The monthly publication - OR Manager

April 2007 Vol 23, No 4

The monthly publication for OR decision makers

In this issueKeynote: Great leaders keep great staff . . . . . . . . . . . . . . .5

PATIENT SAFETY.Number of retained objects falls after count practices reinforced . . . . . . . . . . .8

INFORMATION SYSTEMS.Making the move to online charting . . . . . . . . . . . . . .11

INFORMATION SYSTEMS.Firm provides independent ratings on OR info systems . . .12

INFORMATION SYSTEMS.Upgrading software? Developing the RFP . . . . . . . . .14

MANAGING PEOPLE.Family & Medical Leave Act and OR staffing . . . . . . . . .17

ASCs lobby on Medicare pay plan . . . . . . . . . . . . . . . . . . .21

AMBULATORY SURGERYCENTERS.Bariatric surgery: Is your OR ready? . . . . . . . . . . . . . . . . . .23

AMBULATORY SURGERYCENTERS.Is your ASC leaving money on the table? . . . . . . . . . . . . . . . .28

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

ASC section on page 23.Minnesota’s reporting on errorshelps ORs fine-tune patient safety

Minnesota’s hospitals and surgerycenters are taking lessons fromstate reporting on adverse

events to make surgery safer. They arefine-tuning protocols for preventingwrong-site surgery and retained foreignbodies.

In January, the state issued its thirdannual public report on adverse events,which tallies errors from hospitals,ambulatory surgery centers, and treat-ment centers. The report includes thetypes of errors and the hospitals wherethey occurred.

The number of reports was up—154in 2006 compared with 106 in 2005.Minnesota’s Commissioner of Health,Dianne Mandernach, says that is a signthe system is working.

“Minnesota’s facilities are lookingharder for reportable events, and that’s apositive step,” she said.

Wrong-site reports rose slightly, from19 to 23, while the number of retainedforeign objects jumped from 26 to 42.

More awareness and better reportingare probably behind the increase inretained-object reports, notes AlisonPage, MS, MHA, chief safety officer forthe Twin Cities-based Fairview HealthSystem. More facilities realize they needto report sponges left in after vaginaldelivery, for example. About 40% ofretained-item reports involved labor anddelivery sponges, compared with 15% inthe first report.

There’s a shift in wrong-site proce-

Management

Patient safety

One seasoned OR director foundherself at a career crossroads afew years ago. “I’d had many

roles over the years: staff nurse, manag-er, director, vice president,” she says.“You get to a point where you’ve doneeverything and ask yourself, ‘What do Ido now?’” She knew a chief nurse posi-tion wasn’t for her, so she took 3 monthsoff to “sit in my garden” and answerthat question. Opportunity found her inthe form of an interim directorship.

Judith Canfield, RN, MBS, MHA,principal for her consulting business ofCJ Associates in Seattle, is currentlyinterim clinical director at OregonHealth Sciences University in Portland.She says, “There are so many opportuni-

ties to coach and mentor other people toget to the next level.”

Abundance of opportunityCanfield joins a number of OR direc-

tors who are finding satisfaction withinterim management. Mickie Parsons,RN, MS, CNOR, an independent con-tractor in Dillon, Colo, says, “There’sdefinitely growth in the demand andmore growth than there are candidates.”

She reports that 3 firms she knows ofsay requests for interim directors havedoubled in the past year.

Ilah Stolz, RN, MS, executive vicepresident of interim management for B. E. Smith in Lenexa, Kan, says growth

OR directors finding opportunityin interim management positions

Continued on page 9

Continued on page 7

2

Please see the ad for MEGADYNEin the OR Manager print version.

When Linda Kenney enteredthe hospital for a total anklereplacement a few years ago,

she was prepared for the discomfort andrehabilitation she would need.

She wasn’t prepared for what came next.Shortly after receiving a regional

nerve block, Linda began to show confu-sion and then went into a grand malseizure. Within minutes, she was in car-diac arrest. The care team called a codeand tried to resuscitate her, but it wasn’tworking.

Fortunately, a cardiac OR was ready,having just been prepared for an ICUpatient. Linda was taken in and placedon cardiopulmonary bypass. Within afew minutes, her cardiac rhythm hadreturned, and she was transferred to theICU. She was in the hospital 8 days.

Linda recovered physically. But the emotional recovery took longer.“Months after, I’d be driving down

the street and burst into tears,” she said.“Everybody else had moved on. I won-dered whether I was going crazy.”

Her anesthesiologist, too, was suffer-ing. Though he’d done nothing wrong,Rick Van Pelt, MD, says he felt hostilityfrom Linda’s family and isolation fromhis peers.

A path to healing“I felt as if a wall had gone up,” he

says. Though his colleagues were sup-portive, “No physician likes to acceptfailure. There’s always a perception thatif something goes wrong, you’ve failed.”

He wanted to reach out to Linda andher family. He tried several times whileshe was in the hospital. But his col-leagues and the hospital discouragedhim. He felt surrounded by what heterms “a wall of silence.”

Finally, on his own, he decided towrite Kenney a letter. And 6 months laterthey talked on the phone.

The conversation, they say, openedup a path to healing for both of them.Together, they decided to commit them-selves to remaking the way health careresponds to adverse events.

They launched the Boston-based non-profit, MITSS—Medically InducedTrauma Support Services. They define“medically induced trauma” as “anunexpected outcome that occurs duringmedical and/or surgical care that affects

the emotional well-being of the patient,family member or clinician.”

Kenney says someone described it as“normal people having normal respons-es to abnormal events.”

MITSS aims to offer support, healing,and hope. MITSS provides phone sup-port nationally and support groups inthe Boston area. It raises awarenessabout the need for support. It also helpshealth care organizations set up peersupport systems for clinicians and refer-ral programs for patients and families.Recently, MITSS worked with Brigham &Women’s Hospital in Boston to develop apeer support program for OR staff.

You can call MITSS if you or a staffmember has been through an incident.You’ll find a trained person who will lis-ten without judging. ”For nurses, we tryto find a nurse who is a good fit, and forphysicians, we try to find a physician,”says Kenney.

If you want help for a staff member,MITSS can help identify resources inyour own hospital or community, suchas a social worker, employee assistancecounselor, the psychology department,or a chaplain.

Organizations who want to build apeer support system specifically for clini-cians really need a champion like thechief medical officer. Kenney says it takessomebody at the top saying, “We want tochange the way we react to things.”

She adds: “Our vision is for everyoneto have access to this support.” v

—Pat Patterson

3April 2007

Upcoming

OR Manager Vol 23, No 4

April 2007 Vol 23, No 4OR 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 © 2007 OR Manager, Inc. All rightsreserved. No part of this publication may bereproduced without written permission.

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EditorialSupply chain solutions

What would the perfect OR inventorylook like? Organizations share their suc-cesses.

Should MDs disclose financial ties?

Read about the latest guidelines andadvice from experts.

“

“I wondered if I was going

crazy.

How to contact MITSSPhone toll free: 888/366-4877

Website: www.mitss.orgCaregiver support:

[email protected]

4

Please see the ad for SKYTRON, INC.in the OR Manager print version.

What helps more than anythingelse to attract and keep agood staff? Make sure you

have great team leaders and managers.And be sure they know managing peo-ple is a primary part of the job.

Nothing is more important in helpingto achieve the department’s objectivesthan an engaged staff. And nothing ismore critical to engaging them than theirrelationship with their immediate super-visor.

Engaging people needs to move ontoevery manager’s front burner, says CurtCoffman, keynoter for the ManagingToday’s OR Suite Conference Oct 3 to 5in San Diego. His talk is sponsored byKimberly-Clark Health Care.

In 1999, Coffman coauthored withMarcus Buckingham the best seller, First,Break All the Rules: What the World’sGreatest Managers Do Differently (Simon &Schuster, 1999). The book distilled 25years of work by the Gallup Organiza-tion to discover the best ways to attract,focus, and keep the most talentedemployees. Their meta-analysis of 24companies with 105,000 employeeslooked at business units with higher lev-els of productivity, profit, retention, andcustomer satisfaction.

A key finding—by and large, employ-ees form their opinions about the compa-

ny from their experiences with theirimmediate supervisor. That trumps pay,benefits, and other factors.

Coffman, now an independentresearcher, speaker, and consultant, isalso author of Follow This Path: How theWorld’s Greatest Organizations DriveGrowth by Unleashing Human Potential(Warner Books, 2002).

A passion for managementBeing a great manager is as much a

passion as being a nurse, Coffman main-tains. A manager’s passion is about bring-ing out the best in others by focusing onwhat they do best and compensating fortheir weaknesses with other people.

“In the past, the management title in

nursing wasn’t mainly about managingpeople. It was more about managingprocesses. Now we’re finding it is aboutmanaging people,” he says. “It’s makingsure you have the right talent in the rightjob. It’s making sure that talent feelscared about, has a trusting relationshipwith the manager, and is recognized.”

For the past 15 years, health care hashad a culture of competition. Nowthere’s a call back to collaboration, withmore experts seeing that as the way toachieve greater efficiency, innovation,and the best patient outcomes. Thatmeans engaging employees as well asphysicians.

Building collaboration, Coffman says,also takes “a strong, aligned group ofmanagers who know what the outcomesof their jobs are—and that is making surethe right talent is in the right role, know-ing their people well and positioningthem for success, giving them the infor-mation and equipment they need, andrecognizing individuals for outstandingachievement.”

Managers need to be held account-able for engaging their staffs, in additionto other objectives. If the staff is engagedand pulling together, the other objectivesare likely to be achieved as well.

“We’ve gotten it backwards,” saysCoffman. “We’ve made the people side ofthings secondary to the other objectives—something to do when you have time.

“The engagement of people needs tocome off the back burner.”

Attracting new managersWhat can be done to encourage more

nurses to go into management? Theredoesn’t seem to be as much eagerness byyounger people to move into those roles.

“It starts with rewarding great man-agers—rather than making becoming amanager the reward,” Coffman says.

“Frankly, we’ve rewarded people bymaking them managers. They may havebeen great performers in their clinicalrole, and we didn’t want to lose them. Sowe have some people whose turn it wasto get promoted—it wasn’t necessarilybecause their talent was to be a manager.

“Now we need to find people whoget their excitement out of seeing othersgrow, develop, and excel.” v

The conference brochure is included in thisissue. Or phone 800/442-9918 or visitwww.ormanager.com.

