedical director of surgical services, MunsonMedical Center, Traverse City, Michigan

Helen K. Crouch, RN, MPH, CICDirector, infection control & epidemiologyservices; Infection control consultant for Army,Great Plains Regional Command, Brooke ArmyMedical Center, San Antonio

Franklin Dexter, MD, PhDProfessor, Department of anesthesia and healthmanagement policy, University of Iowa, Iowa City

Dana M. Langness, RN, BSN, MASenior director, surgical services, Regions Hospital, St Paul, Minnesota

Kenneth Larson, MDTrauma surgeon, burn unit director, Mercy St John’s Health Center, Springfield, Missouri

Kathleen F. Miller, RN, MSHA, CNORSenior clinical consultant, Catholic HealthInitiatives, Denver

Susan Nielsen, RN, MSA, CNORDirector, Central Processing Department, William Beaumont Hospital, Royal Oak, Michigan

Cynthia Taylor, RN, BSN, MSA, CGRNNurse manager, Endoscopy & BronchoscopyUnits, Hunter Holmes McGuire VA MedicalCenter, Richmond, Virginia

Dawn L. Tenney, RN, MSNAssociate chief nurse, perioperative services,Massachusetts General Hospital, Boston

Judith A. Townsley, RN, MSN, CPANDirector of clinical operations, perioperative services, Christiana Care Health System, Newark, Delaware

Ena M. Williams, RN, MSM, MBANursing director, perioperative services, Yale-NewHaven Hospital, New Haven, Connecticut

Advisory Board

Infection control

Continued from page 1Six types of infectionin compendium

The 6 types of health care-associat-ed infection covered are:• methicillin-resistant Staphylococcus

aureus (MRSA)• Clostridium difficile infection• central line-associated bloodstream

infection• ventilator-associated pneumonia• catheter-associated urinary tract

infection• surgical site infection (SSI).

Two categories ofrecommendations

Each type of infection has 2 cate-gories of recommendations:• minimum basic practices that

should be adopted by all acute carehospitals

• special approaches for use in hospi-tal locations and/or populationswhen infections are not controlledusing basic practices.

6

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The Joint Commission’s new Leader-ship Standards, effective Jan 1, 2009,call for a code of conduct and a

process for addressing disruptive behav-ior. In a Sentinel Event Alert in July, thecommission made its case for why badbehavior is a safety threat and outlined 11recommendations for addressing it. Thestandards and alert are at www.jointcom-mission.org.

The underlying theme is patient safety.The alert cites literature linking bad behav-ior to treatment errors, poor patient satis-faction, higher costs, and staff turnover.

A nurse and risk management expert,

Grena Porto, RN, MS, ARM, CPHRM,advocated for the alert as a member of theJoint Commission’s Sentinel EventAdvisory Group.

Porto says the watershed moment forher came when she was consulting at aclient site and was able to trace a patientinjury directly to a nurse’s disruptivebehavior.

“No one can tell me this is not a patientsafety problem,’” says Porto. “I made itmy cause because I saw so much of thisbehavior. Plus, it has great impact onrecruitment and retention.” Porto has beenpresident of the American Society forHealthcare Risk Management and a boardmember of the National Patient SafetyFoundation. She is a principal in QRSHealthcare Consulting, Hockessin, Dela-ware.

Porto talked with OR Manager aboutthe alert and what managers can do toaddress bad behavior.

Disruptive behavior has been aproblem for years. Why did theJoint Commission decide to issuean alert?

Porto: It’s not possible to have a cultureof teamwork and safety when some physi-cians and nurses are engaging in destruc-tive behavior, intimidation and, in somecases, even violent behavior.

In my consulting, when I’ve talked tostaff about the principles of teamwork,some would look at me and say, “Yeah,well, that guy throws knives at me in theOR,” or “That one won’t talk to me when Iask her questions about a patient.” So it

was pretty apparent that this issue was amajor barrier to some of the changes wewere trying to achieve in health care.

This alert was the result of a long-termdialog by the Sentinel Event AdvisoryGroup. When we looked at the literatureand compared notes, it was apparent theissue needed attention. Research showsthe problem is widespread and not limitedto 1 group, though there is some researchto support what most of us have suspect-ed—this is worse in the OR than any-where else. There is 1 study I’m aware ofthat illustrates that (Rosenstein A H,O’Daniel M. J Am Coll Surg. 2006;203:96-105). Studies of disruptive behavior innursing go back at least to 1987.

For a code of conduct, is there amodel you think is mosteffective?

Porto: In my experience, these are thecritical components:• A code of conduct cannot be just aspi-

rational. It cannot just say, “We are allgoing to treat each other with respect.”That does not provide guidance, partic-ularly in a high-stress environment.You need to know what behavior is OKand what is not. Get away from aspira-tional language, and get into specificwording. Give examples of the behav-ior you want as well as what won’t betolerated.

• The code must be universal. It mustapply to everyone. You want to holdeveryone to the same standard,whether they are physicians, nurses,patients, visitors, subcontractors, orothers.

• The code has to be framed in terms ofthe safe delivery of patient care andsafe operation of the organization. Thecode is not just about saying “please”

and “thank you.” It is about promotingan environment where patients can besafely cared for. Here is an example: A physician is

making rounds on a unit and discoversthat heparin ordered 3 days ago was neverstarted. You would expect the physician tobe angry—that’s normal human behavior.The physician might say assertively, “Iordered this 3 days ago. Why wasn’t itdone?” That is not disruptive behavior.Contrast with a physician who says, “Youare a bunch of incompetent idiots. If itwasn’t for me coming in to check, mypatients would be dead.” That is disrup-tive—you are undermining the confidenceof people to take care of patients.

You have to look at the behavior incontext and consider whether the behaviorwould interfere with patient care or wouldupset someone so much that the personwould lose confidence and feel incompe-tent to care for a patient.

A lot of people who berate the staff tellyou they are just advocating for theirpatients. They fail to consider that if youtreat a person like that, the person won’tbe able to take care of the next patient.That doesn’t mean you can’t be annoyed ifsomething wasn’t done properly. But youhave to draw the line at being so abusivethat the other person is paralyzed by fear.

Does this mean managers aregoing to have to spend a lot oftheir time managing behavior?

Porto: I anticipate a lot of nurse man-agers, already burdened, don’t want tobecome the manners police. But I don’tthink that’s what this is about. It’s aboutraising awareness that it is not OK to berude; it is not OK to be abusive. Some peo-ple will take notice, and that will be all ittakes. Others will need more action thanthat.

This shouldn’t always be the manag-er’s responsibility. If I am a staff member,and a physician speaks to me in a mannerI consider offensive, I should be armedwith the tools to be able to say to thatphysician, “I understand you were upset.But I didn’t like the way you spoke to me.You did it in front of a patient. I wouldappreciate it if that did not happen again.”

Not every nurse, particularly a newnurse or a nurse from a different culture,

Joint Commission

What’s needed to address bad behavior?

Continued on page 8


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“The code must apply to

everyone.

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may be equipped to do that, and the man-ager may have to step in. I think part ofthis is to provide skills to a broad group ofpeople and not to assume the nurse man-ager is going to be enforcing the code ofconduct.

This speaks to the need foreducation and training.

Porto: Exactly. I think there is a need foreducation anyway because people don’tknow how to resolve conflict. Somebehavior affects patients, even if it isn’trude. For example, a nurse says, “I don’tthink this dose is correct.” The physicianinsists, “It is correct.” Then the nurse says,“Well, I’m not giving it—you give it.”That’s not rude per se, but it is also not safepatient care. That speaks to the need fortraining in conflict resolution, aside fromthe code of conduct.

What is needed to make sure thecode of conduct applies toeveryone, even the mostpowerful physician?

Porto: The Sentinel Event AdvisoryGroup spent a lot of time talking aboutthat. Just about every organization willsay, “There is a surgeon who brings a tonof business to this hospital. No one wantsto upset him, because he will take his busi-ness elsewhere.”

That is a failure of leadership. That iswhy the Joint Commission embedded thisrequirement in the Leadership Standards.

Will the requirement help? I don’tknow. I have to think so because the sur-veyors are going to be asking the OR staff,“Do you have this issue? What happens ifyou report it?”

If they say, “Nothing happens,” andthe organization can’t prove this is gettingaddressed, the organization is going to beconsidered noncompliant. The JointCommission is not going to allow CEOs tolook the other way.

The wording of the code of conduct isimportant. But that’s not where the powerof this initiative comes from—it comesfrom the Leadership Standard.

When a physician says, “I will takemy business down the road,” considerthis. First, for a physician to change hos-pitals is not easy, particularly if the per-son is high volume. Plus, if the otherorganization has the same standards, it isan empty threat. My response would be,

“If they are accredited, they have to dothis, too.”

Doesn’t the hospital have toworry about a lawsuit if it takesaction against a physician?

Porto: Yes, but if a hospital follows itsbylaws, there is no legal claim. A hospitalcan’t arbitrarily lift someone’s privileges.There is a process, and if the hospital fol-lows the process, it’s fine. That is not to saya physician won’t sue, but they won’t win.When I hear the argument from executivesabout lawsuits, I want to say, “Here is anissue that is putting your patients in dan-ger. And you are worried about gettingsued by the doctor? You should be wor-ried about getting sued by the patient!”

One thing I want to mention—I thinknurse managers and nurse leaders own apiece of this problem. In every organiza-tion I go into where I see disruptive physi-cian behavior, especially in the OR, I say tothe staff, “What do you do about it?” Theysay, “We report it to the director.” When Igo to the director, she or he says, “My jobis to calm everyone down. Pretty soon itall blows over.” I ask, “You don’t pursue itany further?” And the director says, “No.”That to me is enabling the behavior.

I find this a lot with nurse managers—they are focusing on maintaining the sta-tus quo. They don’t want to upset any-body. That is not dealing with the prob-lem.

But managers may not feel theywill be supported if they reportbad behavior, particularly by apowerful physician.

Porto: I know people are intimidated,and lack of leadership has been a barrier.But many times I have sat down withCEOs, and they say, “No one ever toldme.” Then I go back to the chief nurse andother administrators, and I find it is true—they try to contain it and say, “Oh, no. Wecould never report that.” Why not?

I am amazed by how often administra-tors try to deny and ignore the problemand insist they can’t take it on. To me, it isno different than saying, “We don’t giveantibiotics here. It’s just too expensive.”

As a nurse manager, you have to pushthe envelope. You have to say, “This is asafety issue. I am not putting up withthis.” v

ReferencesBad behavior in OR threatens patient safety,

stresses teams. OR Manager. 2006;22(10):1,19, 21, 25.

Conduct codes address OR behavior. ORManager. 2006;22(10):23-24, 25.

Porto G, Lauve R. Disruptive clinicianbehavior: A persistent threat to patientsafety. Patient Saf Qual Healthcare. July-August 2006.www.psqh.com/2006archives.html.

Rosenstein A H, O’Daniel M. Impact andimplication of behavior in the periopera-tive arena. J Am Coll Surg. 2006;203:96-105.

Rosenstein A H, O’Daniel M. Disruptivebehavior and clinical outcomes:Perceptions of nurses and physicians. AmJ Nurs. 2005;105:54-64.

Rosenstein A H, O’Daniel M. Managing dis-ruptive physician behavior. Impact onstaff relationships and patient care.Neurology. 2008;70:1564-1570.

