the monthly publication - or manager...2002/12/05 · patient deaths increases by 31%, or 20,000...

December 2002 Vol 18, No 12

The monthly publication for OR decision makers

In this issueLow nurse staffing linked to patient mortality . . . . . . . . . . . . .5

Soap, alcohol rub OK for surgical scrub . . . . . . . . . . . . . . . .6

Outpatient payments to rise by3.7% in 2003 . . . . . . . . . . . . . . . . .7

ASC payment update announced . . . . . . . . . . . . . . . . . .8

JOINT COMMISSION.Expect big changes in JCAHOsurvey process . . . . . . . . . . . . . . .9

NURSE-PHYSICIAN RELATIONS.Ten ideas for preventing verbal abuse . . . . . . . . . . . . . . . .13

Borrowing from Toyota toimprove quality . . . . . . . . . . . . .18

TECHNOLOGY IN SURGERY.Equipment planning for a new OR suite . . . . . . . . . . . . . . .20

WORKPLACE . . . . . . . . . . . . . .21

AMBULATORY SURGERY.What’s the best way to rewardstaff? . . . . . . . . . . . . . . . . . . . . . .22

Helping patients prepare for surgery . . . . . . . . . . . . . . . . .25

HEALTH POLICY & POLITICS . . . . . . . . . . . . . . . . . .26

OR Manager Subject Index 2002 . . . . . . . . . . . . . . . . . . . . . . .27

ASC section on page 22.

The litany of difficulties forrecruiting perioperative nurses isnow familiar—too few young

people entering the profession, feweducational opportunities in nursingschool, more career opportunities forwomen, and on and on.

As nurses become more difficult tofind, every nurse manager has to workharder, not only to attract new employ-ees but to hang on to those who arealready there.

Retention isn’t just a matter of betterpay. It takes a systematic effort to findout how many nurses are leaving andwhy and then to plan strategies toimprove the odds they will want tostay.

Improving retention “is not as hard

as you think. And the good news isthat you can make a tremendous differ-ence,” Greta Sherman, recruitment andretention expert for JWT SpecializedCommunications Healthcare Group,Louisville, Ky, told audiences at theManaging Today’s OR Suite confer-ences this fall.

“The better news is your competi-tion is not all that good at recruitmentand retention either. So if you are just alittle better, you are going to be betterthan the hospital down the street.”

What should your strategies be?• Find out what is happening in your

OR. Monitor key indicators onretention. Get specific numbers for

Developing a plan to improve the odds of retaining your staff

Continued on page 10

Recruitment & retention

To anyone who’s been the targetof hurtful words, the kids’ say-ing, “Sticks and stones can break

my bones, but words can never hurtme,” can seem like a lie. Healing fromwords can seem as tough as healingfrom a physical injury.

Though it’s politically correct to referto verbal abuse as disruptive behavior,many employees choose to define it as aform of workplace violence.

With the worst nursing shortage inhistory, verbal abuse is taking centerstage. Nurses fed up with miserableworkplaces are leaving and are notcoming back. Many nurses who remainon the job feel trapped and are not asproductive as they could be.

As society becomes more litigious,employers are paying closer attentionto disruptive behavior to minimize thechance of lawsuits. They are learningthat healthy workplaces attract andkeep the best nurses as well as otheremployees.

Employers are developing codes ofethics and workplace behavior, sendingthe message that verbal abuse andother violent behavior will not be toler-ated. Nurses who are looking for jobsare asking about these policies—andfinding out if they are enforced.What is disruptive behaviorand verbal abuse?

Helen Cox, RN, EdD, a nurse

What you as a manager can do to overcome verbal abuse of staff


Nurse-physician relations

© 2002 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.

Now there’s one name for the companies you’ve always trusted.

The leading provider of products and services supporting the health care industry.

www.cardinal.com

Tis the season…Hardly have the summer bathing

suits been stashed away, when theChristmas catalogues begin to overflowthe mailbox.

I know that you are very, very busy,so I have moseyed through some of myfavorite catalogues to find some sug-gestions for holiday presents.