Keynote: Great leaders keep great staff

5OR Manager Vol 23, No 4April 2007

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

Amy Bethel, RN, MPA, CNAExecutive director, surgical services, IowaHealth, Des Moines

Mark E. Bruley, EITVice president of accident & forensicinvestigation, ECRI, Plymouth Meeting, Pa

Ramon Berguer, MDChief of surgery, Contra Costa RegionalMedical Center, Martinez, Calif

Helen K. Crouch, RN, MPH, CICDirector, infection control & epidemio-logy services; Infection control consul-tant for Army Great Plains RegionalCommand, Brooke Army MedicalCenter, San Antonio, Tex

Christy Dempsey, RN, BSN, MBA, CNORVice president, St John’s Regional HealthCenter, Springfield, Mo

Franklin Dexter, MD, PhDAssociate professor, Department of anesthesia, University of Iowa, Iowa City

Mary Diamond, RN, MBA, CNORDirector of surgical services, SharpHealthcare, San Diego

Marion L. Freehan, RN, MPA/HA, CNORNurse manager, main operating rooms,Massachusetts General Hospital, Boston

Jo Harbaugh, RN, BS, CGRNEndoSite advisor, Olympus America IncNormal, Ill

William J. Mazzei, MDMedical director, perioperative services,University of California, San Diego

Mary M. Murphy, RN, BSN, CNORDirector, surgical services, MunsonMedical Center, Traverse City, Mich

Susan Nielsen, RN, MSA, CNORDirector, central processing department,William Beaumont Hospital, Royal Oak,Mich

Barbara Pankratz, RN, MSNDirector, surgical services, University ofWisconsin Hospital & Clinics, Madison

Ena M. Williams, RN, BSNursing director, perioperative services, Yale-New Haven Hospital, New Haven, Conn

Advisory Board

Curt Coffman

6

Please see the ad for CARDINAL HEALTHin the OR Manager print version.

dures. In the new report, 50% occur out-side the OR, in procedures such as nerveblocks. In the first report, 90% were inthe OR.

The proportion of events causingdeath or serious disability was about thesame as the previous year—20%.

There was 1 death from a retained for-eign body. The circumstances were notdisclosed.

The most frequently reported eventoverall was a Stage 3 or 4 pressure ulcer.

The events are rare. In 2005, Minne-sota hospitals reported more than 2.7million patient days and saw nearly 8million outpatients. Ambulatory surgerycenters treated more than 150,000patients.

Under the Minnesota law, signed in2003, all of the state’s hospitals, ambulato-ry surgery centers, and regional treatmentcenters must report to the state 27 types of“never events.” These are events identifiedby the National Quality Forum as onesthat should never happen to patients.

Lessons learnedA group of 10 Twin Cities-area hospi-

tal systems called Safest in America hasused the state’s report to develop andfine-tune a protocol for surgical site veri-fication. A new protocol for preventingretained foreign bodies is planned forrelease this spring.

The surgical site protocol has justgone through its third update, based onthe new data and reports from the litera-ture. Safest in America visits each mem-ber hospital that has a wrong-site error tolearn what happened and why.

“Each year we have strengthened it.This is a living, breathing document,”says Dana Langness, RN, BSN, MA,leader of the protocol work group.

Safest in America says the protocol isconsistent with the Joint Commission’sUniversal Protocol for site verification,though it is more specific in somerespects.

Protocol updates The 2007 protocol includes algorithms

for preoperative, intraoperative, andbedside site verification outside the OR,as well as sample checklists.

Major updates: • An alert was added about anatomical

variation, which was the source of 2wrong-site errors in 2006. The proto-col says that when a patient is knownto have an anatomical variationinvolving the procedure site, theinformation will be shared with thecare team, and additional steps willbe taken to confirm the correct site.This may include additional imagingor a second physician confirming thesite.

• A requirement was added for anes-thesia providers to confirm thepatient’s identity, procedure, and sitebefore local or regional anesthesia.This was another source of errors in2006. Marking the injection site is notrequired to avoid confusion with thesurgical site mark.

• Site marking must be done with ini-tials by the person performing theprocedure. An X is not acceptable.The accountability may not be dele-gated. “We say the initials of the per-son performing the procedure will bemarked on the site or close to the siteof entry,” says Page. “That eliminatesany ambiguity.” Safest in America previously adopted

a number of other changes to reinforcesafety.

In 2005, the CEOs of Safest in Americahospitals agreed to a “hard-stop” policy,meaning the procedure is halted if anypart of the verification process is not fol-lowed and/or there is a discrepancy insite identification. If the situation cannotbe resolved, the procedure is cancelledand rescheduled.

For spinal surgery and other proce-dures involving levels, the protocol wasstrengthened to say, “High-quality intra-

operative imaging with opaque instru-ments marking specific bony landmarkswill be taken and compared to the preop-erative imaging to confirm the correctlevel/site prior to the procedure.”

Preventing retained itemsThis spring, Minnesota’s first protocol

for preventing retained foreign bodieswill be issued. Some areas discussed are:• making sure a thorough baseline

count is completed before the patientcomes in the room

• using a whiteboard in the OR torecord the count

• after a case, having the nurse checkthe OR before the next patient comesin to make sure all items from the lastcase were removed, and the white-board was erased

• conducting a formal wound explo-ration before the incision is closed. v

The adverse events report is atwww.health.state.mn.us/patientsafety.The safe site protocol is posted atwww.icsi.org. For more information, visitwww.safestinamerica.org.


Patient safety

Adverse events in MinnesotaOct 7, 2005-Oct 6, 2006

Total events 154Deaths 24Serious disabilities 7

Source: Minnesota Department of Health,2007. www.health.state.mn.us/patientsafety

Minnesotaadverse events

2005 2006Total events reported 106 154

Surgical events 53 74

Wrong procedure/patient 26 23

Retained foreign objects 26 42

Other surgical events 1 9

Criminal events: 4Medication events: 6Other

surgicalevents: 9

Otherevents:

10

Falls: 12

Wrong-sitesurgery: 23

Retainedobjects: 42

Pressureulcers: 48

Continued from page 1

The number of items unintentionallyleft behind after surgery remainedat zero for the second full year after

counting practices were reinforced at theUniversity of Minnesota Medical Center(UMMC) in Minneapolis. In contrast, 8such incidents were reported in the yearand a half before the project.

In Minnesota, such incidents must bereported and are made public (relatedarticle, p 1).

Though root cause analyses were per-formed for each incident, the problemkept happening.

UMMC started its reevaluation in mid-2004 by conducting a failure mode andeffects analysis (FMEA). In addition,human factors experts from the Universityof Minnesota spent 5 days observingsurgery with an OR nurse adviser. Humanfactors experts focus on how to design sys-tems and technology to make workprocesses easier and more user friendly.The hospital also held focus groups withphysicians, circulating nurses, and surgicaltechnologists. (See April 2005 OR Manager.)The university has 38 ORs and performsabout 20,000 cases annually.

Among issues the human factorsexperts observed were:• lack of awareness or knowledge by the

staff of details of the counting policy• lack of standardization in practices

such as counting and verifying thecount and recounting if the count is off

• distractions during counting, such asbeeping pagers

• not recording the counts in a consistentformat

• frequent changes in policy, causingconfusion

• cultural factors, such as the hierarchybetween physicians and nurses, whichsometimes prevented communicationof potential problems; for example, anurse might notice a mistake but hesi-tate to point it out to a physician.

An action planThe analysis led to an action plan to

address the issues, notes Carol Hamlin,RN, MSN, director of departmental perfor-mance for perioperative services. Issuesidentified during the FMEA formed the

basis of a detailed plan with separateaction items for each issue.

Changes implemented include:• Standardizing of best practices for

counting and verifying the count,including what to count, when tocount, what to do about an incorrectcount, and how to document.

• Ensuring staff compliance with thecount policy by clarifying expectations,observing practice, and following upwith noncompliant clinicians.

• Managing distractions at critical timesduring surgery.

• Introducing a required “time-out forpatient safety” when a staff memberfeels a situation in the room hasbecome unsafe. Specifically:—Whenever caregivers realize they orothers are task saturated, they areexpected to call for additional help. —Options for help include other avail-able clinical staff, supervisors, chargepersonnel, managers, etc.—When delegating to supplementalhelp, caregivers assigned to the patientshould retain patient and case-relatedtasks, such as documentation, counts,and vital signs. Tasks to delegateinclude getting supplies, lab results, orblood products; setting up equipment;phone or pager activities, etc.

• Developing a position statement byperioperative staff and leaders aboutprioritizing tasks and handling inter-ruptions, such as pages.

• Introducing the OR staff to appropriate-ly assertive communication methods.

• Standardizing policy development andimplementation, including minimizingfrequent policy changes that cause con-fusion.To maintain compliance with policies,

UMMC conducts quarterly observationalaudits of its counting process. Five proce-dures are observed per quarter in each ofthe center’s 3 surgical sites. Observerstypically watch the whole procedure,including the time-out, the counts, speci-men management, and management ofmedications on the sterile field, saysHamlin. v

8 OR Manager Vol 23, No 4 April 2007

Number of retained objects fallsafter count practices reinforced

Patient safety

Root causes ofsurgical events

Root causes submitted byMinnesota facilities:• Perceived pressure to complete

procedures in a certain amount oftime led to rushed preoperativeverification procedure.

• Staff reluctant to voice questions orconcerns to surgeons.

• Noise, interruptions, multiple com-peting responsibilities, and otherdistractions immediately prior tosurgery made it difficult to focuson the time-out or other preproce-dure verification policies.

• Policies related to site marking donot include the operating surgeon.

• Policies used in the OR to verifysurgical sites may not be used inprocedure rooms or during bedsideprocedures, or it may not be clearto the staff that these policies applyin other settings.

• Policy was in place requiring apause before the beginning of aprocedure, but the policy did notassign one person to be account-able for completion of the process.

• No policy was in place requiringfinal visual inspection ofsponge/gauze counts followingvaginal delivery.

• Sponges used during a procedurebecome more compact when moistand are difficult to separate, lead-ing to an incorrect count.

• Surgical drapes, Betadine, or othermaterials obscured the surgical sitemarking.

• There was lack of training for new,temporary, or floating staff onsponge count procedures or use ofcertain types of equipment.

• There was a lack of communicationduring staff handoffs.

• No policies were in place for count-ing certain materials/equipmenton the surgical field, or communi-cation of policies to staff in all areasof the facility was inadequate.

• Accountability for tracking certainitems before, during, and after theprocedure was not clear.


has been as much as 100% in this areaover the past 5 years. Paul Wafer, RN, BS,MBA, principal of Alpha ConsultingGroup, Inc, Manhattan Beach, Calif, sayshis business tripled last year, and heexpects it to double in 2007.