Rosenstein A H, O’Daniel M. A survey of theimpact of disruptive behaviors and com-munication defects on patient safety. JtComm J Qual Patient Saf. 2008;34:464-471.

8 OR Manager Vol 24, No 11 November 2008

Joint Commission

Continued from page 7Disruptive behaviorin periop areaHow often does disruptivebehavior occur?How often others observedisruptive behavior in thesedisciplines:

Daily WeeklyAttending surgeons 15% 22%Anesthesiologists 7% 12%RNs 7% 21%

What is the impact ofdisruptive behavior?Participants in the study who were aware of a specific adverse event resulting from disruptivebehavior 19%

Source: Rosenstein A H, O'Daniel M.J Am Coll Surg. 2006;203:96-105.

Q

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Patients can be the eyes and ears fordetecting physician behavior thatposes a risk to patient safety, a

Vanderbilt group has learned. Over 10 to 15 years, Vanderbilt has

developed a model for addressing inap-propriate behavior that relies on unso-licited patient complaints as an earlywarning system for at-risk behavior andoutlines interventions.

Often, these physicians don’t realizetheir behavior is a problem. If no oneintervenes early, it can become a pattern,says Gerald Hickson, MD, associate deanfor clinical affairs and director ofVanderbilt’s Center for Patient andProfessional Advocacy, which provideseducation and consulting on the model.

Intimidating and disruptive behavioris often noticed by patients and families,and they may take their concerns to thehospital administration.

A handful of physiciansIn a study analyzing thousands of

patient complaints at Vanderbilt, DrHickson and his colleagues discovered ahandful of physicians—8%—who had themost patient complaints also accountedfor more than 40% of the hospital’s mal-practice claims and 50% of related costs.

That discovery became the basis forthe Vanderbilt model, now used in atleast 34 organizations across the country.

“I think increasingly, people understandthe value of addressing this behavior earlybut fairly,” Dr Hickson told OR Manager.

The model has these major elements:• a surveillance system called PARS

(Patient Advocates Reporting System),guided by a physician committee,which tracks and categorizes patientcomplaints to identify behavior pat-terns of at-risk physicians

• a model with 4 levels of interventionsfor identifying and addressing dis-ruptive behavior (sidebar)

• physicians trained to intervene withpeers.

“Cup of coffee” conversationThe first-level intervention, called a

“cup of coffee” conversation, is for a singleincident of unprofessional behavior, which

happens in 20%to 25% of med-ical profession-als, Dr Hicksonnotes. The inci-dent may beisolated or thefirst in a pat-tern. All clini-cians should betrained and em-powered to ad-dress these in-dividual inci-dents, he says.

A “cup ofcoffee” conver-sation is aninformal talkwhere a trainedpeer sits downwith the physi-cian to discuss the behavior, ask for thephysician’s point of view, and state behaviorexpectations. The key is to intervene early,because if no one intervenes, the behaviorcan become a pattern.

There are exceptions—claims of dis-crimination, allegations of sexual bound-ary violations, substance abuse, or otherimpairments affecting ability to practicesafely immediately go to a higher level ofintervention.

Going to a higher levelA much smaller group of physicians,

about 2% to 3%, have a pattern of disrup-tive behavior that is a threat to quality andsafety and needs to be addressed at a high-er level on the pyramid, Dr Hickson notes.

These interventions require improve-ment and evaluation plans with account-ability by the physician.

Finally, if there is no change in behav-ior despite these interventions, the top-level intervention entails disciplinaryaction, including restriction or termina-tion of privileges.

Dr Hickson says the Vanderbilt centerhas used the model to oversee 1,000-plusphysician interventions.

“We believe this behavior canrespond to an organized approach, butthe organization’s leadership has to bewilling to respond,” he says. Leadershave to be willing not to blink whenfaced with bad behavior by a powerful

physician. Some back away when theyrealize what’s necessary, he says.

Some physicians objectSome physicians criticized the Joint

Commission’s alert on disruptive behav-ior, saying a code of conduct could beused to remove physicians who disagreewith the administration or aren’t seen as“team players.”

“I think there are legitimate concerns,”Dr Hickson acknowledges. “But why isthe Joint Commission saying medicineneeds to do something about this? Part ofit may be a failure by physicians at thelocal level to address these issues.”

Vanderbilt is careful to take its processinto organizations where the medicalstaff will own it, he notes.

“These processes need to be driven bythe medical profession. Members of theprofession need to take steps to addressinappropriate behavior, whether it’scussing, throwing things, being chroni-cally late, or not answering calls.”

If it’s true, as some physicians charge,that tools like a code of conduct can bemisused, “then shouldn’t we as a profes-sion be out in front in making sure thesetools are used properly?” he asks. v

Information on Vanderbilt’s Center forPatient and Professional Advocacy is at www.mc.vanderbilt.edu/centers/cppa.


Spot at-risk behavior, intervene earlyJoint Commission

Source: Vanderbilt University Center for Patient and Professional Advocacy.Special focus: Codes of conduct

Disruptive behavior pyramid No

changesLevel 3:

Disciplinary intervention

The vast majority of doctors: No lapses in behavior. Many are

models of professionalism.

Pattern PersistsLevel 2: Authority

intervention

Apparent patternLevel 1: Awareness intervention

Single “unprofessional incident”Informal “coffee cup” intervention

When an orthopedic surgeonthrew a pair of scissors in theOR last summer at North

Shore Medical Center’s Salem Hospital, apolicy was in place to address the incident.

Introducing a “civility and respect”policy was one of the first things MarcRubin, MD, did when becoming chief ofsurgery in 2005.

The policy was invoked to address thescissors incident. The surgeon was disci-plined, and there have been no incidentswith this surgeon since, Dr Rubin said.

The policy, in streamlined form, has nowbeen adopted by the entire medical center, atrauma facility based in Salem, Mas-sachusetts, with 2 campuses and 23 ORs.

“The policy is part of my personal phi-losophy about what is important in theworkplace. Non-negotiable mutual respectis something I think is essential,” Dr Rubintold OR Manager.

The policy defines the conduct expect-ed (sidebar) and outlines a 2-level processfor addressing disruptive behavior.

Level 1Level 1 of the process focuses on de-

escalating the conflict.“The first level is to put the people

involved in a room together, try to get thefacts, and encourage them to understandeach other’s point of view and understandbetter what happened,” Dr Rubin says.

“The vast majority of these incidentscan be handled in the department and de-escalated.”

The Level 1 goal is for the parties tounderstand that certain behaviors are unac-ceptable and to part holding no grudges.

“People can see the effects of theiruncivil behavior, why it is unacceptable,what it does to their peers, and how itmakes our OR less safe for our patientsand less of a good place to work,” he says.

If an informal discussion does notresolve the situation, a more formalmeeting is held, still at Level 1, attendedby the people involved and their imme-diate superiors. The person filing thecomplaint must submit a written accountof the incident, and the policy specifies atimeframe for investigating and address-ing the complaint.

Level 2Conflicts that can’t be resolved at Level

1 go to Level 2. For physicians, the com-plaint goes to the Physician ProfessionalConduct Committee. For nurses and otheremployees, complaints are handled underthe human resources policy.

Egregious incidents such as physicalabuse go straight to Level 2—”there is nodiscussion,” Dr Rubin says. If an offense isthe third such incident by a physician, italso goes directly to the conduct committee.

The conduct committee reports its find-ings to the Medical Executive Committee,which follows the medical staff bylaws indeciding what action to take.

Creating a culture of safetyThe civility and respect policy is part of

an agenda to develop a culture of safetyand quality for perioperative services.

“It’s all about communicating betterwith one another and putting layers ofsafeguards in place,” Dr Rubin says.“Basically, your coworker has your backall of the time.”

Like many health care leaders, he istaking a cue from aviation. Cockpit crewshave taken a number of steps since the1970s that have made crashes rare. Thepremise is that many errors result fromfailures in communication and teamwork.The airlines now teach crew resource man-agement (CRM) to build in situationalawareness, communication, and team-work across disciplines.

Dr Rubin learned about CRM from hisown reading and a session given by pilotsat the American College of Surgeons con-ference.

“It’s about including everyone, ensur-ing the plan is clear, and making everyoneunderstand it’s OK to speak up if some-thing goes wrong,” he explains.

“After each case, we hold a debriefingwhere we discuss what went well, whatdidn’t go well, and what we can do betternext time. Then we take those suggestionsand find ways to make improvements, sowe have a continuous quality improve-ment environment.”

Dr Rubin first sold the idea of team-work training to the surgical divisionchiefs. He then got the administration’sapproval to close the ORs for 2 half daysfor the training and make attendancemandatory. Most of the staff except for an

emergency crew attended, as did about 60surgeons. The ORs are now introducingbriefings and debriefings.

Asked how the heightened focus oncivility has been received, Dr Rubin says,“It’s a work in progress. Cultural shiftslike this take time. People are respondingas people normally do. The early adoptersimmediately embraced the change. A mid-dle group took more of a wait-and-seeapproach. A few are waiting for the lastminute to change behavior. But we’ll getthere. I’m very encouraged.” v


A ‘civility and respect’ policy for surgery

Joint Commission

Disruptive behaviordefined

The definition from the North ShoreMedical Center (NMSC) Medical StaffPolicy:

Civility and respect“Personal conduct, whether verbal

physical, or written, that negativelyaffects individuals or that potentiallymay negatively affect patient care consti-tutes disruptive behavior (AMACode ofMedical Ethics, E-9.045). This includes,but is not limited to, conduct that inter-feres with one’s ability to work withother NSMC staff and/or physicians.

“Disruptive behavior may include,but is not limited to, behaviors such as:• Verbal abuse (including demeaning

or disrespectful comments, particu-larly in front of other staff oremployees)

• Inappropriate, loud, or obscene ver-balization and/or physical behavior

• Physical behavior including misuseof medical or surgical instruments orequipment

• Inappropriate or unprofessionalphysical contact or gestures

• Offensive comments based upon anindividual’s gender, race, ethnicity,religion, disability, or sexual orienta-tion.

“Unless constituting disruptivebehavior, constructive criticism isacceptable as long as it is offered ingood faith with the aim of improvingperformance, service, and/or patientcare and, in most cases, should first bedirected to the appropriate manager.”


Shared governance (SG) has become ahallmark on the journey to achieveMagnet status by demonstrating

exemplary professional practice. SG is anintegral part of Magnet hospitals, whichachieve this status through the MagnetRecognition Program. The AmericanNurses Credentialing Center developedthe program to recognize organizations fornursing excellence.

Setting up an SG structure is only halfthe challenge. The other half is maintain-ing it once Magnet status has beenachieved and celebrated. To borrow aphrase from real estate, the most impor-tant factor is commitment, commitment,commitment.

“We’ve had shared governance a longtime, but we still have to work to keep italive,” says Lydia Forsythe, RN, PhD,MA, MSN, CNOR, director of surgicalservices and orthopedic service line forOSF Saint Anthony Medical Center inRockford, Illinois. She chairs the man-agement council and represents thedirectors’ group on the Magnet hospital’snurse practice council. “Administrationneeds to commit financially, and leader-ship needs to commit to being presentand supportive.”