• The tiny tykes in your householdwant to follow in your footsteps?You can get kiddie size scrubs atSensational Beginnings for $24.95(www.sb-kids.com). Add a Play-mobil Surgery with plastic figures,bed, lights, and monitors for $18.95.

• Your pound pooch a bit down fromtoo much rain? Get matching ensem-bles for you and your pup fromupscale designer Kate Spade—yourraincoat for $395, rainhat for $110,and the pup’s coat for $125. Toomuch? You can go downscale atLands’ End with Nordic sweaters forthe whole family, including the dog,ranging from $14 to $49.50 (www.-landsend.com).

• Want the ultimate giftfor your family?Go to the NeimanMarcus Christ-mas Book,always full ofexcess andextrava-gance.

3December 2002

December 2002 Vol 18, No 12OR Manager is a monthly publication forpersonnel in decision-making positions inthe operating room.

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

Clinical editorBillie Fernsebner, RN, MSN:

Consulting editorJanet K. Schultz, RN, MSN:

Consulting editorOR Manager (USPS 743-010), (ISSN

8756-8047) is published monthly by ORManager, Inc, 1807 Second St, Suite 61,Santa Fe, NM 87505-3499. Periodicalspostage paid at Santa Fe, NM and addi-tional post offices. POSTMASTER: Sendaddress changes to OR Manager, PO Box5303, Santa Fe, NM 87502-5303.

OR Manager is indexed in the CumulativeIndex to Nursing and Allied HealthLiterature, the Hospital Literature Index, andthe National Library of Medicine’s HealthPlanning and Administration Database.

Copyright © 2002 OR Manager, Inc. Allrights reserved. No part of this publicationmay be reproduced without written per-mission.

Subscription rates: $86 per year. Canadian,$98. Foreign, $108. Single issues $10.Address subscription requests to PO Box5303, Santa Fe, NM 87502-5303. Tele:800/442-9918 or 505/982-0510. Web site:www.ormanager.com

Editorial Office: PO Box 5303, Santa Fe, NM87502-5303. Tele: 800/442-9918. Fax: 505/983-0790. E-mail: [email protected]

Advertising Manager: Anthony J. Jannetti,Inc, East Holly Ave/Box 56, Pitman, NJ08071. Telephone: 856/256-2300; Fax:856/589-7463. John R. Schmus, nationaladvertising manager. [email protected]


UpcomingBlock scheduling

Frequently asked questions onblocks are answered by your peers anda researcher.

The changing surgical scrubAre ORs choosing the new alcohol-

based hand preparations or going withthe traditional scrub?

Learning from OR leadersMeet some of your colleagues nomi-

nated for OR Manager of the Year.Learn how they thrive in today’s toughenvironment.

Publisher’s Note

OR Manager Vol 18, No 12

Pass up the London Taxi at $58,900and go straight for action figures ofyour very own family. These 6-inchaction figures are created from full-body three-dimensional digitalscans, then molded, cast, and paint-ed. Skipped out on the gym lately?The experts can provide a more buffbod. Price, of course, is no object. At$7,500 per figure, the price does notinclude travel and accommodations.You’ll need to travel to Burbank,Calif, for the body scan.

• Need something for the house hus-band? The Self-Navigating Sweeper-Vac is a self-propelled vacuum thatcleans your floors by itself. It will doits work even while you sleep.Available for $199.95 at www.ham-macher.com.

• Have time on your hands? TheMartha Stewart Catalogue for Livinghas fun projects for you. Get thesnow globe kit for $34, the pom-pommaker for $28, or the soap-makingkit for $34.

• Tired of getting lost while driving?Get a Turn-by-Turn Guidance Porta-ble GPS. It provides auto routingnavigation with a voice that alertsthe driver to turns, distances, and

course deviations. You can avoidfamily arguments on the roadand get to Grandma’s new con-do for that holiday dinner foronly $999.95, also from www.hammacher.com.

If you find these suggestionsnot quite what you have in mind,remember—it is not what’s underthe tree, or on the table at holiday

time. It’s what’s in your heartwhen you celebrate the holidayswith family and friends.