Why the need for interim manage-ment? Wafer says hospitals know theycan’t leave ORs in inexperienced hands.“It doesn’t take long for things to spiralout of control unless you have an experi-enced team. Of course, the key is findingexperienced leaders with a good trackrecord.”

That’s proving difficult. Says Parsons,“We’re getting older, and there aren’t alot of people coming after us.” Waferagrees, noting, “Generation Y has otherpriorities and doesn’t want to take onthe responsibility of management. Addthis to years of ‘lean’ organizations tak-ing out the middle management in mostORs, and you’re left with a tremendousvoid at the director level.”

Experienced OR directors can fill thatvoid as interim managers. Experts reportopenings across the country in all typesof facilities, from small to large.

Denice Higman, RN, MSN, presidentof Soyring Consulting, St Petersburg, Fla,reports, “We’re always looking for addi-tional surgery people.”

What it takesThink interim management might be

for you? Experts recommend askingyourself several questions before takingthe plunge (sidebar, p 10).

Linda Slezak, RN, MSN, RedwoodShores, Calif, who has more than adecade of experience as a perioperativeconsultant, says the first question is,“Why do I want to do this?” Ideally, theanswers are positive, such as more inde-pendence, travel, and a way to shareyour expertise with others. Be wary ofanswers such as burnout or changes insenior leadership that have left you dis-satisfied.

“My experience is that OR directorsare a resilient group. Interim OR direc-tors have to be even more flexible andself-assured,” she says. “Often, the clienthas been without leadership for sometime, and the challenges are significant.The interim must be able to hit theground running, fix problems, and movethe department forward in a short time.”

Many interim managers cite the bene-fits of not being a permanent part of anorganization.

“Interim managers have brought a lotof value to past organizations but arenow looking for a different quality oflife,” says Stolz. “They don’t want thestress that comes with making a long-term commitment to an organization,typically 3 years or more. Plus, they getto take time off between assignments aslong as they wish.”

Like any job, interim managementhas its challenges and rewards.

“The hardest part is not being in yourown home for extended periods of time,”says Canfield.

Larry Noriega, RN, PhD, is an experi-enced interim director as well as principalof Spinnaker-Health Partners, Houston.He notes that interims get to know thestaff well. “You really do care about thepeople and become invested, so it’s a littlesad when you make closure.”

Adds Carreen Andrada, RN, MSN,CNOR, “I like traveling and meeting dif-ferent people and working in differentfacilities. It keeps me fresh and on mytoes.” A consultant with 6 years’ experi-ence as an interim, she is currently inter-im director of perioperative services atAnaheim Memorial Medical Center inCalifornia.

What will you do?If you choose to become an interim

manager, you may be asked to maintainthe status quo. More often, however, thehospital wants change.

“You take over and push through ini-tiatives that are needed to keep up themomentum,” says Slezak. “This mightbe managing the capital budget, workingwith the physicians, or being a changeagent while they are recruiting a newperson.”

You might be called on to implement

a new service line, provide executivecoaching, or prepare for a visit from theJoint Commission or state regulatoryagencies.

Interim roles last from about 3 to 9months, with 6 months the most com-mon.

Types of modelsInterim management has 3 basic

models.The staffing company that brokers with

the hospital to find an interim director isone model. The company’s responsibilityoften ends when you are matched, andyou are paid by the hospital.

In the most common model, a compa-ny supplies interim management alongwith consulting as needed. Those in thefield recommend starting out this way.

“If you work as an interim, you haveto be concerned about indemnification,”says Slezak. “The benefit of working fora firm is that it carries the insurance.”

Some firms provide support duringthe assignment, such as data analysis,databases of policies and procedures,and benchmarking services. It’s wise todetermine the extent of support inadvance, she suggests.

In most cases, you’ll be a consultantinstead of a full-time employee. Waferrecommends hooking up with 2 or 3 dif-ferent companies if you want to work 12months a year. Look for companiesonline, through advertisements in ORpublications, or in direct mail advertise-ments. Another avenue is to talk withvendors you know who also provide thistype of service. Don’t forget word ofmouth; networking is key in this field.

Send your resume to the companyand ask to be listed. Wafer says a compa-ny will want to know the value youbring and your connections.

Forming your own independent busi-ness is the third model, although expertswarn against taking that route first.

“If you want to get started, I wouldsay you should work for a consultinggroup; they will give you the resourcesupport,” says Andrada. “Administra-tion won’t want to hold your hand whileyou learn the computer system. You’rehired to solve problems.”

If you decide to venture out on yourown, Wafer recommends working withan accountant to set yourself up as a soleproprietor, limited liability company, or

Management


Continued on page 10

“

“You are coaching others

to get to thenext level.


corporation to make it easier to contractwith clients and manage your business.This will also help in taxes and liabilitymatters.

Before you leapIf you are employed full time by a

firm, you most likely won’t interview theclient. If you meet the client, Parsons rec-ommends asking about key issues, whathas or has not been done to addressthose issues, and why the previous per-son left. Learn as much as possible aboutthe nursing staff and the situation.

Noriega recommends talking withpotential direct reports and leaders ofother departments, such as finance andmaterials management. Ask about avail-able resources, including secretarial sup-port, and whether OR educators are onstaff. Canfield advises tapping into yournetwork of fellow directors to learn moreabout the facility.

Most important, establish expecta-tions: “Are they expecting you to apply aBand-Aid or move forward?” asksSlezak. Be sure you understand whatdeliverables are expected at the end ofthe commitment.

Pay and benefitsPay for independent consultants

ranges from $900 to $1,000 or more perday. Firms usually pay less, $400 to $500per day because of the overhead, insur-ance, and additional services they pro-vide. Although the pay is typically morethan an OR director can make at a singleorganization, remember that health ben-efits or retirement aren’t typically includ-ed unless you are employed full time.

The firm or hospital pays yourexpenses, including lodging, car rental,and airfare. You can negotiate the num-ber of times you return home for visitsduring your tenure.

You’ll need to purchase your own lia-bility insurance and, unless your state hasa compact arrangement with the state inwhich you are going to practice, apply forlicensure in the state where you’re work-ing. Some companies don’t allow you todo hands-on care because of their insur-ance requirements, and you may need toundergo a background check.Get ready!

“Everyday, I’m talking with peopleabout how interim management is a

career path, not just something to dobetween jobs,” says Stolz. This careerpath can bring a better quality of life.Canfield used to commute 2.5 hoursevery day; now she is never further than5 minutes from her assignment. Shechooses when and where she works andsays, “It’s the capping off of a long and

fruitful career to have the ability to go todifferent facilities to coach and mentorother professionals to get to the nextlevel.” v

—Cynthia Saver, RN, MS

Cynthia Saver is a freelance writer inColumbia, Md.

Management


Here are some questions to ask.

Personal issues• Why do I want to do this? Ask your-

self if you are running towardsopportunity or away from a situa-tion you don’t like.

• What are my commitments athome? If you have a sick parent orare going through a divorce, youwon’t be able to give your full atten-tion to your job. On the other hand,many times, retired spouses travelwith the interim director.

• Can I be away from my home forextended periods? How often youcan return home during your tenurevaries. Frequent travel can take atoll on you.

• Do I like to travel? Travel can be fun,and with many companies, you canchoose how many assignments youtake a year.

• Am I adventuresome? “Your assign-ments will take you into all differentcultures, communities, and walks oflife,” says Ilah Stolz, RN, MS, of B. E. Smith.

• Do I like meeting other people?“You can’t be an introvert and dothis,” says Stolz.

• Am I comfortable being alone? “Itcan be lonely,” says Paul Wafer, RN,BS, MBA, of Alpha ConsultingGroup. “You have to be willing tohave dinner on your own or makefriends in the area.” On the otherhand, you may end up havingfriends across the country.

• Am I adaptable and flexible? “If youneed structure, don’t become aninterim manager,” advises CarreenAndrada, RN, MSN, CNOR.

Professional issues• Am I confident in my abilities? “You

need to be able to hit the ground

running, so you have to be confi-dent in your ability and be a risktaker,” says Wafer.

• Can I help people grow? “I don’twant people to be dependent onme,” says Judith Canfield, RN, MBS,MHA. “I am about giving peoplewings.”

• Can I let go? It’s easy to becomeattached to the people you workwith, but you have to move on.

• Am I committed to being engaged?“You can’t just drop in,” says LarryNoriega, RN, PhD, of Spinnaker-Health Partners. “You need to workactively with the nursing staff, med-ical staff, and other hospital lead-ers.”

• Do I have the necessary experience?Most interim mangers have 10 to 20years or more experience at thedirector level. “If you’ve bouncedaround a lot in your career, that canbe a red flag,” says Wafer. “On theother hand, those who have spentmost of their careers at only oneplace don’t do as well.”

• Do I have a graduate degree?Although some experts reportedopenings for experienced directorswith a BSN, a master’s or higherdegree opens more doors.Certification as an OR nurse isimportant too.

• What size of OR do I like to man-age? How many rooms am I com-fortable with?

• Am I open to other’s ideas?Although you bring a wealth ofexperience, it’s important to be opento different ways of doing things,says Mickie Parsons, RN, MS,CNOR. “You don’t win friends andinfluence people by saying, ‘This ishow we did it.’ Stand back and sur-vey the landscape.”

Considering interim management?

Are you planning to introduceintraoperative nursing documen-tation as part of your OR’s infor-

mation system?A veteran perioperative nurse has tips

on how to make the process go smoothly.Helen Blanton, RN, who has a rare com-bination of perioperative nursing and ITexperience, assists with implementationprojects for surgical services departmentsfor the 5 Oregon-based hospitals of thePeaceHealth system.

Get staff buy-inIf possible, have the staff participate in

the review and selection of the software.Though that often doesn’t happen, “ithelps create ownership,” Blanton says.

Not all nurses will warm to the ideaof documenting online.

“You have to insist that it’s going tohappen, but they can have some owner-ship in it.”

Another way to engage the nursingstaff is to involve them in developingpolicies for the electronic record.

Organize a project teamIn Blanton’s organization, the project

team for intraoperative documentationincluded the OR director, charge nurse,and specialty charge nurses. If you’reincluding preoperative and postoperativedocumentation, include those representa-tives as well. The medical records depart-ment needs to know that the paper recordis being revised and that when the elec-tronic record is live, the paper record willno longer be in the chart.

The team needs a close relationshipwith the IT team—“they should bejoined at the hip,” she says.

Get your paper record right Before moving to the electronic

record, revise your paper record and getit fully functional so the staff is comfort-able with it. “That will help your buy-in,” Blanton suggests.