Shared, not self-governance“If managers are new to shared gover-

nance or management, they get the sensethat it’s only about the staff. But it’s a col-laboration between staff and leadership,”says Forsythe.

As Peggy Guastella, RN, MS, says, “It’snot self-governance; it’s shared gover-nance.”

Guastella, who is director of surgicaland ambulatory services at AdvocateGood Samaritan Hospital in DownersGrove, Illinois, says SG has been part ofthe OR for 15 years. She acknowledges ittakes a significant time commitment bymanagers.

“I expect managers to coach and men-tor people working on shared governancecommittees. Staff don’t always have thefacilitation or team skills to work throughother people to achieve an outcome,” saysGuastella.

Another area of support is time forstaff to attend meetings and work onprojects, says Forsythe. At OSF SaintAnthony, managers attend unit-based

council meetings so they know how theycan support staff projects. The staff chairruns the meeting.

Managers at all levels need to line upbehind the program, says Robert Hess,RN, PhD, a leading expert on SG and thefounder of the Forum for Shared Gov-ernance (www.sharedgovernance.org).“Unit managers are coaches, educators,and facilitators. Directors have all 3 roles,plus the important task of marketing theprogram to the rest of the organization’scommunities.” Both the CNO and theCEO must also support the program.

Strategy and structureHess recommends having a strategic

plan for SG, including goals and how toachieve them.

“You have to have realistic goals forimplementation. One shared governancemodel does not fit all,” he says. SG may beimplemented differently in a union envi-ronment, and an evolving body of litera-ture shows that SG in the VA medical sys-tem differs from other hospitals because ofcentrally determined personnel policiesand purchasing practices.

Most hospitals, including the SetonHealthcare Network in Texas, use theCouncilor Model to structure SG. VickiBatson, RN, MSN, CNOR, NEA-BC, a staffnurse in the OR at Seton Medical CenterAustin, has seen 2 views of SG—she was adirector of surgical services until shereturned to school for her doctorate.

Batson says the surgery specialty coun-cil comprises the OR, postanesthesia careunit, cardiac interventional laboratory,endoscopy, and specialty clinics. Sub-councils include those for clinical ladder;education; policy and procedure, whichBatson chairs; and process improve-


Leadership

Tips for keeping up momentum

Robert Hess, RN, PhD, and othersinterviewed provide tips for makingsure shared governance stays embed-ded within the organization.• Have a strategic plan with goals

and means to achieve them. Keepyour goals realistic.

• Expect a steep learning curve andongoing education. Both staff andmanagers need ongoing educa-tion. For example, staff needs helpin learning how to delegate, andmanagers and staff need to learnhow to share authority. Don’t for-get to educate everyone on whatSG means to professional practicefor the individual and the organi-zation.

• Don’t hesitate to fine-tune theprocess. Christiana Care adjustedhow committee members wereselected and how committeeswere organized, based on feed-back from staff and managers.

• Provide challenges to help staffand managers grow. At OSF SaintAnthony, Forsythe helped staffdevelop a narrative researchstudy to dig deeper into the issueof nurse satisfaction. She is alsousing appreciative inquiry to helpstaff and managers develop the“next steps” of SG.

• Document effectiveness. Collectdata so you can justify the organi-zation’s continued investment inSG.

• Make successes visible. Peopleneed time to celebrate—or at leastacknowledge—their accomplish-ments. At Seton, accomplishmentsare reported in unit-based andsystem newsletters.

• Keep the heroes moving. Bringfresh members into committeesand let the experienced membersguide them.

• Remember that shared gover-nance is a journey, not a destina-tion. Be in it for the long term.

Continued on page 12

“

“We made participation

an honor.

How to keep shared governance alive

ment/patient safety. The council includesrepresentation from all 7 hospitals.

The councilor structure can becomecomplex, so an overall coordinator isessential. In perioperative services atChristiana Care Health System, Newark,Delaware, that person is Mary CayCurran, MSN, CAPA, manager for clinicalstandards. Curran attends the monthlycouncil meetings as an advisor and servesas the link to Judith Townsley, RN, MSN,CPAN, director of clinical operations, peri-operative services.

“Mary Cay lets me know when I mightneed to intervene from a director’s per-spective,” Townsley says, such as the needto work with a manager who is not sup-porting the staff’s time away from theunit.

Some hospitals make participation incouncils mandatory, such as Bay Pines VAHealthcare System, Florida. JackieDitchcreek, RN, BSN, CNOR, nurse man-ager for the OR, says all staff, includingsurgical technologists, must select 1 of 4committees to serve on; membership isrotated annually.

An honor to participateAfter attempting a mandatory system,

Christiana Care, which has a total of 51ORs at 4 operative sites, switched to vol-untary membership, partly in response tofeedback from staff and managers. Theyfelt committees had become unwieldy dueto the number of members, and somemembers were not invested in the com-mittees’ work.

“We made participation an honor,”says Curran, who adds that council size islimited, and staff has to apply for a spot.“Now the people on the council want tobe on the council. They are looking forways to make perioperative services bet-ter.” Curran and Townsley believe that asstaff see how councils make a difference intheir daily work life, more will want toparticipate.

They may end up with a “good” prob-lem like the one Advocate Good Samar-itan has—a plethora of volunteers. Staffended up voting for members to fill com-mittee slots.

Guastella adds an important pointrelated to staff participation: “We tell staff,‘You don’t have to participate, but you arerequired to support the decisions yourpeers make.’”

Time and moneyHospitals typically pay for staff to

attend committee meetings, which canaverage from 2 to 4 hours a month. Curransays a single block of 4 hours works betterthan 1 hour per week because staff hastime to get the work done. Council chairsreceive 12 hours per month so they canfulfill their additional responsibilities.

Curran emphasizes the need for strongclerical support. “There’s nothing worsethan chairs spending 2 hours trying totype minutes from a meeting because theydon’t know how to use Word.”

Payment for project work varies.Guastella estimates staff is reimbursed forabout half of project time, adding that thework is part of the staff’s professionalcommitment.

Time is money, and budgets are tight.So how can managers justify SG to theircolleagues in finance? New regulationsand greater transparency related to pay forperformance provide the method—im-proved patient outcomes. For example,the surgical services council at Advocatedeveloped a process that significantlyreduced use of flash sterilization.

“When I think of the cost of 1 surgicalsite infection, it’s easy to justify the moneyfor shared governance,” says Guastella.

Hess acknowledges, “Shared gover-nance can be budget neutral because everyhospital uses committees to get institution-al and professional practice work done.Shared governance committees justreplace the traditional committees, usingthe same resources.”

He also points to research that showswhen nurses’ perception of their participa-tion in governance increases, they feelmore empowered, have greater job satis-faction, and better retention.

The right people on the busSustainability depends on getting the

right nurses and managers on the SG bus.

The good news is that the OR staff iswell suited to SG, according to Ditchcreek:“In the OR you need to be the patients’advocate, and shared governance goeshand in hand with that.”

Batson says during orientation, newnurses observe a surgery council and anursing congress (the top governing coun-cil) meeting. “This gives them an idea ofhow shared governance is done.”

Guastella looks for managers withexperience in SG but is open to hiringthose who don’t—as long as they can meetexpectations.

“If they don’t have the experience, weuse behaviorally based questions and peerinterviews to identify those who are likelyto succeed in our setting,” she says. “Ittakes a different kind of thinking. You haveto be a good delegator and facilitator.”

Batson advises watching for loss ofenergy and momentum by staff. “It’s theresponsibility of leadership to help councilmembers figure out—not to do it forthem—what the problem is so we can getback on track,” she says.

Keeping nurses onboard requires man-agers to be aware of current issues in SG.

“An emerging issue is that shared gov-ernance seems to function differently in anenvironment that’s ethnically weightedwith certain groups, such as Asians, whomay be socialized to participate at a lesserlevel and may be more deferential toauthority,” says Hess. “Resocialization hasto take place to allow shared governance totake hold.”

Managers can take a leading role in reso-cializing by openly dealing with these issueswith staff and maintaining a dialogue aboutthe importance of participation.

Dedication and honorSG isn’t always easy, but the rewards

are great. “I’ve worked in shared gover-nance for the last 20 years,” says Guastella.“It’s all about dedication and honoringpeople for where they are. We in manage-ment need to realize that the closer you areto where the patient is, that’s where thebest decisions are made. It’s a win-win fornurses and managers—and patients.”v

—Cynthia Saver, RN, MS

Cynthia Saver is a freelance writer inColumbia, Maryland.


Leadership

Continued from page 11

“

“The rewards are

great.

For the first time in the US, surgeonsat New York-Presbyterian Hospital/Columbia University Medical Cen-

ter in July removed a woman’s gallblad-der without any external incisions. Usingthe technique called NOTES (natural-ori-fice transluminal endoscopic surgery), ateam of surgeons led by Marc Bessler,MD, inserted a flexible endoscope intothe woman’s abdomen through a 1-inchincision behind her uterus and removedher gallbladder.

The 3-hour outpatient procedure waspart of an ongoing clinical research trialat the hospital. The surgeons performedthe same procedure in April 2007 using aflexible endoscope, aided by severalexternal incisions for added instrumenta-tion. (See July 2007 OR Manager.)

NOTES refers to intra-abdominalsurgery through the wall of an abdominalorgan. Abdominal surgery through a nat-ural orifice is the culmination of minimallyinvasive surgery’s progression to smallerand fewer incisions, says Dr Bessler, direc-tor of laparoscopic surgery and director ofthe Center for Obesity Surgery at NewYork-Presbyterian Hospital/ColumbiaUniversity Medical Center and assistantprofessor of surgery at ColumbiaUniversity College of Physicians andSurgeons in New York City.

What’s new?For the most recent procedure, the

team used the same long flexible endo-scope as for the 2007 procedure, DrBessler told OR Manager. The scope issimilar to a gastroscope with 2 channelsfor instrument insertion. As with laparo-scopic surgery, the abdomen wasexpanded by insufflation with carbondioxide gas.

New for this procedure was a semi-rigid articulating instrument (RealHand,Novare) to hold up on the gallbladderthat was inserted alongside the scope viaa second small incision.

The team used the same techniquesfor dissection and cutting through theflexible scope as they did last year, butthis year they also used clips through thescope instead of through a trocar port inthe abdomen.

Also, this time they did not use anabdominal port for visualization as theyentered the abdomen through the vagina.

Instead, they used direct vision throughthe vagina to make the incision into thepelvic floor and watched as they made theincision going forward rather than watch-ing it from the inside coming in.

“As we became more comfortablewith our technique, we started to removeabdominal ports, eventually getting tonone,” Dr Bessler says.

What’s coming?Companies are working on new

instruments and scopes with 3-dimen-sional views for the NOTES procedure.

The instruments and flexible endoscopeused today will not be the same in a fewyears, says Dr Bessler.

Flexible endoscopes were developedfor use in the stomach, not the sterileabdomen, and there have been someproblems with reprocessing thembetween cases in the past, he says. Forthis reason, his team gas-sterilizes theflexible endoscope. As more of thesecases are performed, hospitals will needmore than 1 scope to allow time for aera-tion after gas sterilization.


Cholecystectomy with no external incisions

Innovations in surgery

The transvaginal route for theNOTES cholecystectomy.


“Right now, we’re doing 1 case amonth, so 1 scope is enough,” he says.