All of us here at OR Managerwish you a joyous holiday season. ❖

—Ellie Schrader

Decked with chile lights, Maizie, ourgolden retriever, is ready to celebrate theholidays in southwestern style. She’s beenpawing through the pet catalogues andhopes to find neat doggie stuff under thetree on Christmas morning.

Patients who had surgery in hospi-tals with the worst nurse staffinglevels had up to a 31% increased

chance of dying, in sobering findingsfrom a new study.

Patients with life-threatening compli-cations were less likely to be rescued inhospitals where nurses’ patient loadswere heavier.

With each additional patient in anurse’s workload, the risk of patientdeath and failure to rescue rose by 7%each. And each additional patientincreased the nurse’s risk of burnout by23% and the risk of job dissatisfaction by15%.

The researchers, led by Linda Aiken,RN, PhD, of the University ofPennsylvania, Philadelphia, noted thatmore nurses at the bedside could savethousands of lives a year.

Specifically, the study found, afteradjusting for nurse and hospital charac-teristics:

• If hospitals staff at eight patients pernurse rather than four, the risk ofpatient deaths increases by 31%, or20,000 avoidable deaths annually.

• Adding two patients to the workloadof a nurse who is already caring forfour increases the risk of death by 14%.

• Having too few nurses actually costshospitals more because of the highcosts of replacing burned-out nursesand caring for patients with pooroutcomes.

The researchers analyzed data fromsurveys of 10,184 staff nurses; outcomesfor 232,342 surgical patients; and admin-istrative statistics from 168 hospitals inPennsylvania over 19 months from 1998to 1999.

The surgical procedures included com-mon general surgeries, such as gallblad-der removal; orthopedic surgeries, such asknee and hip replacements; and vascularsurgeries, excluding cardiac surgery suchas coronary artery bypass. Some routinebut emergency surgeries also were includ-ed, such as appendectomies.

The researchers concluded that byinvesting in registered nurse staffing,hospitals might avert both preventablepatient deaths and problems with nurseretention.

What nurses have been sayingThe worsening nursing shortage and

California legislation mandating patient-to-nurse ratios, which goes into effect nextyear, prompted Aiken and associates toexamine how nurse staffing levels affectpatient outcomes and nurse retention.

The findings underline what nurseshave been saying about working condi-tions and staffing levels for the pastdecade.

Exhausted nurses are leaving the pro-fession in droves. Job dissatisfactionamong nurses is four times greater thanthe average for all US workers, and 20%say they intend to leave their current jobswithin the next year, according to a pre-vious study by Aiken and colleagues.

Though the study may fuel efforts tomandate ratios, the American Organi-zation of Nurse Executives said ratiosoversimplify the issue. Nurses’ experi-ence varies as does patient acuity.

“To mandate ratios when these factscan vary wildly in a 24-hour period is anirresponsible response to a complicatedsituation,” the association said. AONEinstead suggested cutting down on thesea of paperwork nurses must completeand funding legislation to improverecruitment and retention.

The study was funded by theNational Institute of Nursing Research ofthe National Institutes of Health. ❖

—Aiken L H, Clarke S P, Sloane D M,et al. Hospital nurse staffing and patient

mortality, nurse burnout, and job dissatis-faction. Journal of the American Medical

Association. Oct 23/30, 2002;288:1987-1983. www.jama.com

Low nurse staffing linked to patient mortality

5OR Manager Vol 18, No 12December 2002

Gail Avigne, RN, BA, CNORNurse managerShands Hospital at the University of Florida, Gainesville

Mark E. Bruley, EITDirectorAccident & Forensic Group, ECRIPlymouth Meeting, Pa

Judith Canfield, RNC, MNA, MBAAssociate administrator of surgical servicesUniversity of Washington MedicalCenter, Seattle, Wash

Michele Chotkowski, RN, MSHADirector of perioperative servicesLawrence Hospital/Healthstar NetworkBronxville, NY

DeNene G. Cofield, RN, BSN, CNORDirector of surgical servicesMedical Center EastBirmingham, Ala

Larry Creech, RN, MBA, CDTVice president, perioperative servicesClarian Health SystemIndianapolis, Ind