Steps to take:

Check for regulatory requirementsHave your organization’s experts

review the record to make sure allrequired information is being collectedappropriately. Check for compliancewith government regulations, Joint

Commission standards, core measures,medical-legal issues, charging compli-ance, and so forth.

Consider quality measures The record should be up to date with

quality measures nurses have to docu-ment, such as surgical site verification,appropriate hair removal, and timelyadministration of prophylactic antibiotics.

Share the draftCirculate a draft of the revised form to

the staff for review. One organizationposted an enlarged version of the form,provided markers, and invited the staffto add their comments.

Involve a document design expertHave an expert review the form for

function and readability. Is there room towrite everything that needs to be docu-mented? Is the type readable by nursesover 40? Is there room for a 3-holepunch? Where will the patient stickerand bar code be placed?

Have the staff test the formHave the staff use the revised paper

record for a trial period, usually 90 days. “They need to have the paper record

imprinted on their memories,” Blantonsays. “That way, when they move to theelectronic record, they don’t have tolearn new data elements or fields. Thattakes away a lot of the stress.”

Audit charting complianceDuring the trial period, audit charts

for compliance, completion, and accura-cy. Are there areas the staff is havingproblems with or consistently missing?

Finalize the paper formIncorporate all changes and refine-

ments into the paper form. The paperversion is likely to be the backup if thecomputer system goes down. Decidehow the paper form will be reproducedand stocked.

Consult with softwaredesigners

While testing the paper form, beginconsulting with the software expertsabout translating the form to the com-puter screen. Make sure a nurse worksclosely with them so the electronic formwill follow the OR work flow. Have staffvolunteers test the electronic form as it isbeing developed.

“You want the electronic form to mir-ror the paper form as closely as possible,but the electronic form will flow differ-ently,” Blanton says. The screen does nothave as much room as a sheet of paper,so the form will break differently. Someinformation will be on drop-downmenus.

Carefully consider default charting.You may want the system to import stan-dard information for certain cases, suchas positioning, equipment, and patientassessment.

“These defaults are a key for staffacceptance, especially on short cases suchas D & Cs and ear tubes when they don’thave much time to chart,” she says. Butthe defaults need to be planned—youdon’t want the default to create opportuni-ties for errors or legal problems.

Emphasize to the staff that they areresponsible for editing any importeddefault fields. These are just as essentialto their documentation as the directentries.

Also identify which fields will havereminders if missed—a note will appearif the nurse tries to move to the nextscreen without completing an item—andwhich fields will be mandatory—therecord cannot be closed until they arecompleted.

Assess computer skills Also while the paper form is being

revised and tested, conduct a compre-hensive computer skills assessment forthe staff. Determine which ones are com-puter literate and need training only onthe electronic charting and which ones

Information systems


Making the move to online charting


“

“Plan how youwill staff for

training.


Information systems

need basic computer skills training aswell (eg, how to use a mouse).

“There are folks who will retire, if eli-gible, to avoid doing this,” Blanton says.“The impact on staffing is a piece man-agers often don’t think about. Thatshouldn’t stop implementation, but it issomething you have to consider.” Theremay be rare instances when a valued vet-eran nurse needs to be reassigned toduties that don’t involve charting. Forexample, the person might be trained tobuild preference cards for the new sys-tem. Once the nurse is comfortable withthe computer, he or she may elect toreturn to the circulator role.

Plan staff trainingA nurse with average computer skills

probably will need about 4 hours oftraining and perhaps more to learn elec-tronic charting.

“The training needs to be uninterrupt-ed,” she says. “You need to plan time forthe training and how you will staff for it.”

One hospital she worked with staffedup and assigned 2 circulators to eachcase during the 2 weeks before imple-mentation.

“The circulator alternated betweendocumentation and providing care sothey could get a feel for both. Then theytransitioned to having the same circula-tor do both,” she says. “I think that’s theideal way to do it.”

In addition, the postoperative staff,which is accustomed to having the paperrecord for reference, needs to be informedabout the new system and trained in howto access the electronic form.

Audit during the transitionIn the early weeks of electronic chart-

ing, Blanton recommends printing outthe completed charts. Audit for mistakesto see if there are trends. For example, isJane regularly missing incision times? IsJohn missing the positioning? See whereyou need to counsel staff and reinforcetraining.

Some information systems have built-in quality reporting functions that willproduce reports of charts that were notcomplete. But Blanton says in her experi-ence, it helps to audit the actual charts,particularly in the early weeks afterimplementation to identify and addressissues immediately. v


If you’re selecting or upgrading a peri-operative information system, youmight like to ask your peers what they

think of their systems. If they could startover, which system would they choose?Which vendor is the strongest for docu-mentation? Materials management?How do companies rate on integration?

KLAS Enterprises provides objectiveperformance ratings for health care soft-ware, including surgery information sys-tems.

OR Manager interviewed KLAS’ssenior vice president, Ralph Reyes, abouthow the company compiles its ratingsand how OR project teams can use theinformation.

How does KLAS compile itsperformance ratings of software?

Reyes: KLAS tracks data on over 175vendors and 500 products and services.Our performance ratings are based solelyon input from users of software andmedical equipment, which is compiled ina live database that is updated daily.

This is how we compile the data.Evaluations are submitted by a softwareuser (manager or above) in a confidentialdirect submission to KLAS. We receivehundreds of evaluations and conductover 1,000 verification interviews eachmonth from the more than 4,500 acutecare organizations and 2,500 clinics thatuse KLAS data. They come to our web-site seeking performance data on infor-mation systems submitted by their peers.

To grant software users free access tothe basic version of the KLAS data, weask them first to submit an evaluation oftheir current software. The evaluationtakes about 5 minutes and has 40 ques-tions. Among areas rated are productquality and technology, support, imple-mentation quality, on-time/on-budgetimplementation, and documentation.

After the evaluation is submitted, wedo a short telephone interview to verifythat the person submitting it is a manag-er or above (or is approved by the man-ager to submit data) and is not employedby a consultant or vendor. The user’sname, position, and facility are alwayskept confidential.

In addition, we do in-depth reportson specific product categories such assurgery management. For those reports,we seek additional input from users onfeatures, functions, and strengths of sur-gical services software.

How do users know KLASreports are objective?

Reyes: This is a critical issue for us. Inaddition to the steps outlined above, thedata must pass quality screens. Forexample, if we get an evaluation thatrates a vendor’s product as 7, 8, and 9(on a scale of 9), but our database showsthe typical score for that product is 3, 4,and 5, we quarantine the data for furtherinspection. We do the same if the evalua-tion is lower than the average. We con-tact the person who submitted the evalu-ation to validate the person’s role andresponsibility, and then we interviewsomeone else in the organization to vali-date that person’s ratings. The objectiveis to assure that the submission is accu-rate and unbiased. We also use vendors’client lists, but we don’t limit these to theshort “golden lists” vendors provide.These typically do not provide a com-plete picture of clients’ experiences.KLAS seeks additional customers toensure a broad, unbiased sampling.

Do ratings for surgerymanagement systems comefrom OR or IT personnel?

Reyes: The clinical executive inputranges from 30% to 60%, depending onthe application or department we aremeasuring. In our last surgery manage-ment report in August 2005, 36% ofrespondents were clinical, 51% werefrom IT, and 12% were from senior man-agement. The Surgery InformationSystems 2005 report was based on 381interviews from about 800 installations.The next report will be released in the lat-ter half of 2007.

If an organization is planning topurchase or upgrade its ORsoftware, how could it use KLASdata?

Reyes: There are 3 ways organizationstypically use the KLAS data and website:

Firm provides independentratings on OR info systems

Q

Q

Q

Q

1. When they are getting ready to sendRFPs (requests for proposal) to ven-dors, the software selection teamsearches the KLAS website’s VendorDirectory to see which companieshave software in that area. Over 1,000vendors are listed.

2. During presentations, demonstra-tions, and contract negotiations, selec-tion teams review current data sub-mitted by their peers online. If theirorganization has contributed data toKLAS, they get free access to KLASOnline, a database where providerscan view the OR system ratings, aswell as data on all applications in thedatabase. They can read specific com-ments (eg, what has been positive ornegative) in areas such as implemen-tation, contracting, support, and func-tions. This data is useful to the teamas they listen to presentations, view

demonstrations, and go on site visits.In addition, the data are useful duringcontract negotiations, providing fac-tual information that needs to beincluded in the final agreement. Forexample, if the vendor’s “implemen-tation within budget” score is low, theteam can use this information to justi-fy a clause in the contract that protectsthe budget.

3. If the contract is already signed, theimplementation team can read com-ments submitted by their peers tolearn what experiences they have hadwith the implementation or productso they can address similar issues.If an organization contributes data

and is interviewed for our specialreports, such as the upcoming 2007Surgery Systems Study, they get a freesummary of that study.

The price of reports for provider facili-

ties that haven’t submitted data or arenonsubscribers is $980. For facilities sub-scribing to KLAS, the cost is $737.Members of the Association ofperiOperative Registered Nurses (AORN)receive a 15% discount, regardless ofwhether they subscribe or submit data.KLAS encourages users to submit databecause it makes the database more usefuland robust. The report price for vendorsand consultants is approximately $7,000because they do not contribute data. v

The KLAS Enterprises website is atwww.healthcomputing.com.


Information systems

2006 Overall Scores94.25

82. 94

25.35

63. 55 81. 74

90.9 5

67.25

88. 25

67 .16

5 5. 32 01. 12

97.32

1 0.62

2 2.02

8 4.52

41 .42

3 8.12

43. 62

0

10

20

30

40

50

60

70

80

90

100

CernerMillenniumSurgiNet

GE CentricityPerioperative

McKessonHorizon

Surgical Mgrv.9-10

Meditech C/SORM

MediwarePerioperative

Solutions

Per-Se ORSOSv.9-10

Picis ORManager

SIS SurgerySoftware

USA ORMS

Business Indicators

Performance Indicators

67.40

77.31

84.57

70.38

76.0474.71

88.10

76.90

81.37

Source: KLAS Enterprises. Reprinted with permission. The business indicator score is based on a series of yes-no questions about the finan-cial aspects of the system, such as would you buy the system again, fair contract terms, etc. Performance indicators include issues such asthe quality of training, implementation, interface service and capability, system response time, etc.*Per-Se Technologies, Inc, has been acquired by McKesson Corp.

2006 overall scores for surgery management systems

*

Check our website for the latest news, meetingannouncements, and other

practical help. www.ormanager.com

Selecting the right software for yourperioperative services departmentis one of the most important deci-

sions a manager makes. The softwareused to manage perioperative services iscritical because the OR drives the hospi-tal’s inpatient capacity as well as the rev-enue and margin. The software mustenable the OR manager to access dataneeded to guide strategic decisions, sur-gical scheduling, and quality.