Some 300 NOTES procedures havebeen performed worldwide. In the US, 4centers are now performing NOTES pro-cedures, and many more are preparing todo them, says Dr Bessler.

“The technology is rudimentary rightnow, and the data doesn’t yet exist tosupport this procedure as beneficial,” hesays. “It’s going to take us a couple ofyears to generate the data, and if the datais positive, it’s going to take a couple ofyears to train other physicians. I thinkwe’re looking at 3 to 5 years before thisbecomes routine.”

In April 2008, NOTES was discussedat a University of Minnesota conferenceon the design of medical devices, accord-ing to St Paul’s Pioneer Press. BostonScientific’s endoscopy business and aunit of New Jersey-based Johnson &Johnson are among companies workingwith a nonprofit group coordinatingresearch to produce new instruments forNOTES.

NOTES not just for womenThe NOTES procedures are not just

for women, says Dr Bessler. Three cen-

ters in the US are offering the transgastricapproach to men as well.

Dr Bessler presently is only doing thetransvaginal approach because surgerythrough the vagina does not pose agreater infection risk than a procedurethrough the abdominal wall. Both can beprepped with povidone-iodine or otherprep solutions.

He and other researchers are develop-ing ways to prep the stomach, thoughthe stomach is already relatively sterilebecause of the acids.

In general, the problem isn’t in open-ing the stomach, it is in the closure, hesays. If the stomach incision doesn’t healand continuously leaks nonsterile oracidic contents into the peritoneal cavity,it can become a significant problem. DrBessler noted that leaks in the stomachincision have occurred in patients inSouth America.

“I figure that while we’re waiting toprove the benefit of this procedure, weshouldn’t take any more risks than weneed to. Therefore, going vaginallymakes the most sense,” he says.

“If patients are hurt early on withoutknowing there’s a benefit because theirstomachs don’t heal well, then I thinkthis could hurt the field. But if things gowell in the stomach, we’ll be ahead of the

game, knowing the procedure is benefi-cial for patients both transvaginally andtransgastrically,” he says. “It’s experi-mental right now, so it’s hard to knowwhat the right answer is.”

In addition to gallbladder surgery, theNew York-Presbyterian/Columbia clini-cal trial offers the transvaginal NOTESprocedure for appendectomy, abdominalexploration, and biopsy.

Dr Bessler is recruiting patients forthe clinical trial. Those interested maycontact his office at 212/305-9506. v

—Judith M. Mathias, RN, MA

ReferencesBessler M. Transvaginal cholecystectomy,

laparoscopically assisted, for gall-stones, a human case. Presentation atthe Society of American Gastrointesti-nal Endoscopic Surgery, Las Vegas,April 2007.

Marescaux J, Dallemagne B, Perretta S, etal. Surgery without scars: Report oftransluminal cholecystectomy in ahuman being. Arch Surg. September2007;142:823-826.

Ramos A C, Murakami A, Galvao N M, etal. NOTES transvaginal video-assistedcholecystectomy: First series.Endoscopy. July 2008;40:572-575.


Innovations in surgery

Undisciplined use of cell phones andother such devices in the OR maypose a distraction and compromise

patient care, the American College ofSurgeons (ACS) says in a new statement.

ACS suggests use of cellular devices inthe OR be guided by the following: • Surgeons should be considerate of the

duties of OR personnel and refrainfrom engaging them in unnecessaryactivities, such as assisting with cellularcommunication, that might divertattention from the patient or procedure.

• Cell phones must not interfere withpatient monitoring devices or otherpatient care technology.

• Whenever possible, the OR team, includ-ing the operating surgeon, should onlyengage in urgent or emergent outsidecommunication during surgery. Personaland routine calls should be minimized.Calls should be as brief as possible.

• Whenever possible, incoming calls

should be forwarded to the OR desk orhardwired OR telephone to minimizedistraction.

• Whenever possible, cell phone calls anddata transmissions should be forward-ed to voice mail or memory. The ringtone should be silenced. An inaudiblesignal may be used.

• Whenever possible, a signal such as apage should be enabled for urgent oremergent calls.

• Use of cellular devices or accessories(such as earphones or keyboards) mustnot compromise the sterile field. Specialcare should be taken to avoid sensitivecommunication within the hearing ofawake or sedated patients.

• Use of hardwired OR phones is subjectto the same discipline as use of cellulartechnology.

• Use of cellular devices to take andtransmit photographs should be gov-erned by the hospital policy on photog-raphy of patients and government reg-ulations on patient privacy and confi-dentiality. v

The statement (ST-59) was developed by theACS Committee on Perioperative Care andapproved by the Board of Regents in June 2008.The statement appears in the September 2008Bulletin of the American College ofSurgeons.www.facs.org.


Limit cell phone use in OR, surgeons advise

“

“Calls can be a

distraction.

In 2001, the ORs at Banner BaywoodMedical Center were struggling—physicians were dissatisfied, case vol-

ume was down, and 13 staff positionswere vacant.

“There was a general lack of urgency.There just was no culture of efficiency,”says Christine Halowell, RN, MS-HSA,CNOR, director of perioperative servicesfor the Mesa, Arizona, hospital.

Seven years later, things are lookingup. Surgical case volumes have risenfrom under 8,000 a year to close to10,000. Gross revenue is up by 62%. Staffretention rose to 94% in 2007, up from90% in 2004. The 10 ORs perform about10,000 cases a year, with about two-thirds of those in general surgery andorthopedics.

Banner Baywood’s ORs are now con-sidered to be among the most productivein Banner Health’s network of 20 hospi-tals. The improvement project wasdescribed in a poster abstract at the 2008AORN Congress in Anaheim, California.

When Halowell took her position 6years ago, she knew changes were need-ed. These are steps she and her teamtook to turn the culture around.

Talked to the physiciansSoon after she arrived, Halowell

began forming relationships with thephysicians and staff.

“I would ask, ‘How can we better

serve you and your patients?’” sherecalls. She found they were eager totalk. “I don’t know that anyone had everasked them before.”

Formed OR LogisticsCommittee

From the most vocal physicians, sheenlisted volunteers and formed the ORLogistics Committee.

“We are a multidisciplinary opera-tional team. We handle things theSurgery Committee doesn’t have timefor,” she explains. Members include 2surgeons, an anesthesiologist, an admin-istrator, Halowell, and staff from the pre-operative area, OR, postanesthesia careunit (PACU), and sterile processingdepartment (SPD).

Developed an issue listThe committee started by developing

a list of issues it wanted to tackle. “We looked at everything from

turnover times to late starts to block uti-lization,” she says. “We looked at howthe H&Ps (histories and physicals) weregetting on the charts.”

Early on, the committee was assistedby a management engineer in flow chart-ing some processes it wanted to improve.

“This was a tremendous help,”Halowell says. “It allowed us to have acritical eye for flaws and make improve-ments.”

The next step was to prioritize theproblems.

“We looked at what we could fiximmediately—the low-hanging fruit—and what needed medium-term andlong-term fixes,” Halowell says.

Started with the easy fixesOne of the easier fixes was improving

the preadmission testing (PAT) processand getting the H&Ps into the patients’charts before surgery.

The PAT staff and management teamstarted by inviting surgeons’ office per-sonnel to a hospital-sponsored “lunchand learn.” They requested that H&Ps befaxed to a specific number.

“Once the H&Ps arrived, they wereplaced on patients’ charts by PAT staff,and this issue was resolved,” she says.

About 90% of surgical patients areseen 3 to 7 days prior to surgery by nurs-es in the PAT department. The remainderreceives at least a phone call, which hasminimized cancellations on the day ofsurgery.

For H&Ps that are not on the chart bythe day of surgery, a short form wasdeveloped, which is placed on the chartwith the original H&P. This form satisfiesthe Joint Commission’s requirement todocument an update to the patient’s con-dition prior to surgery or within 24 hoursfor inpatients.


Turning around the culture of an OR Performance improvement

Anesthesia report

How do you stack up?0700 & 0730 case start times

Reporting cases between 4/1/2008 and 4/30/2008.Note: Each bar represents 1 physician. (Names have been removed.)

Source: Banner Baywood Medical Center, Department of Perioperative Services.


Min

utes

‘Kamikaze squad’ for turnover A more complex problem was tight-

ening up turnover time, which in 2001averaged 35 minutes from patient out topatient in for to-follow cases. A key stepwas defining and choreographing rolesof team members, including a new“kamikaze squad” of OR assistants andhousekeepers.

This is the way a turnover is conduct-ed now:• Circulating nurse. At the end of the

case, the circulator takes the patient tothe PACU, gives report, finishes thedocumentation, and goes to the preoparea to assess the next patient andbring the patient to the OR.

• Surgical technologist (ST). The ST,who is still gowned and gloved, tiesthe trash and linen bags, sets them inthe hallway, takes the used instru-ments to the SPD, and may take ashort break.

• Kamikaze squad. OR assistants havebeen taught how to check the prefer-ence lists and open sterile supplies.Before the previous case finishes, anOR assistant checks the preference listfor the next case, checks the case cartfor completeness, and places equip-ment for the next case outside the ORdoor. As soon as a case ends, a housekeeper

does the heavy cleaning while the ORassistant cleans the flat surfaces. The ORassistant then brings in the case cart,spreads the supplies, and begins openingthem. The ST joins in the setup and countswith the circulator. The circulator thenhelps the anesthesiologist bring the patientto the OR, and the case is ready to begin.

OR assistants part of teamWhen Halowell introduced the idea

of OR assistants opening sterile supplies,she got some pushback from the RNs.

“Then I had the nurses teach them sothey would feel comfortable,” she says.“Once they saw that the OR assistantslearned well, everybody was fine with it.”

It’s also a plus for OR assistants’ jobsatisfaction. “They feel more like part ofthe team. It promotes teamwork in theOR, and you have the right person doingthe right job,” she says.

Turnover time statistics are sharedwith the staff monthly. Initially, Halowell

says teams were recognized and reward-ed for short turnover times when no cor-ners were cut. Teams and individualsthat did not comply with turnoverexpectations were coached, and somewere disciplined for noncompliance.

“In this way, the staff realized we heldeveryone accountable to our standards,”she says. “Now good turnover times arepart of our culture.”

Turnover times for 2007 averaged 22.6minutes from patient out to patient in forto-follow cases, including total jointreplacements, which average about 25 to30 minutes between cases.

Improved on-time startsAnother major focus was improving

on-time starts for the first case of the day,which Halowell says was “really bad” at21% and affected the rest of the day’sschedule.

The first step was to define an on-time start. The OR Logistics Committeeconsulted the surgeons and decided todefine “start time” as the time the patiententers the OR. The committee decidedsurgeons and anesthesiologists would be

considered late if they had not seen thepatient at least 15 minutes before thescheduled start time.

In the beginning, a patient enteringthe OR even a minute past the scheduledtime was considered late. Now there is a5-minute grace period.

Preop nurses record when surgeonsand anesthesiologists arrive, and thetime is correlated with the time thepatient enters the OR. Data showed late-ness by physicians was the major issue.Staff lateness was not a problem,Halowell says.

Steps to improve on-time startsincluded:• Sending a reminder letter to all sur-

geons to heighten awareness. Thatstep alone brought on-time starts toabout 45%.

• Sending individual monthly “reportcards” to surgeons with their on-timerecords (illustration).