Finding the best vendor to fit yourorganization can be a challenge. Amongquestions that must be answered are:• Will you need a “niche” solution only

for the OR? Or will your softwareneed to integrate into a facilitywidesystem?

• Will you need new hardware toaccommodate the application?

• Are upgrades necessary and support-ed?

• What are the interface requirements?How successful are the various ven-dors at implementing interfaces?

• Will you be able to retrieve reportsyou need? The best way to start is to send vendors

you will consider a request for proposal(RFP). An organized, well-thought-outRFP not only provides vendors with yourspecific requirements but also establishesclear communication between your orga-nization and vendors. It allows you todefine your hospital’s mission and needsand to obtain information about how eachvendor will meet and support thoseneeds. These are steps to consider indeveloping your RFP. (A sample outline isin the sidebar.)

Identify the scope of theproject

The decision about a niche systemversus an integrated solution should bemade first. All vendors are not equal—integrated systems (designed to provideenterprisewide solutions) are differentfrom niche systems intended for a specif-ic service area. While enterprisewidesolutions may not have all of the special-ty-specific features a niche solution mayhave, they provide greater access toinformation across the continuum,decreasing the need for interfaces. Eachinterface that needs to be developed for a

niche system raises issues of compatibili-ty and errors.

The choice between an enter-prisewide or service-specific productmust be made before taking the next stepof identifying potential vendors.

Identify prospective vendorsOnce you have determined the scope

of the project, you’re ready to identifyprospective vendors. National confer-ences, site visits to observe vendors’ sys-tems in a live environment, and vendordemonstrations are good ways to identi-fy prospective vendors.

A letter of introduction should be sentto prospective vendors to request infor-mation about their company—they mayor may not be able to meet your needs.The letter should request informationabout the company’s growth, capacity,and viability—is the software well estab-lished, or is it “vapor ware”? Your orga-nization will need to decide if it wants toconsider software that is in alpha or betatesting.

After the vendors have been identi-fied and background checks performed,develop a list of vendors to whom youwill send the RFP.

The vendors probably will have ques-tions once the RFP has been received.Appoint a single contact in the organiza-tion to ensure suppliers are given consis-tent information. It is important thatdeadlines are met and communicationoccurs in writing in the way specified inthe RFP overview.

Receipt of proposalsOnce the proposals are received,

weed out those that do not meet theorganization’s needs. Narrow the field tothose best able to address the needs of

your organization and evaluate theirproposals. Check references and arrangesite visits to assure that the proposal isaccurate, and the company is able to pro-vide what its proposal promises. It maybe beneficial to visit the vendor’s head-quarters as well. Expenses for site visitsmay be paid by the vendor or hospital.Who will cover the expense should havebeen addressed in the RFP so there areno surprises.

After the proposals have been evalu-ated, the organization may need toreassess and discuss or negotiate somecomponents with the vendors. Aftercompleting these steps, the organizationshould have a sense of the 2 to 3 possiblevendors.

The final offerThe vendors should then provide

their best and final offer. The organiza-tion must decide which vendor will bestmeet its needs. The organization’s seniorleadership should be briefed on the final-ists and the budgetary requirementsclearly delineated.

After the purchase has been made,the vendors who were not chosen shouldbe contacted with the decision. It is acourtesy to allow them to question thedecision so they can improve future pro-posals based on your feedback. All docu-mentation between the chosen vendorand your organization should be main-tained for the contract period. v

—Christy Dempsey, RN, BSN, MBA,CNOR

Vice President, Perioperative andEmergency Services

St John’s Regional Health CenterSpringfield, Mo

ResourcesCustom Software RFP sample.

www.infotivity.com/rfp-template-request-custom-ann.html.

Porter-Roth B. Request for Proposal: A Guideto Effective RFP Development. Boston:Addison-Wesley, 2002.


Upgrading software? Developing the RFP

Information systems

“

“Will you be able to retrieve

reports youneed?


Information systems

An outline for an RFP for a periopera-tive information system.

I. OverviewThis section provides the vendor with

the invitation to submit a proposal toyour organization and describes theway the proposals will be managed. Itusually outlines the purpose for therequest or a statement of the issues. Inaddition, this section provides the dead-lines for the proposal as well as the par-ties to whom the proposal should beaddressed. This section may alsoinclude general information about yourorganization and the departments thatmay be involved in the decision and/orimplementation. It may also includebackground information on workprocesses that may affect the implemen-tation. This section should clearly statehow the RFP should be submitted andfor how long the proposal should bevalid.

II. Technical requirementsThe technical section is perhaps the

most important. This section describesthe technical details and the workrequired to meet the needs the productis expected to address. That mayinclude hardware, interfaces, compati-bility, ease of use, reporting capability,etc.

Your organization’s requirements foreach of these items must be clearlydefined so the vendor’s proposal will bespecific in addressing each requirement.The IT department must be involvedwith this portion of the RFP becausethis is generally within their purview.The IT department must rely on theclinical, financial, and operational issuesassociated with the product and writethe technical requirements according tothe needs and capabilities of the organi-zation. Specific requirements aboutupgrades, future growth, and changesin technology should also be addressed.In addition, requirements for staff edu-

cation and training must be clearlydescribed.

III. Vendor qualificationsIn this section, the vendor is asked to

submit information about the company:• How long has the company been in

business?• Has the company demonstrated sta-

bility and positive fiscal performancein the previous 5 years?

• What support does the companyprovide for its product?

• What is the expected timeframe forresolution of issues and response foron-site work?

• How will conflicts or issues beaddressed and resolved duringimplementation and for the length ofthe contract?

The company is asked to provide alist of clients and actual project imple-mentations.

IV. Pricing andimplementation

The pricing section should address allof the requirements outlined in the RFP.For budgeting purposes, the organiza-tion must specify a clear and consistentformat for submitting pricing informa-tion. If proposals are similar, pricingmay be the deciding factor. The require-ments listed in Technical Requirementssection must be linked to pricing.Hardware requirements for servers,routers, computer workstations, inter-face engines, printers, and other ancil-lary devices must be priced. The soft-ware applications; licenses and userfees, and any operational costs such asredundant systems, downtime, work-arounds, or customization costs shouldalso be listed here.

Vendors should be instructed todefine pricing clearly for the quantitiesfor each line item. For example, is thelicense for the organization as a whole,or will each department be required to

have a license? Implementation costs,travel for consultants and implementa-tion specialists, and testing and integra-tion of the software with existing sys-tems should also be priced. Ensuringthat each component is priced separate-ly will reveal any hidden costs that maybe buried in a more global pricing struc-ture. One approach is to include aspreadsheet with the RFP listing eachrequired component and request that allvendors use the spreadsheet for theirsubmissions. Especially important tocapture are any maintenance or annualfees that will continue for the useful lifeof the product.

It is acceptable to state that pricingmust be competitive and, in fact, betterthan other offers if your organizationcommands a higher market share orbuying power than other organizationsof similar size.

In addition, your organization mayoffer vendors a sole-source or longer-term contract in the RFP. You shouldclearly define acceptable and unaccept-able pricing structures. For example, ifyour organization will not accept pric-ing based simply on a percentage dis-count off list price, the RFP should statethat no such proposal will be consid-ered.

V. Contracting sectionThis section describes any contracts

or agreements the vendor must enterinto or disclose for the organization. AHealth Insurance Portability andAccountability Act (HIPAA) agreementis an example. If the software will allowaccess at any time to protected healthinformation, your organization’s legalcounsel may require the vendor to signa binding agreement that will protectthat information. Purchase agreementsas well as any maintenance contracts,warranties, and so forth should beincluded in this section.

Sample structure for a request for proposal

16

Please see the ad for ADVANCED STERILIZATION PRODUCTSin the OR Manager print version.


OR managers are raising questionsabout the federal Family andMedical Leave Act (FMLA). They

say they try to be sympathetic to the needsof employees that the act is supposed toalleviate, but the prolonged leaves cancause staffing problems.

Questions focus on the privacyrequirements of the act. Some managerssay they are kept in the dark by rulesthat apparently allow only humanresources managers to know the employ-ee’s information. Managers say theyoften don’t know why an employee istaking a leave or when the person willreturn. In some cases, they have had toleave an employee’s job open formonths, creating a staffing crunch.

“It’s definitely a hot topic and onethat can be quite challenging to manage,particularly in an OR,” confirmedJeanene Martin, SPHR, MPH, MEd,senior vice president of human resourcesfor WakeMed Health & Hospitals,Raleigh, NC.

We asked Sharon Murphy, SPHR,MHA, HR director for compensation/benefits & HRIS at WakeMed, to answerquestions about the FMLA and itsrequirements. Murphy is a member ofthe American Society for HealthcareHuman Resources Administration(ASHHRA) and president-elect of theNorth Carolina chapter.

What does the FMLA require ofa manager?

Murphy. First, let’s distinguish betweenthe employer, by which I mean the compa-ny the manager and employee work for,and the manager or supervisor. In the caseof OR employees, the OR manager wouldbe the employee’s manager. The employerwould be the hospital, surgery center, orother health care organization.

The FMLA requires a coveredemployer to allow “eligible” employees(sidebar) to take job-protected, unpaidleave, or to substitute appropriate paidleave if the employee has earned oraccrued it, for up to a total of 12 workweeks in any 12 months for specific fami-ly or health-related reasons. The FMLAprohibits interference with an employ-ee’s rights under the law and with legalproceedings or inquiries relating to anemployee’s rights.

Every employer covered by theFMLA is required to post a noticeexplaining the act’s provisions and pro-viding information about procedures forfiling complaints of violations. As thesupervisory representative of theemployer, the manager needs to knowthe basic eligibility requirements forFMLA, because the manager is often thefirst to know an employee may be eligi-ble for a leave.

What can a manager ask (andnot ask) about an employee’srequest for a leave? What is anemployee required to disclose?

Murphy: According to the law, anemployee must provide at least verbalnotice sufficient to make the employeraware that the employee needs FMLA-qualifying leave and to help the employerknow the anticipated timing and durationof the leave when the need for FMLA isforeseeable. The employee need notexpressly assert rights under the FMLA oreven mention the FMLA; he or she canstate only that the leave is needed.

The manager can start the FMLAprocess by asking the employee to fill outa form requesting FMLA leave. Forinstance, an OR nurse may tell her man-ager that the nurse’s son has been diag-nosed with chronic asthma in an acutephase, and the nurse thinks she will needto take off 1 day each week to take herson for treatment. The manager askshow long this situation is expected toremain acute, and the nurse says shethinks it may go on for 2 months.