• Posting a list showing physicians’records for on-time arrival. At first,the report was posted without names.“Now we post it with names, with the


Performance improvement

Case late(average)

Surgeon late(average)

Smith

Deviation from schedule

Deviation from schedule for Dr Smith

Case late (average) -2.8 minutes(Negative numbers indicate minutes early)

Surgeon late (average) -34.4 minutes(Positive “surgeon late” numbers are irrelevant IF cases start on time!)

For these reporting purposes, physicians are considered “late” if they havenot seen their patient at least 15 minutes prior to scheduled start time.

Scheduled start time = Patient in the ORCase late = Deviation from schedule start time

Reporting on cases between 1/1/2008 and 3/31/2008

Source: Banner Baywood Medical Center.


blessing of the chairman of surgery,”Halowell says. These steps broughton-time starts to more than 60%.

• Putting teeth into on-time expecta-

tions. With the agreement of the chair-man of surgery and chair of the ORLogistics Committee, a policy wasimplemented stating that surgeonswho are consistently late cannotschedule cases until 9 am. “We did that for a couple of surgeons,

and that is all it took,” she says. Physician lateness is defined as the

patient in the room 4 or more minuteslate, averaged over 4 cases in a quarter.Physicians who exceed this criterionreceive a warning letter telling them their7 am and 7:30 am case-scheduling privi-leges may be rescinded for 3 months. If aphysician exceeds the lateness criterionfor 2 consecutive quarters, the data isshared with the surgery committee witha recommendation to rescind early-casescheduling privileges for 3 months. Thispolicy is carried out at the discretion ofthe chairman of surgery and/or the ORdirector.

Together, these steps have raised on-time starts to 70% to 75%.

Changing the cultureHow was Halowell able to change the

culture among the nursing staff? Recogni-tion is part of the answer, she notes.

“One thing I do every day is to recog-nize and build up the staff,” she says. “Itell them how good they are.”

She sent the staff a survey to ask howthey want to be recognized. Interestingly,while some liked to be recognized infront of their peers, others weren’t com-fortable with that, so she plans recogni-tion accordingly (sidebar).

Time is provided before every staffmeeting and report for staff to recognizepeers.

“That’s built into our culture now,”she says. “Even if you don’t ask at report,they’ll raise their hands and say, ‘I justwant to say thank you to this personwho did this for me yesterday.’”

If the OR’s performance is slipping,she shares that, too.

“Our dashboard and financials areposted,” she says. “I find if I share thatdata with the staff, they are more in tuneand ready to work for you.”

Staff also participate in the OR’sefforts to improve quality and opera-tions. An example is peer review meet-ings to discuss root cause analyses andnear misses. The group discusses thenear miss, analyzes what parts of the sys-tem or process failed, and proposesimprovements.

Halowell finds positive reinforcementgoes a long way in building morale.

“If you continually tell the staffthey’re the best and celebrate youraccomplishments, one day it just clicksfor them. They realize they are good andstrive to be better,” she says. v


Performance improvement

Ways to recognize staff

Ideas from Banner BaywoodMedical Center, Mesa, Arizona: • Start all meetings, reports, and

huddles with formal or informalrecognitions.

• Write and send thank you cards.• Give lunch (meal) tickets or coffee

coupons.• Give Banner Bucks (good at the gift

shop, cafeteria, or on-line store).• Acknowledge the good work of

our employees to administratorswho send a thank you card to theemployee’s home.

• Place high-performing staff onfacilitywide and corporate teamsand give them time to do a goodjob.

• Have shared leadership or unit-based council announce anEmployee of the Month and anEmployee of the Year, with mone-tary awards.

• Reward and recognize certifica-tions in all disciplines, many timeswith salary increases.

• Recognize employees who attendnational conferences by allowingthem to present what they learned.

• Give extra time off for good atten-dance.

• Celebrate world-class patient satis-faction and Gallup staff engage-ment scores with pizza parties forall perioperative departments.Share in each other’s successes.

• Give thank you cards with mealtickets and/or car wash coupons tophysicians for their good work.

• Leaders round with staff and giverecognition during rounds.

• Recognize clinical practices andbehaviors publicly that the organi-zation wants replicated, reinforcingcorrect behaviors.

• Deliver recognition in a timelyfashion.

“

“Recognitionhelped change

the culture.

New Sentinel Eventalert on anticoagulants

The Joint Commission issued an alertSept 24 saying hospitals need to adoptstrict measures to prevent anticoagulanterrors. Anticoagulants are 1 of the top 5drugs with patient safety incidents.

Anticoagulants are also part ofNational Patient Safety Goal 3 for med-ication safety.

Factors contributing to anticoagulanterrors are lack of standardized labelingand packaging, failure to document andcommunicate patient instructions duringhandoffs, and inappropriate dosing forpediatric patients.

The alert recommends 15 steps toreduce the risk of errors. Among thesteps are:• Assess risks of using anticoagulants.• Use best practices and evidence-based

guidelines.• Standardize dose limits and require a

physician to confirm exceptions.• Clearly label syringes and other con-

tainers used for anticoagulants. • Clarify all anticoagulant dosing for

pediatric patients, who are at higherrisk because these drugs are formulat-ed and packaged for adults.

• Designate pharmacists to manageanticoagulant services. v

—www.jointcommission.org

18

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Sixth and final article in a series on performance management.

This article completes the series onperformance management, pub-lished monthly since June 2008.

The first article gave an overview of theperformance management process. Thenext 4 articles covered the job descrip-tion, initial competencies, orientation,goal setting, on-going competencies,coaching and mentoring, and the perfor-mance evaluation. This article discussesperformance improvement and gives asummary of the entire process.

Sometimes, despite our best effortsincluding coaching and support, a staffmember may not meet the requirementsof the job. When this happens, as man-agers we need to assist these staff mem-bers to understand where they need toimprove. We need to set realistic goalsfor them to improve their performance.Then we need either to reward them forimproving or move them to a job moresuited to their skills and talents, or weneed to move them out of the organiza-tion. This can give them the opportunityto be successful elsewhere.

Setting the stageDiscussing the positive aspects of a

performance appraisal can be easy. Agood introduction to the performanceappraisal meeting may be somethinglike, “I’d like to discuss the points ofyour performance on which we agreefirst. Then we’ll talk about areas wherewe don’t agree. I’ll ask for your perspec-tive on both of these areas so we canlearn from each other throughout thisprocess.” Referring to the performancelog you’ve kept all year gives you detailsabout positive and negative aspects ofperformance that need to be discussed.(See July 2008 OR Manager, p 20.)

To have a productive performancereview, discuss the positive aspects indetail so the staff member and you bothlearn from the successes achieved. Aquestion like, “What was it about thispart of the job that made you success-ful?” encourages the staff member toshare with the manager. The managercan then share thoughts on the reasonsfor success.

Addressing problem areasThis positive interaction sets the stage

for discussion of areas where perfor-mance has not been positive. This discus-sion usually takes longer than the discus-sion about successes. Managers experi-enced in giving performance evaluationsreview the staff member’s viewpoints oneach job function prior to the actualreview. They consider points of disagree-ment that will be easy to resolve andpoints that will take additional time tocome to agreement about the futurecourse of action.

The result may be the need for a per-formance improvement plan for specificaspects of the job where the staff memberis not meeting expectations. The need fora performance improvement plan mayalso be identified at other times duringthe performance year.

Performance improvement is definedby nurse author and consultant JoManion, RN, PhD, FAAN, as “a rigorous

feedback and documentation processthat generally spans 60 to 90 days,depending on the nature of the prob-lem.” (See sidebar for Manion’s model ofa positive discipline process.)

Documenting the processMost organizations have a form for

documenting and tracking the perfor-mance improvement process. (A sample isin the OR Manager Toolbox at www.ormanager.com.)

The form should include the follow-ing areas:• Space for identifying the exact perfor-

mance area where there is a gapbetween expectations and perfor-mance.Example: “Policy states that patients

will not be moved from the holding areainto the OR (except in an emergency)until all preop requirements, includingsigned, dated, and timed consents, and


Managing people

When a staff member needs to improve

Standards and expectations set and communicated

Address deviation from standard

Give concrete feedback. Ask for compliance

Source: Reprinted with permission from Manion J. Create a Positive Health CareWorkplace! Chicago: Health Forum, 2005.

Model of the positive discipline process

ImprovementGive recognition

Consider:• Seriousness of

deviation• Consistency in

organization• Part of a

pattern?

Suspension or termination

No improvement

Written documentation


Decision day

Formal disciplinary

action


No improvement

OR

No improvement

g

ff

f ff

fff f}

f


20

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updated H&P are on the chart. In the last3 months, you have taken 6 patients tothe OR without this requirement com-pleted.”• Documentation of what is expected in

the future.Example: “No patients who are under

your care will be transported to the OR(except in an emergency) until all preoprequirements, including consents andH&P, have been completed.”• Notes on how manager will assist staff

member with meeting expectations.Example: “If you are placed in a situa-

tion where the surgeon or anesthesiolo-gist is requesting that you move thepatient into the OR inappropriately, youwill page me or the medical director ofthe OR for assistance with enforcing thepolicy.”• Timelines.

Example: “Results will be reviewedmonthly for 6 months.”• Outcome.

Example: “If any instances of taking apatient into the OR without policy beingfollowed occur, we will proceed to level 3of corrective action (final warning). Anadditional instance after that will resultin termination.”

It’s important to align the reasons forimproved behavior with the staff mem-ber’s values, skills, and reason for doinga good job.

The example above is extremebecause it refers to a specific policyrequirement that must be followed.Many other performance improvementaspects are less extreme but need to beimproved to make the staff membermore effective. An example is a plan toimprove the performance of a staff mem-ber who does not help others duringdown time but tends to go to the lounge.In this instance, the reason for improve-ment should be based on the staff mem-ber’s values and/or personal reasons forwanting to do a good job. This reasonmight be something like, “Fellow staffmembers will be less likely to help you inthe future when you may need help,” or“Fellow staff members are seeing you asnot being a team player.”

Involve HRIt’s also important to include a repre-


Managing people


Here is a summary of the elements ofperformance management covered inthis series.

1. Job descriptionA good performance management

system begins with a well-written jobdescription that includes essential jobfunctions as well as behavioral aspectsof the job. It’s essential to collaboratewith Human Resources when writingjob descriptions. The job description isthe platform on which all other aspectsof performance management are built.

2. Orientation, initialcompetencies

Each new staff member can be set upfor success through a well planned self-directed orientation and initial compe-tency program. Staff members need tobe fully involved in completing orien-tation and competencies by using aself-directed approach and seeking outwork situations that satisfy their learn-ing needs. The educator and preceptorserve as coaches to assist staff memberswith finding the appropriate learningexperiences.

3. Goal settingGoal setting is essential in any per-

formance management system. Goalskeep all of us on track not only for com-pleting tasks in a timely manner butalso for improving our functions in ourroles. One of the most important sug-gestions in this series is to keep a per-formance log on each staff member.(See the example in the July 2008 ORManager.) Spending a few minuteseach day or each week logging staffmember’s progress toward yearly goalsand completion of individual compe-tencies will make the actual evaluationgo much smoother for you and the staffmember.