At that point, the manager wouldsuggest FMLA leave and give the nursethe request form to fill out. The form alsowill include requirements for medicalinformation from the nurse’s son’s healthcare provider.

This is where the privacy issue getstricky. The employer, ie, the company,decides whether the leave requested isFMLA-qualified, based on the documen-tation in the application for leave. But thedirect manager of an employee shouldnot have access to an employee’s person-al medical records, nor those of theemployee’s family members.

The law is clear: an employee’s med-ical records are private from a manager.The question arises: Who does reviewthe documentation and decide the leavecan be approved? At WakeMed, we havedeveloped an administrative process forhandling these applications so theprocess is the same for everyone and isfair for everyone. I recommend such aprocess for any organization.

How does it work at WakeMed?

Murphy: Let’s return to ourexample. The nurse has told her managershe needs to take off 1 day a week for 2months, and the manager has advised herto request FMLA leave. The employee fillsout the application, and her son’s doctorattaches appropriate documentation of theasthma condition, including an estimate ofhow long the health care situation is likelyto last. The application and documenta-tion are filed with WakeMed’sOccupational Health and SafetyDepartment (OHSD), the designateddepartment in our organization for reviewof those records. OHSD makes the recom-mendation for leave and advises HR andthe OR manager of its decision.

The important thing is to have anobjective and qualified third party withinthe organization that reviews the medicalrecords that document need for a leave.

At that point, is the ORmanager out of the loop?

Murphy: Not at all. It’s true that amanager should not ask specific medicalquestions about information in theemployee’s private files. But managershave the right to have some dialoguewith the employee about the leave. Inour example, the OR manager can cer-tainly ask the nurse to make periodicreports, informal or formal, on her leavestatus and intent to return to work full

Family & Medical Leave Act and OR staffing

Managing people


“

“The manager can ask for

periodic reports.

Q

QQ

Q


time after the approved leave. The formrequires some estimate of how long theleave being requested will be. If a latercircumstance requires an extension, theemployee must notify the employer andfurnish further documentation as neces-sary.

There is nothing in the law to prohibita manager from asking the employeewhen he or she expects to return orwhether the situation has changed. It isthe employer’s responsibility, not theemployee’s, to designate leave, paid orunpaid, as qualified FMLA leave.

Must the employer leave thesame position open?

Murphy: Any eligible employee whotakes leave under Section 102 for theintended purpose of the leave is entitledon return to (a) be restored to the posi-tion held by the employee when theleave commenced or (b) be restored to anequivalent position with equivalentemployment benefits, pay, and otherterms and conditions of employment.

What if an employee’s annualreview time arrives while theperson is on leave? Is theemployee entitled to a cost-of-living increase or any otherraise that might be givenordinarily?

Murphy: An employee is entitled toany unconditional pay increases thatmay have occurred during the FMLAleave period, such as cost-of-livingincreases. Pay increases conditionedupon seniority, length of service, or workperformed would not have to be grantedunless it is the employer’s policy or prac-tice to do so for other employees on“leave without pay.”

What terms can an employerstipulate for the leave? Forexample, can the employee berequired to inform theemployer of plans as the end ofthe leave time approaches? Ifthe employee requests anextension, must that begranted?

Murphy: An employer can require anemployee on FMLA leave to report peri-odically on the employee’s status andintent to return to work. The employer’spolicy regarding such reports cannot be

discriminatory and must take intoaccount all of the relevant facts and cir-cumstances related to the individualemployee’s leave situation.

If an employee gives unequivocalnotice of intent not to return to work, theemployer’s obligations under FMLA tomaintain health benefits (subject toCOBRA requirements) and to restore theemployee cease. But these obligationscontinue if an employee indicates he orshe may be unable to return to work butexpresses a continuing desire to do so.

If an employee needs more leave thanoriginally anticipated, the employer mayrequire a reasonable notice of thechanged circumstances where foresee-able; ie, within 2 business days. Theemployer may also obtain informationon such changed circumstances whereforeseeable.

What is an employer allowed todo about filling the positionwhile the employee is on leave?

Murphy: On return from FMLAleave, an employee is entitled to rein-statement even if the employee has beenreplaced or his or her position has beenrestructured to accommodate theabsence.

How does your facility handlethe stresses on staffing createdby leaves?

Murphy: To support staffing needs,WakeMed provides special pay incentivesfor employees who cover additional shiftsoutside of their normal work schedule. Wehave various methods that also includeutilizing our in-house supplementalstaffing pool. This curtails the need to usetravelers and agency personnel. v

—Kate McGraw

Kate McGraw is a freelance writer in SantaFe, NM.

ASHHRA can be reached at 312/422-3720 orvisit www.aha.org/ashhra.

ReferencesUS Department of Labor Employment

Standards Administration: Fact Sheet#28: The Family and Medical LeaveAct of 1993. www.dol.gov/esa

Smith S, Mazin R. The HR Answer Book.New York: American ManagementAssociation, 2004. www.amacombooks.org.

Managing people

Continued from page 17Facts on the FMLA

The purpose of the federal Familyand Medical Leave Act (FMLA) is tohelp employees balance work andfamily responsibilities by allowing aneligible employee to take “reasonableunpaid leave” (up to 12 weeks in asingle year) for certain family and/ormedical reasons. The FMLA applies toall public agencies, all public and pri-vate elementary and secondaryschools, and all companies with 50 ormore employees.

The circumstances under which theunpaid leave must be allowed are:• for the birth and care of the new-

born child of an employee• for placement with the employee of

a child for adoption or foster care• to care for an immediate family

member (spouse, child, or parent)with a serious health condition

• to take medical leave when theemployee is unable to workbecause of a serious health condi-tion.

Employees are eligible for leave ifthey have worked for their employerfor at least 12 months and for at least1,250 hours over the past 12 monthsand work at a location where the com-pany employs 50 or more employeeswithin 75 miles. Whether an employeehas worked the minimum 1,250 hoursis determined according to federalprinciples for determining compens-able hours or work. Time taken offwork due to pregnancy complicationscan be counted against the 12 weeks offamily and medical leave. Any healthcare coverage provided under theterms of the employer’s group healthinsurance plan must be continued forthe duration of the leave.

Source: US Department of Labor.

Q

Q

Q

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Ambulatory surgery center (ASC)leaders sent a message toWashington in recent weeks that

they want the government to revisit theformula it is considering as part of its planto change the ASC reimbursement system.

The new system is scheduled to takeeffect in 2008. Under the proposal issuedby the Centers for Medicare and Medi-caid Services (CMS) in August 2006, ASCfacility payments would be pegged tothe hospital outpatient department(HOPD) rates. But ASCs are dismayedthat the government proposes to paysurgery centers only 62% of what hospi-tals get for the same procedures.

Meeting with senior officialsFASA’s state leaders aired concerns

with 2 senior Bush administration officialsMarch 1 at FASA’s Alexandria, Va, head-quarters. They met with Acting DeputyDirector of CMS Herb Kuhn and Healthand Human Services Secretary MikeLeavitt’s chief of staff, Rich McKeown.

Originally, when ASCs started asking

for a change in the payment system, “ourpayments were 85% of the HOPD rate,”said the executive director of the IllinoisASC Association, Mark Mayo. “The pro-posed 62% rate will be a substantial lossto ASCs.”

Gastroenterology would be particular-ly hard hit, with rates dropping by 11%,noted Rob Quinton, the public policy chairof the Washington Ambulatory SurgeryCenter Association.

CMS’s acting administrator, LeslieNorwalk, addressed the FASA group Feb28. Without saying anything specific aboutwhat CMS might be considering for its finalrule, she noted that CMS was aware thatmany consider the 62% proposal too low.

“We are spending a lot of time tryingto get the right balance,” she said.Congress has mandated that the finalrule be budget neutral.

Seeking lawmakers’ supportThe American Association of Ambu-

latory Surgery Centers staged a message-writing campaign urging Congress to sup-

port legislation directing CMS on ASCmatters. The message:• CMS should adopt the proposal from

the Medicare Payment AdvisoryCommission (MedPAC) to allow ASCsto receive Medicare payments for anyoutpatient surgery, except thosedeemed a safety risk by the Secretary ofHealth and Human Services.

• CMS should pay ASCs at 75% of thehospital outpatient rate for the same ser-vice.

• ASCs’ annual payment updates shouldbe aligned with hospital updates. ASCleaders are concerned about importantdifferences in update methods pro-posed for the 2 settings.

The CMS proposal was published in the Aug23, 2006, Federal Register. Go to www.gpoac-cess.gov/fr/index.html and search by date.More information is at www.fasa.org andwww.aaasc.org.

ASCs lobby on Medicare pay plan

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COMPVIEWMEDICAL

in the OR Managerprint version.


22

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Lee Anne Blackwell, RN, BSN, EMBA, CNORNational director, clinical education,ambulatory surgery division, HealthSouthCorporation, Birmingham, Ala

Nancy Burden, RN, MS, CAPA, CPANDirector, health services, Morton PlantMease Health Care, Clearwater, Fla

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

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

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

Ann Geier, RN, MS, CNOR, CASCVice president of operationsAmbulatory Surgery Centers of AmericaNorwell, Mass

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

LeeAnn PuckettMaterials manager, Evansville SurgeryCenter, Evansville, Ind

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

Ambulatory Surgery Advisory Board

Bariatric surgery: Is your ASC ready?More Americans are turning to

bariatric surgery as the answerto morbid obesity. In the past,

they faced open gastric bypass surgeryas the only surgical route to lose weightand improve their health. But endoscopicinnovations, including laparoscopic gas-tric bypass and laparoscopic adjustablegastric banding (LAGB), result in fewercomplications, a faster recovery time,and less pain than open procedures.

Surgeons are starting to perform theseless-invasive procedures in the outpatientsetting, primarily LAGB. Some offer onlyLAGB, while others offer LAGB and otherlaparoscopic options such as Roux-en-Y.

Payoff for patientsWhat is it like to start an LAGB pro-

gram? Those who have done it say thework is well worth the payoff forpatients. As patients lose weight, “yousee them come off insulin or heart med-ications that they’ve taken for years,”says Dee Willey, RN, clinical manager atSurgery Center of Richardson, Tex. Atpress time, the Surgery Center was theonly outpatient center accredited by theAmerican College of Surgeons (ACS)Bariatric Surgery Center Network. Willeyadds, “You see their self-esteem improveand a total lifestyle change.”

Supportive care before and aftersurgery, including psychological evalua-tion, support groups, and nutritionaleducation, is as important for outpatients

as for inpatients. (For more information,see “Weighing the decision to become abariatric center of excellence,” in theJanuary 2007 OR Manager). In the outpa-tient setting, the physician group doingthe procedure may provide the support-ive care.

Making the leapDepending on your situation, you’ll

choose one of 3 models for outpatientbariatric surgery. One is the hospital thatoffers outpatient surgery. A second, morerecent model is the freestanding, multi-specialty ambulatory surgery center(ASC) that includes bariatric surgery as aservice line. The newest model is theASC that offers only bariatric surgery.This article focuses on the second model.

Whichever model you choose, saysJeffrey Simmons, president, WesternRegion, for Regent Surgical Health, LLC,Westchester, Ill, “You have to be commit-ted to a center of excellence model. Don’t

do it haphazardly.” Regent SurgicalHealth is a management company forASCs that offer bariatric surgery. Abariatric center of excellence meets stan-dards established by the ACS or theAmerican Society for Bariatric Surgery(ASBS).

Commitment begins with a physicianchampion for the program, one who hasextensive experience with the procedure.

Next, you’ll need equipment. Simmonssays it can cost $250,000 to start up if youdon’t have endoscopic equipment inplace. The good news is that if you arealready doing endoscopic gastrointestinalprocedures, startup costs may be closer to$30,000 to $50,000 to add lap-bandinginstruments and a wide variety of bandsizes.

An underestimated costDon’t forget to consider facility and

equipment changes such as wider ORbeds and stretchers, larger gowns, andcommodes fixed to the floor instead ofthe wall. These changes are important forpatient safety and dignity.

“That’s a cost often underestimated,”says Anne Roberts, RN, BSN, adminis-trator of the Surgery Center of Reno,Nev, which has been offering bariatricsurgery since April 2006. Simmons esti-mates those costs can be as high as$25,000.

You’ll need to determine if your antic-Continued on page 25

“

“You have to becommitted to

a center of excellence model.

24

Please see the ad for DUPONTin the OR Manager print version.

ipated volume will justify the expense.The number of cases per month varies fromcenter to center, making it difficult to esti-mate average volume, although severalcenters report 30 to 75 LAGB proceduresper month. It’s best to have several sur-geons so you can build sufficient volume.

Who’s safe for the outpatient setting?

Another factor that influences volumeis eligibility criteria. Patients who under-

go bariatric surgery as outpatients musthave a lower body mass index (BMI)than inpatients, usually less than 50,which is usually associated with fewer,less-severe comorbidities, such as dia-betes mellitus that is well controlled. Inaddition, patients should have anAmerican Society of Anesthesiologistsclassification of 3 or less. Patients withhigher BMIs or significant comorbidities,such as severe cardiac disease, shouldhave their surgery in an inpatient setting,regardless of BMI.

More research is needed to flesh out

these general guidelines and determinethe best candidates for outpatientbariatric surgery, says Daniel Jones, MD,associate professor at the HarvardMedical School and director of bariatricsurgery at Beth Israel Deaconess MedicalCenter, Boston.

“We need to base patient choice onsound data,” says Dr Jones, who is amember of the ACS Bariatric Network.He cautions against offering only onetype of procedure.

“A surgeon needs to be skilled in boththe gastric bypass and the band sopatients have choices.”

To better compete with other centers,you may want to seek accreditation fromeither the ACS or the ASBS program,which is administered by the SurgicalReview Corporation (SRC) (sidebar, p 27).Both organizations report that many ASCsare in the application process.

To stay or not to stayAn LAGB takes from 30 minutes for

surgeons who are past their learningcurve for the procedure to 2 hours forlarger patients. What happens nextvaries. Some patients stay in thepostanesthesia care unit (PACU) only 2to 3 hours and then go home. OtherASCs have overnight capabilities, mostof which allow patients to stay for up to23 hours. Several factors influence thedecision, including the surgeon’s andfacility’s comfort with the procedure, thepatient’s home situation, and how far apatient lives from the ASC.

“When we started, surgeons wanted usto keep patients overnight,” says KarlaTacey, RN, administrator at SurgeryCenter of Richardson. “We had to con-vince them it wasn’t necessary.” Since theybegan offering the procedure in 2003, theCenter has had only 2 emergency transfersout of more than 3,000 LAGB procedures.Patients go home the same day.

“We thought lots of patients wouldstay the night, but fewer than 5% do,”Roberts says. Simmons reports that ayear ago, when one center started doingLAGBs, all patients stayed overnight, butnow more than two-thirds go home thesame day.


AmbulatorySurgery Centers



Laparoscopic-adjust-able gastric banding(LAGB) is the least inva-sive surgical techniqueto reduce weight. WithLAGB, the surgeonplaces a single-use band,which comes in differentsizes, high on the stom-ach to create a smallpouch, about 15 mL involume, and a stoma.The band is sutured inplace. The port forinflating and deflatingthe band is sutured ontothe abdominal wall. Aspatients lose weight,adjustments are madeseveral times a year toachieve restriction andsatiety. One advantageof the band is that it canbe completely removed.

Mortality ranges from0.05% to 1.1%. Potentialcomplications include gastric prolapsefrom band slippage or explantation,and dysfunction of the port reservoir ortubing, although complication rates arelow. Reoperation is needed in 4% to18% of patients.

Patients can gradually lose 65% to70% of their excess body weight (EBW)and about 35% of their body massindex (BMI), with an average EBW lossof nearly 50% 2 years after surgery.

ReferenceBuchwald H. Consensus conference

statement: Bariatric surgery for mor-bid obesity: Health implications forpatients, professionals, and third-party payers. J Am Coll Surg. 2005;200:593-604.

Edwards M, Grinbaum R, Schneider B,et al. Surgical Endoscopy. In press.

Lap-adjustable gastric banding

Reproduced with permission from Jones D B. Atlas ofMinimally Invasive Surgery, Cine-Med, 2006.

26

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Sometimes geography factors into thedecision. Many patients at Beth IsraelDeaconess travel a significant distancefor surgery.

“A lot can happen before you gohome. You need to get used to the band,understand your diet, and have yourpain well controlled,” Dr Jones says. Forthat reason, most patients stay overnight.

Overnight optionDr Jones and others strongly recom-

mend having an overnight option if youwant to do procedures other thanLAGBs.

At Harmony Ambulatory Surgery,LLC, Fort Collins, Colo, surgeons havebeen performing laparoscopic Roux-en-Yprocedures since 2001 and are gettingready to add LAGB. Patients’ averagelength of stay is 47 hours, according toHarmony’s administrator, Rebecca Craig,RN, CNOR, CASC.

“We have 6 overnight beds and aquiet place to recover,” says Craig. Thebeds are licensed as a convalescent careunit under Colorado regulations. Somecenters may use a PACU bed for theovernight stay, depending on statelicensing requirements.

Dr Jones and Simmons also recom-mend having the capacity for an overnightstay even with LAGBs. “We like to err onthe side of safety,” Simmons says.

Centers he works with keep 1 roomopen in case a patient needs to spend thenight. Of course, that means morestaffing costs. He recommends planningon at least 2 nurses who work 12-hourshifts and will receive overtime.

If patients are not spending the night,you probably won’t need additional staffto start outpatient bariatric surgery.Otherwise, you’ll have to decide how tostaff the night shift. Flexibility is keybecause coverage isn’t needed every night.

“We use our own per diem staff nurs-es who are willing to work nights andpay them time and a half,” says AnnMeyer, RN, BSN, CNOR, nurse managerat the Surgery Center of Reno. Craig saysher facility always has 2 RNs availablefor the convalescent center. “The mostpatients a nurse has is 3, which helpsdecrease how long patients need to stay.”

However long a facility keepspatients, it needs transfer agreementswith hospitals, as with other surgeries.

Follow-up carePostoperatively, patients have the

most pain from the carbon dioxide gasused in the endoscopic procedure.

“We try to get them up and walkingright away,” Willey says, because “painmedication doesn’t help that type ofpain.” The staff calls patients the nextday.

Follow-up doesn’t end after patientsleave the ASC. They need access to sup-port groups and other resources. Suchprograms can be offered by the ASC orby the physician group performing theprocedure. Cynthia Winker, chief operat-ing officer for Bariatric Partners,Charlotte, NC, which has opened 4bariatric-only centers since September2006, says, “The secret to success is towork with patients during the postoper-ative period to help them with lifestylechanges.” Bariatric Partners providessupport groups and education programs.

The surgeon makes band adjustmentsin the office, or the patient can return tothe ASC for adjustments. Some ASCsbuild the charges for the adjustmentsinto the original cost of the procedure.

Number crunchingUnlike inpatient bariatric surgery, the

Centers for Medicare and MedicaidServices (CMS) does not reimburse forbariatric surgery in the outpatient set-ting. Other types of reimbursement varyby area of the country and insurance car-rier. Although accreditation as a center ofexcellence is not required for outpatientreimbursement, Tacey believes it helps.

Some centers say significantly morethan half of their patients pay cash. ASCssay the financial investment can pay offbecause the procedure is profitable, par-ticularly when the ASC takes time tonegotiate with insurance carriers. Insome areas, facility reimbursement canrange from $9,000 to $20,000 comparedwith a cost of around $5,000 plus $1,000to $2,000 in labor costs for staffing thenight shift.

Simmons points to the businessadvantage of offering another surgeryoption. “Every business has its ups anddowns,” he says. “You need a diversified

Sample outpatientaccreditationrequirements

Both accrediting bodies for bariatricsurgery will accredit outpatientbariatric programs only for endoscopicprocedures, and application fees arethe same as for inpatient bariatricsurgery programs. An onsite visit isrequired, and facilities must have atransfer agreement with an inpatientfacility.

American College of Surgeons The center must perform at least 50

procedures annually, with at least 1 cre-dentialed bariatric surgeon performinga minimum of 50 primary proceduresannually.

American Society forBariatric Surgery SurgicalReview Corporation

Centers must perform at least 100cases per year. Patients must be lowrisk: younger than 60 years, BMI lessthan 55, weight less than 425 pounds,and an American Society ofAnesthesiologists classification of lessthan 4, with no past history of deepvein thrombosis or pulmonaryembolism.

Procedures must not involve sta-pling or division of the GI tract.


“

“Patients needsupport groupsand resources.




First in a series of articles on improvingrevenue.

As reimbursement gets tighter, it’smore important than ever forASCs to receive the appropriate

payments for their services. Some easilyoverlooked areas can make a differencein being paid the right amount. In thisseries, we’ll suggest avenues to explorethat could immediately add to your bot-tom line.