4. Ongoing competenciesTechnology used in surgery is chang-

ing rapidly. Ongoing competencies areessential in ensuring your staff is pre-pared to handle each new piece ofequipment and procedure theyencounter. The manager and educatorneed to assess changes in technology,procedures, and patient populations to

decide on competencies for the staff tocomplete each year. Excellent commu-nication with the staff throughout thecompetency process will help them tounderstand the reasoning for the com-petencies and to complete them in athoughtful and timely manner.

5. Coaching and mentoringEffective use of coaching and men-

toring skills can help managers to miti-gate some of the negative feelings staffmembers may have about their currentwork situation. Operating rooms areexperiencing staffing difficulties, moreacutely ill patients, heavier workloads,more call time, and pressure for moreefficient processes.

The pressure on staff members leadsto lower morale and less enthusiasm.Coaching and mentoring staff in theirdaily work can help to keep theminvolved and excited about their cho-sen career.

6. Performance evaluationThough managers and staff may see

performance evaluation, including self-evaluation and peer evaluation, as achore, if done correctly, the process canbe positive. Staff members should comeout of their performance evaluationsessions with a good understanding ofwhat is expected of them, how they canimprove, how they have met the goalsthey have set, and what new goals theycan strive for. If all of the steps of per-formance management are completedin a timely and thoughtful manner, theresult will be positive for all.

7. Performance enhancementEven when we’ve used our best

efforts, we may still have to providemore help and support for a fewemployees through a performanceenhancement plan. Allowing poor per-formance brings down the morale ofthe entire staff. Turning around a poorperformer can be 1 of the most reward-ing aspects of management. It’s a hugestep in the pursuit of our ultimategoal—providing safe, quality care topatients through appropriate manage-ment of the performance of those staffmembers who care for them.

7 Elements of performance managementContinued from page 19

22

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sentative from Human Resources (HR) inthis process. HR professionals work withthese situations more frequently than anindividual manager. They can guide themanager in appropriate actions to take aswell as ensure that the process is consis-tent throughout the organization.Though it’s uncomfortable to give a staffmember negative feedback and to createa performance improvement plan, it’seven more uncomfortable to sit before anarbitrator or lawyer and hear that noother manager in your organization usedthe corrective action steps the same wayyou did. HR professionals can also helpin conducting difficult face-to-face meet-ings with staff members.

Managing problem performers is notat the top of the list of ways most man-agers achieve job satisfaction. It is, how-ever, a necessary part of managing peo-ple. If handled proactively and with skill,it can be less daunting and more fulfill-ing than allowing problem performers tocontinue in their current mode of opera-tion. Solving the issues of problem per-formers leads to a more productive workforce with staff members who are able tofocus on quality patient care. v

—Kathy Shaneberger, RN, MSN, CNORDirector of Surgical Services

Holland Hospital, Holland, Michigan

ReferencesManion, J. Create a Positive Health Care

Workplace! Practical Strategies to RetainToday’s Workforce and Find Tomorrow’s.Chicago: Health Forum, 2005.


Managing people


A sample RN job description, initialcompetencies record, and perform-ance log are in the OR ManagerToolbox at www.ormanager.com.Look under Performance manage-ment for perioperative staff.

Arecount of surgical sponges mayprolong a case, but does it affectthe patient’s outcome? Do patients

fare better if an OR uses a certain staffingpattern? How does OR staff experiencerelate to outcomes?

These are examples of questions anurse researcher at the University ofMichigan (UM), Ann Arbor, plans toinvestigate in a study funded by a 3-year$350,000 grant from the Robert WoodJohnson Foundation (RWJF).

“There is not much information pub-lished on OR nursing. We don’t knowwhether that’s because no one haslooked at this or because there is nolink,” says the researcher, AkkeNeelTalsma, RN, PhD, assistant professor ofnursing at UM. She earlier participatedin a key study on failure to rescue, whichrefers to caregivers’ failure to respond topreventable patient complications thatlater lead to a fatality.

OR staffing and outcomesThe new study will focus on testing

the relationship between OR staffingcharacteristics and patient outcomes.Data sources will include the OR nursingrecord and the database from theAmerican College of Surgeons NationalSurgical Quality Improvement Program(NSQIP), which captures data aboutsurgery and patient outcomes.

The study has 2 major components:• To capture OR staffing patterns, such

as what types of personnel are in theroom, their experience, and whetherthere were interruptions or a shiftchange during a case.

• To evaluate the relation between theseOR nursing factors and patient out-comes. These may include immediateoutcomes, such as the need to take anx-ray to confirm a count, and moredistant outcomes, such as bleeding orwound problems.OR staffing is based on 1 RN circula-

tor and 1 surgical technologist as thescrub person. Traditionally, staff mem-bers have been assigned and rewardedbased on their knowledge and skill andlength of service in the OR.

“In the current OR environment, thisformula has limited success,” Talsma says.Surgical procedures are more complexwith the need for more technical skill with

equipment, greater specialization, andsometimes more than 2 staff membersassigned to a case. The generalist staffmember cannot keep up with all of thechanges and innovation in each specialty.”

Data for better decisionsThere is also the issue of staffing costs. “Some states are looking at having

surgical technologists circulate for casesand have 1 RN to cover charting for sev-eral ORs,” she notes. ”RNs are necessaryfor excellent, quality patient care withpositive patient outcomes.” For example,nurses are aware of the rationale for pre-operative antibiotics, normothermia,grounding pad placement, positioning,estimated blood loss, and expedited sur-gical processes.

“This study should be able to capturesome of the information needed tounderstand staffing concerns and patientoutcomes,” Talsma says. “The findingswould help OR nursing managementand leadership make informed decisionsfor better outcomes.”

The study will be conducted in sever-al phases. The first phase this fall will beto develop the OR nursing measures.Talsma has worked with OR manage-ment at UM and AORN members todefine measures. A pilot study to test themeasures will be conducted at UM. Thenin 2009, the plan is for the study to beexpanded to 6 or 7 other Michigan hospi-tals. Talsma plans to include some hospi-tals with Magnet recognition for nursingexcellence as well as union and nonunionfacilities. v

More information is atwww.ns.umich.edu/htdocs/releases/story.php?id=6694.

Study to focus on OR staffing,relation to patient outcomes

AkkeNeel Talsma, RN, PhD

24

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Hardwiring the process for givingand discontinuing prophylacticantibiotics for surgery helped a uni-

versity hospital drive up compliance withnational guidelines, the July 2008 Journal ofthe American College of Surgeons reports.

Finding education wasn’t enough, theauthors developed a process with “hardstops” at key points before and aftersurgery.

“Gentle education doesn’t do it,” thelead author, Glenn Whitman, MD, FACS,a cardiac surgeon, told OR Manager.

“To assure quality, you have to applya process to make it happen.” The studywas conducted at Temple UniversityHospital in Philadelphia. Dr Whitman isnow director of the surgical cardiac careunit at Philadelphia’s Thomas JeffersonUniversity Hospital.

Over 18 months, Temple took stepsthat led to a more structured process:

Period 1During 2005, surgical chairs were

asked to develop an antibiotic protocolfor their departments based on nationalguidelines. A new surgical schedulingform was created with specialty-specificantibiotic prophylaxis in the physicianorders. Still, compliance lagged for selec-tion of the appropriate antibiotic (76%)and correct timing (55%).

Period 2In July and August 2006, a policy was

adopted mandating that completedscheduling forms with physician ordersbe available in the preadmission testingarea (PAT) before patients would be seenfor their preoperative appointments.That ensured that orders for the appro-priate antibiotic would be on the chartbefore the day of surgery. Selection of theappropriate antibiotics rose to 91%, andcorrect timing improved to 78%—“clear-ly not good enough,” Dr Whitman says.

Period 3 Next, a requirement was added that

no patient could leave the preoperativearea for the OR without the antibioticbeing given according to the standard-ized orders. Compliance with timingrose but only to 90%.

Period 4 In the first half of 2007, the Department

of Anesthesia agreed to take responsibilityfor giving the antibiotic in the OR. Givingthe antibiotic was added to the timeoutchecklist, and timing and choice of antibi-otic were documented by the anesthesiaprovider. Specialty-specific antibiotic pro-tocols were laminated and posted in ORsfor use by specialty teams. These measuresboosted compliance to 95%. (The resultswere significant at the p = 0.07 level, a dif-ference that would have been significanthad the sample size been larger, theauthors note.)

Stopping antibiotics on timeAutomation helped improve the

process for discontinuing antibioticswithin 24 hours after surgery, as guide-lines recommend.

Despite reminders, residents contin-ued to write orders that said, “AntibioticIV now and 8 hours x 3 doses.” As aresult, the last dose was often given out-side the 24 hours.

To hardwire the process, the hospitaladded a pathway to its computerizedphysician order entry system titled “pro-phylactic postoperative antibiotics.”When ordered immediately after theoperation, the pathway created an orderthat automatically limited antibioticdoses to the proper timeframe.

The pathway helped improve compli-ance from 60% to 86%. But physicians canbypass the pathway, and compliance withthis aspect of the guidelines has been diffi-cult to improve, the authors say.

Stiff measures neededDr Whitman says stiff measures were

needed to move the process forward. “We struggled for 18 months to find

what worked,” he says.“It really required us to hardwire the

process to get the attendings to write the

antibiotic order 100% of the time. We toldthem, ‘We will not see your outpatientsin PAT unless we have the orders 24hours in advance. If we don’t have theorders, your patient will be called thenight before and asked to reschedule.’

“We thought that was draconian,” headds. “But as soon as we did it and stuckto our guns, compliance improved.”

Along with that, the PAT unit had tosolve the problem of missing faxes, achallenge in a unit that receives hun-dreds of faxes a day.

“To get compliance with the orders,we had to promise the physicians wewould never lose their orders,” DrWhitman says.

The solution was found in a softwareapplication called My Medical File, amove Dr Whitman calls a “Grand Slamhome run.”

With the software, surgeons’ officescan fax the forms, which are sent both tothe PAT and to an online service thatelectronically assembles the patientcharts. If a form is missing that has beensubmitted, the staff can go online toretrieve it, preventing lost records ordelays on the day of surgery.

That solved the problem of missingpaperwork, which has also been a boonfor surgical consents.

Another major step was the Depart-ment of Anesthesia’s agreement to beresponsible for giving the antibiotic inthe OR as part of the timeout.

Dr Whitman says he hopes the pub-lished study will help others move theirprocess forward.

“The article provides hospitals andORs with the leverage to put in placeprocesses that might appear immutable,such as being able to say: ‘This studydetermined that it works best whenanesthesia gives the antibiotic during thetimeout and writes the time.’

“No one gives the scalpel to the sur-geon until the appropriate antibiotic isgiven.” v

ReferenceWhitman G, Cowell V, Parris K, et al.

Prophylactic antibiotic use:Hardwiring of physician behavior, noteducation, leads to compliance. J AmColl Surg. 2008;207:88-94.


Hardwiring a process for antibioticsPerformance improvement

“

“Stiff measures were

needed.


Lee Anne Blackwell, RN, BSN, EMBA, CNORDirector, clinical resources and education,Surgical Care Affiliates, Birmingham,Alabama

Nancy Burden, RN, MS, CAPA, CPANDirector, Ambulatory Surgery, BayCareHealth System, Clearwater, Florida

Lisa Cooper, RN, BSN, BA, CNORExecutive director, El Camino SurgeryCenter, Mountain View, California

Rebecca Craig, RN, BA, CNOR, CASCAdministrator, Harmony AmbulatorySurgery Center, LLC, Fort Collins,Colorado

Stephanie Ellis, RN, CPCEllis Medical Consulting, IncBrentwood, Tennessee

Rosemary Lambie, RN, MEd, CNORNurse administrator, SurgiCenter ofBaltimore, Owings Mills, Maryland

LeeAnn PuckettMaterials manager, Evansville SurgeryCenter, Evansville, Indiana

Donna DeFazio Quinn, RN, BSN, MBA,CPAN, CAPADirector, Orthopaedic Surgery CenterConcord, New Hampshire

Ambulatory Surgery Advisory Board

A small ASC’s automated supply chain

Two things are true about informa-tion technology: It is critical fororganizations to succeed, or even

survive, and it is expensive.For one small ambulatory surgery

center (ASC) striving to meet financialand growth objectives, ingenuity provedto be the answer.

At The Center for Special Surgery atTexas Center for Athletes in San Antonio,one of 17 surgery centers managed byRegent Surgical Health, Painesville,Ohio, administrator Eric Day, materialsmanager Joel Medina, and corporatepurchasing director Amy Gagliardi haveestablished an automated supply chainthat uses scanners, bar codes, and a well-organized database to track orders,deliveries, and payments for supplies.

They did this without a major invest-ment in a materials management infor-mation system.

Using an off-the-shelf, web-basedsoftware package, Day arranged to havethe facility’s inventory list and purchas-ing records uploaded to a database by athird-party data entry firm, PurNet,Worthington, Minnesota. The informa-tion came back in the form of reports inthe easily available spreadsheet program,Microsoft Excel.

“Once you have the ability to extractdata, you have the ability to manipulateit,” Day says. “This not only applies towhat you can do from an inventory stand-

point but just as well, from a financial, sta-tistical, or even quality perspective.”

While it took Day’s ingenuity andcomputer savvy to work out the details,the new system is easy to learn and inex-pensive to maintain. Regent’s motivationwas no different from that of manyASCs: the need to improve efficiencywithout a large up-front investment.

Day and Gagliardi discussed theirmethod during the Ambulatory SurgeryCenter Association conference in SanAntonio in May.

Old system was not workingThe supply chain at Regent was typi-

cal of ASCs, and so were the problems,such as: • Inventory was stored at multiple loca-

tions with no overall control.• Product identifiers were assigned by

vendors, so any product could havemultiple IDs.

• Purchase orders were generated man-ually, a tedious task.

• Every vendor had its own system.• Par level management and inventory

replenishment were performed man-ually, and errors were common.

• Chargeable products had to betracked and reported manually.

• Because the purchasing and financialsystems were not integrated, data hadto be entered twice.Regent decided to look for a system

that would solve at least some of thoseproblems and developed specificationsfor one that would integrate purchasing,reporting, receiving, par management,inventory, and accounts payable.

Regent selected a system developed byAliso Viejo, California-based InventoryOptimization Solutions (IOS) Corporation.IOS, which specializes in health care,makes its system available through severaldistributors, including Henry Schein andMcKesson Medical. Regent, however,obtained the software through its agree-ment with PurNet.

IOS uses an application servicesprovider (ASP) format to provide inter-net access to its software. The company’sEnterprise Materials Manager system,which Regent selected, meets most ofRegent’s specifications. It works withhandheld wireless scanners to enterinventory and patient use data. Usersenter requisitions electronically, and

“

“Ingenuity was the answer.


these are automatically transmitted tovendors. Because the operation takesplace online, it does not matter whatkind of in-house system the vendor has.Finally, the system provides a 3-waymatch of invoices, purchase orders, andreceipts before sending invoices electron-ically to accounts payable.

The cost to Regent is about $400 permonth, with no initial investment,according to Day. “Inventory and laborsavings pay for the system immediately,”he says.

Gagliardi estimates Regent will save$700,000 annually using the system.

The labor savings begin with the ease

of transferring data from the customer’ssystem to the IOS database. Re-keying isthus not necessary.

According to a study at LehighUniversity, conversion to this type of sys-tem can save an organization about 40%on both purchasing transaction costs andorder fulfillment time, and reduce pur-chasing-related FTEs by about 7%.

Day notes that ASCs are now at astage in automating the supply chainthat many hospitals went through a fewyears ago, converting to electronic com-merce and barcodes for inventory man-agement.

Transparency and accuracyWith the electronic system, functions

are displayed clearly on the screen andare easily traceable through the system.

For example, the surgery centerorders 3 boxes of urinary leg bags, size270 mL. The price per box is $100, so theestimated total cost is $300. The itemnumber is 2009, and the vendor numberis 21866-030.

The information appears in theOperations section under PurchaseOrders. Later, accounts payable sees thetransaction under Operations-AccountsPayable, with the same identifiers plus ageneral ledger code of 8000-300.

At both ends of the operation, unitand price totals provide statisticalrecords. Records can be sorted by prod-uct, vendor, usage, and cost to identifypotential savings or spot unusual pat-terns.

They also provide the building blocksof reports that offer flexibility to the ASC.They can be used to locate and trackitems, establish and modify par levels,maintain physician preference cards, and

even document case costs by physician.The key, Day says, is to generate

reports that are compatible with Excel.With an Excel spreadsheet in hand,

Day is able to create barcodes and trans-fer them to a Microsoft Word file forprinting as labels.

From the online IOS reports, heextracts the complete inventory into anExcel file that includes, at a minimum, anitem number, product description, andcost expressed in unit price, regardlessof whether the product is delivered bybox or case. This makes case costing easi-er later on, Day explains.

The key Excel functions to know are:• naming cell ranges within the spread-

sheet• using VLookup• Mail Merge in Microsoft Word, using

Excel’s named range as data• how to download the free barcode

font (the name of the font is “Free 3 of9 Extended”).“Once you understand these areas, it

opens the door to developing tools onlylimited by your own needs,” he says.

Serving a needSteve Britt, managing director of sales

at IOS, says about 750 surgery centers,nursing homes, and physician practicesnationwide are using IOS software,mostly through their medical-surgicaldistributors.

During the past decade, he says,health care organizations have becomeaware of the need to manage supplycosts, yet even some small hospitals arefinding standard materials managementinformation systems (MMIS) unafford-able.

“We decided to tackle the alternatecare market,” Britt says, “because noneof the traditional software suppliers tar-geted it.” The key was to avoid a majorcapital investment and instead to chargea monthly subscription fee based on theservices provided.

“Physician-owned organizations donot spend a lot for accounting or supplychain systems,” he notes. “Surgery cen-ters are in the same boat: They’re not

AmbulatorySurgery Centers

So you want toautomate yoursupply chain

Issues an ASC should considerbefore deciding to automate, suggestedby Steve Britt talks of InventoryOptimization Solutions (IOS): • Has your facility expanded, so sup-

ply costs are increasing?• What are your goals and ambitions

regarding the supply chain?• Is the OR manager too busy to spend

time with materials management?• Are you looking to standardize on

fewer vendors? Or do you use fewvendors, in which case you may notneed to automate.

• Are your primary vendors helpful insetting up electronic data interchange(EDI) through their own systems?

• Do you have many facilities or justone or a few in a limited geographicarea?

Britt notes that while ASCs of anysize can benefit from automation, theaverage IOS client has 3 or 4 operatingrooms. The main factor is how smooth-ly and economically the supply chainoperates.

Britt cites a national study that foundthe average cost of processing a manu-al purchase order from sourcingthrough payment is $97, and 40% canbe saved through automation.


“

“Case

costing is easier.


Ambulatory surgery centers (ASCs)are preparing to join hospitals,physicians, and other health care

providers in reporting quality data to theCenters for Medicare and MedicaidServices (CMS).

Though it’s unlikely ASC qualityreporting will be required in 2009, ASCsneed to start preparing, according toDavid Shapiro, MD. He is a principal atthe consulting firm Ambulatory SurgeryCompany, Tallahassee, Florida, and withKim Wood, MD, co-chaired the ASCQuality Collaboration, a multi-disciplinarygroup formed in 2006 to develop a set ofquality measures for surgery centers.

In that year, Congress ordered theDepartment of Health and HumanServices to add outpatient care to itsrequirements for quality reporting. Thepenalty for not submitting data would beto forfeit 2% of any annual reimbursementincrease, according to provisions in the TaxRelief and Health Care Act of 2006.

Though CMS is expected to postponeASC quality reporting for 2009, Dr Shapiroadvised ASCs to begin gearing up.

Working togetherThe collaboration included ASC associ-

ations and management companies,health care professionals, and accreditingorganizations such as the Joint Commis-sion. After the group agreed on a set of 10quality measures, it submitted them to theNational Quality Forum (NQF), a volun-tary standards organization. The NQFboard approved 5 of those measures.

“It was a very long process,” DrShapiro recalled. “It wasn’t easy, it was-n’t straightforward, and it didn’t happenovernight.”

One problem, which emerged whenthe group attempted to list and comparecurrent ASC quality measures, was thelack of common terminology. “As forstandard definitions, there were none,”he said. “People were collecting dataconcerning similar things, but nobodywas talking about them in a commonlanguage.”

An example was the standard for

patient transfer to a hospital. The timeframe and the meaning of the term dif-fered among different organizations.

The group first developed criteria thatwould apply to any quality measure theymight consider. First, it would have to bewithin the scope of an ASC’s care orinfluence.

“They found some measures thatwere used in hospitals but were notapplicable to ASCs because we have dif-ferent types of patients in a different clin-ical environment,” Dr Shapiro recalled.

Second, ASC staff must be able toobserve directly and verify the behaviorto be assessed. Third, the measure mustbe understandable and important to allstakeholders, such as patients and insur-ers. “They were looking for data that isvalid but also understandable.”

The final 5At the end of the process, the NQF

agreed to adopt the proposed standards for5 treatment or procedural areas (sidebar).

The measures relate either to outcomeor process. An outcome measure refers towhat happens to a patient as the result oftreatment. A process measure evaluates aparticular aspect of the care. Of the 5, onlythe antibiotic timing measure is process;the others are outcome measures.

To quantify results, measures areexpressed as a fraction, where thenumerator is all patients receiving a par-ticular process or having that outcome,and the denominator is the group ofpatients being evaluated.

In an implementation guide for mem-bers, the ASC Quality Collaboration

gives the following instruction for com-puting the result: “To report each mea-sure, count the number of patients meet-ing the numerator criteria and the num-ber of patients meeting the denominatorcriteria. To calculate your results as a per-centage, divide the numerator by thedenominator and multiply by 100.Although the frequency with which


Getting ready for ASC quality reportingASC qualitymeasures

Patient burnIntent: To capture the number ofadmissions (patients) whoexperience a burn prior todischarge.

Prophylactic IV antibiotictimingIntent: To capture whetherantibiotics given for prevention ofsurgical site infection wereadministered on time.

Patient fall in the ASCIntent: To capture the number ofadmissions (patients) whoexperience a fall within the ASC.

Wrong site, wrong side,wrong patient, wrongprocedure, wrong implantIntent: To capture any ASCadmissions (patients) whoexperience a wrong site, side,patient, procedure, or implant.

Hospital transfer/admissionIntent: To capture any ASCadmissions (patients) who aretransferred or admitted to ahospital upon discharge from theASC.