The place to start is at the front end—scheduling. Schedulers receive importantinformation about cases. If they knowthe right questions to ask, it can make abig difference in your center’s reimburse-ment.

Here are some areas to review withyour schedulers.

Is the case due to an accident?The scheduler should ask the physi-

cian’s office if the case was caused by anaccident. If so, is the injury workplacerelated and thus covered by workers’comp or was it due to another type ofaccident like a car wreck?

Workers’ comp cases usually havestrict requirements for approval on thefront end, which can affect the schedul-ing of the case and may involve a nursecase manager.

For accident-related cases, the sched-uler needs to obtain the following infor-mation:• date of injury (DOI)• name and address of the workers’

comp or insurance carrier• claim adjuster ’s name and phone

number• case manager ’s name and phone

number• case number for the claim.

Is the case a colonoscopy?When the physician’s office calls to

schedule a colonoscopy, the schedulershould ask about the nature of the proce-dure. Is the colonoscopy being per-formed as a diagnostic procedure forsymptoms (such as blood in the stool,

abdominal pain, constipation, or diar-rhea)? Or is it being performed only as ascreening colonoscopy?

Asking the right questions duringscheduling can make a difference in theASC being reimbursed what it expects orreceiving only a minimal amount andhaving to ask patients to pay more thanthey expected to.

It’s also important to ask the rightquestions when verifying insurance.Scheduling and insurance verificationare closely tied.

Questions to ask when checking bene-fits depend on the payer and whether thecolonoscopy is diagnostic or screening. Ifthe case was scheduled for screening, beclear in telling the payer that the ASCneeds benefits for a screening colon-oscopy (rather than for a nonspecificcolonoscopy only). Many payers havevastly different benefits for screeningcolonoscopies and those performed forsymptoms.

If the colonoscopy is set up as ascreening, obtain benefits for bothscreening and diagnostic colonoscopies.

Sometimes a colonoscopy scheduled as ascreening becomes a diagnostic studyduring the procedure if a problem isfound. If an invasive procedure is per-formed, such as a biopsy or polypremoval, the procedure is coded andbilled using the appropriate codes for adiagnostic or surgical colonoscopy ratherthan a screening colonoscopy code.

Does the case involve lesion removal?

When a plastic surgeon’s officeschedules lesion removals for a Medi-care patient, be sure the proceduresappear on Medicare’s list of procedurescovered in ASCs (ie, the grouper list). Ifthe surgeon ends up removing smallerlesions that do not appear on thegrouper list, it can cause billing andreimbursement problems. ASCs are notallowed to bill Medicare patients forprocedures that Medicare does notcover in the ASC setting even ifMedicare does cover the procedures ina physician’s office or hospital.

In 2001, the Centers for Medicare and

Is your ASC leaving money on the table?Billing an MD for a noncovered ASC procedure

To determine how much to charge a physician for a procedure performed in theASC that is not on the Medicare grouper list but is covered in a physician's office:• Take the Medicare Part B physician fee schedule (available on the website of the

Medicare carrier for that state). • Look up the procedure code in question, for example, code 11403 for a benign

lesion excision.Code Participating physician fee schedule11403 $138.1411403 $104.85

The $138.14 fee includes the overhead amount the physician is being reimbursedfor the procedure. The $104.85 amount is the physician's portion of the procedurealone.

Subtract the 2 amounts. The difference is the amount the ASC can charge thephysician (in this case, $33.29).

Remember, the ASC cannot charge the patient for a procedure not covered in theASC that is covered in another setting. If more than one noncovered procedure isperformed, this process would be repeated, adding the amounts to determine thetotal to bill the physician.

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Medicaid Services ruled that ASCs could no longercharge Medicare patients for procedures not on thegrouper list. It is a compliance risk to charge patients forthese procedures. (FASA Inc has more information onthis at www.FASA.org.)

If the physician does perform a procedure not on theASC grouper list, the physician can still be reimbursedfor the procedure. The physician should also receive apayment for the overhead portion of the procedure (as ifit were performed in the office). A method for determin-ing how much to charge the physician is in the sidebar.

Technically, the ASC should charge the physician forthis overhead portion. If the ASC doesn’t bill the physician,the federal government can consider that a violation of theAnti-kickback Statute. This is a political hot potato forASCs because many of the physicians who operate thereare also owners of the facility.

If a physician consistently schedules cases for ASC-covered procedures but ends up performing noncov-ered procedures, that should be addressed by theASC’s board of directors. v

—Stephanie Ellis, RN, CPCPresident, Ellis Medical Consulting, Inc

www.ellismedical.com

The next article will offer tips for insurance verification andprecertification.

CPT codes are copyrighted by the American MedicalAssociation.

Nominate ORManager of Year

Each year at the Managing Today’s OR Suite conference,a manager or director is named OR Manager of the Year.This year’s conference will be Oct 3 to 5 in San Diego.

The OR Manager of the Year will receive an expense-paidtrip to the meeting, including airfare, hotel, meals, and regis-

tration. The winner will alsoreceive a Kimberley-ClarkHealth Care scholarship to theGeorgetown University Health-care Leadership Institute inWashington, DC.

In recognizing an individ-ual manager, the award honors

all OR managers for their important roles. It is a way of cele-brating nursing management in surgical services.

Readers of OR Manager are invited to nominate a man-ager for the award. Simply write a letter of about 300 wordsdescribing what makes the manager deserving of the award.Supporting letters may also be sent.

Send the entry to OR Manager, Inc, OR Manager of theYear Award, PO Box 5303, Santa Fe, NM 87502-5303. Thedeadline for entries is July 1. Nominations are judged by theOR Manager advisory board.

A conference brochure is in this issue. The brochure and registra-tion information are also at www.ormanager.com.

The ORManagementSeriesThree new modules!n Patient Safety in the OR, Second Editionn OR Efficienciesn Materials Management in the OR

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business to withstand changes in the marketplace and mini-mize your risk.”

Even with the high percentage of patients paying cash,reimbursement may limit growth of outpatient bariatricsurgery. Dr Jones notes that one Massachusetts health planrequires patients to have a BMI of at least 50 to be a candidatefor bariatric surgery, yet lower BMIs are better for outpa-tients. “If we can get them earlier, before they are really sick,it’s safer surgery,” he says.

Future outlookSurgeons are working to develop newer, less invasive pro-

cedures. One is partitioning of the stomach, which is beingdone in the laboratory and is about 3 to 5 years away fromwidespread use, according to Dr Jones. With these new pro-cedures, and if the reimbursement picture clears, weight lossprocedures could continue to grow.

If your facility decides to expand with it, you need a well-trained and committed staff.

“Patients are very sensitive,” says Meyer. As with any surgery, outcomes are key. “It’s a positive service line to add if you have positive out-

comes,” says Craig. v—Cynthia L. Saver, RN, MS

Bariatric surgery


31

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P O Box 5303Santa Fe, NM 87502-5303


The monthly publication for OR decision makers Periodicals

Surgery patients face risk for medication errors

Children are at highest risk forsurgery-related medication errors. Hand-offs and lack of coordination contributeto a high rate of harmful errors for allsurgical patients. These are the findingsof the 7th annual MEDMARX report,which examined more than 11,000 peri-operative medication errors.

The data showed 5% of surgery-relat-ed medication errors resulted in harm,including 4 deaths—one of whom was achild. Nearly 12% of pediatric medica-tion errors resulted in harm.

Mistakes included failure to adminis-ter preop antibiotics, note allergies andset up IV pumps correctly, and givingmedication overdoses to infants.

Poor penmanship, miscommunication,or math errors resulted in some patientsgetting medication doses 10 to 50 timeshigher than they should have. The reportwas released by the US Pharmacopeia inpartnership with the Uniformed ServicesUniversity of the Health Sciences, Associ-ation of periOperative Registered Nurses,and American Society for PeriAnesthesiaNurses.

—www.USP.org. Look under What’s New,“USP releases new MEDMARX data report.”

Joint Commission holdswrong-site surgery summit

Some 50 organizations met Feb 23 atJoint Commission headquarters for asummit on wrong-site surgery. The JointCommission had not announced the out-comes as of March 8. Among those

attending were the American Academyof Orthopaedic Surgeons, the AmericanCollege of Physicians, the AmericanCollege of Surgeons, the AmericanDental Association, the AmericanHospital Association, the AmericanMedical Association, the Association ofperiOperative Registered Nurses, andthe Partnership for Patient Safety.

CABG surgery getting secondlook in era of stents

After a 10-year decline, heart bypasssurgery may be making a comeback.With new safety concerns about long-term risks of stents and data showing thesickest cardiac patients may live longer ifthey have bypass surgery, some expertsthink the pendulum may have swungtoo far away from surgery, according tothe Feb 25 New York Times. New evidenceshowing drug-coated stents have a slightrisk of forming blood clots long afterimplantation is changing the assessmentof stents vs surgery in patients with mul-tiple blocked vessels.

—www.nytimes.com

Laparoscopic surgery still hasserious risks

Rare but serious complications con-tinue with laparoscopic surgery, accord-ing to the March 12 Newsweek. Most seri-ous is injury to the common bile duct inlap cholecystectomy, which is at least 5times higher than with open surgery.Though experts believed the rate woulddecline as surgeons gained experience, ithas remained the same for 2 decades—

1 out of every 200 cases. Among the rea-sons are anatomic abnormalities—only25% of patients have a normal textbookanatomy. Also, surgeons can becomeoverconfident and fail to double-checkfor errors. Most surgeons make therepairs themselves, though data shows apatient’s risk of death is 11% higher thanwhen the surgery is performed by anoth-er surgeon.

—www.msnbc.msn.com/id/3032542/site/newsweek. Look under Health.

CMS plan to drop paymentsfor SSIs could have big impact

A rule proposed by CMS last fall tocease Medicare reimbursement for man-aging surgical site infections could affecthospital finances and create disincentivesfor surgery on sicker patients with morecomplex conditions, according to areport in the March Surgery News fromthe American College of Surgeons.

The proposed rule CMS-1488-P wouldend hospital reimbursement as of Oct 1,2008 for care associated with hospital-acquired infections that CMS deems pre-ventable, including SSIs. To examine theadded cost of care associated with SSIs,researchers selected a population ofsurgery patients at the University ofMichigan Health System. If other insurersfollow CMS’s lead, they estimate this hos-pital would see a $15.2 million per yearloss in revenue. Researchers said their datashowed sicker patients were more proneto SSIs, which were beyond the control ofthe surgical team. v

—www.facs.org/surgerynews/

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Date post:	03-Dec-2021
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