Source: ASC Quality Collaboration. For afull description of the measures, go towww.ascquality.org.

“

“Five measures were

adopted.


going to pay a lot for a supply chain sys-tem.” He adds, “Is there a need for one?Very much so.”

Other than computers, handheld scan-ners, and the cost of uploading basic setupdata, there is no upfront investment tobegin using IOS’s 2 main packages, calledEnterprise Materials Manager and ClinicalInventory Manager.

Britt says a typical cost is $500 to$1,000 per month, but he has sold entry-level packages for as little as $250 permonth.

Multifacility companies like Regentreceive additional discounts based on thenumber of facilities and users in theorganization. Britt says return on invest-ment can take as little as 3 or 4 months.

Much of that savings comes from theability to track spending, especially withmulti-facility operations, Britt says. Oftendifferent facilities are paying differentprices. Having a central repository ofpurchase information highlights thosedifferences: “If 1 ASC is paying different-ly, our system will catch it.”

Faster, better, cheaperConversion to electronic supply pro-

cessing affects every step from orderingto paying invoices. But it is on the patientcare unit, where supplies are handledand patients are treated, that lifebecomes easier for staff and physicians.

Day explains: “With the barcodelabels in place, we now have the oppor-tunity to place orders via scanner, makelarge inventory counts more quickly, andcreate preference cards for case costingmuch more easily.”

By scanning each item used during aprocedure into a spreadsheet template,the ASC can track usage and cost byphysician. The VLookup function is thedriver of most of the case-costing tem-plate as well. It is able to look at the itemnumber scanned, and then return, fromthe inventory extract table, the descrip-tion of the item, the manufacturer, andthe unit cost.

The user then only needs to enter thenumber of items used. Simple multipli-cation combines the “unit cost” and“number of units used” cells. Ultimately,the case costing sheet shows what prod-ucts each surgeon has had pulled for a

particular case as well as the price ofeach and the total spent.

As the manager’s proficiency with thesystem grows, so do the possibilities,Day says. “Once you start working withExcel and barcoding, most likely you willstart discovering new uses for them on aregular basis.” v

—Paula DeJohn

Paula DeJohn is a freelance writer in Denver.


these assessments are performed can cer-tainly vary, we suggest you collect thedata on a monthly basis.”

As an example, a measure for patientfalls per 1,000 patient days would haveas a numerator every admission to theASC in which the patient fell “within theASC.” A fall in the parking lot or else-where outside of the building would notbe included.

The NQF’s decision to include thismeasure was based on the fact that fallsassociated with outpatient surgery are onthe increase. “We ask patients to get upand dressed much sooner than in the olddays,” Dr Shapiro noted.

The definition is specific: “a sudden,uncontrolled, unintentional downwarddisplacement of the body.”

The transfer/admission measure trackspatients who, after leaving the ASC, areadmitted to a hospital for inpatient care. Ahigh number of admissions may indicate

inappropriate patient selection or choice ofprocedure for those patients.

Reporting made simple?There are 3 potential sources of data,

but only 1 is preferred, Dr Shapiro said.The first, abstraction of clinical data, is atime consuming pencil and paper method,especially for smaller ASCs with limitedstaff. The second, using electronic medicalrecords, would be better, but the adoptionrate is still too low for this to be a realisticoption now for most ASCs. The third, aug-mented claims submission, is likely to bethe most feasible, Dr Shapiro said. Withthis method, ASCs would add supple-mental tracking codes to each Medicareclaim. These “Category II Codes” wouldrefer to specific quality measures such astreatment given and test results.

Consolidation and reporting would besimple, reducing the need for chart reviewand production of record abstracts.

CMS originally planned to startrequiring ASC quality reporting in 2008and then in 2009. But in July, in the pro-posed 2009 Medicare outpatient andASC payment rule, CMS said it wouldpostpone issuing a rule on qualityreporting. The final payment rule wasexpected by Nov 1.

Though Shapiro believes it is nolonger likely that CMS will require ASCquality reporting in 2009, he said it is nottoo early to consider how to collect andorganize quality data. v

More information on the ASC QualityCollaboration is at www.ascquality.org.

ReferenceASC Quality Collaboration. ASC Quality

Measures: Implementation Guide, Version1.0. April 2008:3. www.ascquality.org.

Check our website for practical help on

personnel evaluation, codes of conduct, and

patient assessment.

Go to: www.ormanager.com Look under The

OR Manager’s Toolbox.

ORManager’s Toolbox

Supply chainContinued from page 27


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By passing then overriding PresidentBush’s veto of legislation that wouldhave reduced Medicare payments

to physicians, Congress demonstrated anoften-forgotten fact: citizen voices canmake a difference.

On July 15, the House voted to rein-state HR 6331, the Medicare Improve-ments for Patients and Providers Act of2008. The act eliminated a pending 10%payment cut to physicians treatingMedicare patients, among other provi-sions.

According to US RepresentativeCharles Gonzalez (D-Texas), ambulatorysurgery centers (ASCs) should take note.

“This bill’s overwhelming bipartisansupport in Congress, coupled with itsstrong grassroots support in the medicalcommunity and among everydayAmericans, speaks volumes about theimportance of this legislation,” Gonzalezsaid in a statement following the vote.

A few months earlier, during the MayASC Association conference in SanAntonio, Texas, Gonzalez offered a simi-lar message to ASC administrators, own-ers and staff.

“You must let Congress know howlaws impact your job,” he told them dur-ing a general session.

Medicare’s far-reaching impactMedicare, he noted, is a good exam-

ple of how a law can have far-reachingimpact.

“Medicare is not going away,” hesaid, “so we’d better make it work. Notonly the government but private insur-ance companies follow Medicare guide-lines.”

What many citizens, and perhapssome health care professionals, don’tunderstand about Medicare is that it isnot designed to reflect the cost of provid-ing care, Gonzalez noted. Medicare fund-ing for physicians is based on the federalgovernment’s “sustainable growth rate”concept, which is used to compute reim-bursement. “It’s not based on the cost toprovide care but on the budget.” Thesame is true for ASC facility and hospitalreimbursement.

Gonzalez said analysts who reviewclaims are paid based on the size of over-payments they find, which provides anincentive to overestimate claim discrep-ancies to the disadvantage of health careproviders.

“It’s always going to be about moneyand budgets,” he said.

ASCs need to speak upGonzalez acknowledged to the crowd

that ASCs have been at a disadvantagewhen competing for Medicare reimburse-ment dollars. “Why should ASC paymentsbe less than for hospitals?” he asked.

Overall, the prospect for improve-ment is dim: “CMS will reduce paymentsevery year,” he said, “but will target dif-ferent specialties.” In some cases, henoted, rather than cutting payments,CMS will reduce proposed increases.

To be in the game, ASCs will have toget the attention of lawmakers. “Writinga letter is a start, but is not enough,”Gonzalez said, because a letter usuallyends up on the desk of a staff member.

He said the reason he knows ASCsreceive lower payments than hospitals isthat an ASC executive visited him per-sonally and explained the industry’s con-cerns.

“You have to educate policy makers,”Gonzalez said. “You have to be evenmore active than you are now.” v

—Paula DeJohn

Paula DeJohn is a freelance writer in Denver.

“

“We had

better make itwork.

Make sure lawmakers know howMedicare policy affects your ASC

What’s workingfor your ASC?

Has your ASC found a way tosave on supply costs, improvequality, smooth your patient

flow, or recruit and retain staff?Share your successes!

Contact Pat Patterson, editor, for a possible interview at

[email protected] or 800/442-9918.

31

Please see the ad for INTEGRATED MEDICAL SYSTEMS

in the OR Manager print version.


P O Box 5303Santa Fe, NM 87502-5303


The monthly publication for OR decision makers Periodicals

Beta blockers cut postopdeaths in COPD patients

Contrary to previous belief, givingbeta blockers before surgery may signifi-cantly reduce mortality in patients withchronic obstructive pulmonary disease(COPD), a new study in the Oct 1American Journal of Respiratory and CriticalCare Medicine finds. The study, whichincluded more than 3,000 COPD patientshaving vascular surgery over a 10-yearperiod, found patients who did notreceive beta blockers were twice as likelyto die within a month of surgery as thosewho did. Physicians have been reluctantto give COPD patients beta blockersbefore surgery, fearing they would wors-en symptoms.

—Van Gestel Y R B M, Hoeks S E, Sin DD, et al. Am J Respir Crit Care Med.

2008;178:695-700. http://ajrccm.atsjournals.org.

New free guide to VTEprevention

The Agency for Healthcare Researchand Quality has published a guide tohelp prevent hospital-acquired venousthromboembolism (VTE)—the mostcommon preventable cause of hospitaldeath. Though pharmacologic methodsto prevent VTE are safe, cost-effective,and recommended by guidelines, thesemethods are underused, AHRQ notes.

Without prophylaxis, the risk of deepvein thrombosis in hospitalized patientsis significant. The AHRQ guide providesa framework for improving performancebased on practices at the University of

California San Diego Medical Center andEmory University Hospitals, Atlanta.

—www.ahrq.gov/qual/vtguide/

Surgical mortality higher forseniors in poor areas

Elderly patients who live in low-income areas are more likely to die aftersurgery than those who live in higher-income Zip codes, according to a studyin the September Medical Care.

The risk of death was 17% to 39%higher for seniors in low-income areas,mainly because of the differences in hos-pitals where these patients are treated,University of Michigan researchers con-cluded. The study analyzed Medicaredata for 6 high-risk surgical proceduresbetween 1999 and 2003.

—Birkmeyer N J O, Gu N, Baser O, et al.Med Care. 2008;46:893-899.

www.lww-medicalcare.com

NOTES raises hopes, questionsQuestions remain about risks of nat-

ural orifice transluminal endoscopicsurgery (NOTES), but many surgeonsare enthusiastic, according to the Sept 21Washington Post. NOTES may promise afaster recovery with less pain and no vis-ible scars, but some fear surgeons willrush ahead before they have perfectedtheir techniques.

More than 400 patients worldwidehave had NOTES, most to remove gall-bladders through the mouth or vagina. Afew surgeons are experimenting withNOTES for obesity. Surgeons at theUniversity of California San Diego

Medical Center performed the first obe-sity surgery through the vagina in the USon Sept 16.

—www.washingtonpost.com

Caution on color-codedwristbands

A national movement to standardizecolor coding of hospital wristbands isfacing hurdles, according to the Sept 24New York Times. There is particular con-cern that purple “Do Not Resuscitate”bands may inadvertently broadcastpatients’ choices to family and friendswho have not been consulted. There’salso concern that some children tradewristbands like baseball cards. Pro-ponents argue standardized colors areessential for patient safety.

—www.nytimes.com

Cardinal to spin off clinicaland medical products business

Cardinal Health announced Sept 29 itplans to spin off its clinical and medicalproducts business as a separate publiccompany.

The spin-off, to be headquartered inSan Diego, will offer products for infu-sion, medication and supply dispens-ing, respiratory care, infection preven-tion, medical diagnostics, and surgery.V. Mueller and ChloraPrep will beincluded in the spin-off, while CardinalHealth will retain surgical kits and sur-gical gloves, drapes, and apparel. Thespinoff is expected to be complete bymid-2009. v

—www.cardinal.com

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