Cheryl Dendy, RNDirector, St John Surgery CenterSt Clair Shores, Mich

Franklin Dexter, MD, PhDAssociate professorDepartment of AnesthesiaUniversity of Iowa, Iowa City

Aileen Killen, RN, PhD, CNORDirector of nursing, perioperative servicesMemorial Sloan-Kettering Cancer CenterNew York City

Robert V. Rege, MDProfessor and chairmanDepartment of SurgeryUT Southwestern Medical CenterDallas, Tex

Marimargaret Reichert, RN, MAAdministrator, Surgical Care CenterSouthwest General Health CenterMiddleburg Heights, Ohio

Kathy E. Shaneberger, RN, MSN, CNORGrand Rapids, Mich

Shelly Schwedhelm, RN, BSNDirector, perioperative servicesNebraska Health System, Omaha

Sallie Walker, RN, BA, CGRNCentral Baptist HospitalLexington, Ky

Allen WarrenBusiness manager, surgical servicesMission St Joseph’s HospitalAsheville, NC

Anny Yeung, RN, MPA, CNOR, CNAAAssistant vice president for perioperative services & associate hospital directorSUNY Downstate Medical CenterNew York City

Advisory Board

“More nurses at the bedside

could savethousands of lives.

“

6 OR Manager Vol 18, No 12 December 2002

Surgical personnel can scrub witheither an antimicrobial soap or analcohol-based hand rub, according

to a new guideline from the Centers forDisease Control and Prevention (CDC).

The guideline, the first update inalmost two decades, essentially abolishesthe traditional long presurgical scrub.

The guideline also strongly recom-mends against artificial fingernails forOR personnel and others who havedirect contact with high-risk patients.

The guideline is divided into threeparts.

Part I reviews studies published sincethe Guideline for Handwashing and HospitalEnvironmental Control, 1985, and the 1995APIC Guideline for Handwashing and HandAntisepsis in Health Care Settings. Part IIgives recommendations to improve handhygiene practices and reduce transmis-sion of pathogens. Recommendations areranked according to the strength of theevidence (sidebar). Part III has four per-formance indicators for measuringimprovement in handwashing practices.

Surgical scrub recommendations For surgical hand antisepsis before

donning surgical gloves, the guidelinerecommends:• Removing rings, watches, and

bracelets (Category II)• Removing debris from underneath

the fingernails using a nail cleanerunder running water (Category II)

• Using either an antimicrobial soap oran alcohol-based hand rub with per-sistent activity (Category IB)

• When using an antimicrobial soap,scrub hands and forearms for themanufacturer’s recommended lengthof time, usually 2 to 6 minutes—longer scrubs are not necessary(Category IB)

• When using an alcohol-based handrub, prewash hands and forearmswith a nonantimicrobial soap and dryhands and forearms completely. Afterapplying the alcohol product accord-ing to manufacturer’s instructions,allow hands and forearms to dry thor-oughly (Category IB).At a press briefing, Elaine Larson,

RN, PhD, FAAN, CIC, a leadingresearcher on hand hygiene fromColumbia University School ofNursing, New York City, was askedwhether she saw a time in the futurewhen alcohol rubs would replace the

need for surgical scrub areas.Larson answered: “Hospitals will

want to keep both antimicrobial soapsand alcohol-based products available forsurgical personnel.” She said surgicalpersonnel will choose the one that worksbest for them and that they are mostcomfortable with. She expects alcohol-based products to be used much more inthe next few years.

She also noted that the alcohol rubproducts are not cleaning agents anddon’t remove surface dirt, which is whyhandwashing with regular soap is neces-sary before using them.

The guideline does not make a recom-mendation on use of brushes during thesurgical scrub. The guideline’s literaturereview discusses the skin damage andincreased bacterial shedding that canoccur with a brush. The committee alsodiscussed the potential benefit of brushescleaning under nails. But the committeedecided not to make a recommendationbecause the issue has not been sufficient-ly studied.

Fingernails, artificial nailsThe new guideline strongly recom-

mends against artificial fingernails: • Do not wear artificial fingernails or

nail extenders when having directcontact with patients at high risk,such as those in intensive care unitsand operating rooms (Category IA).Neither the 1985 CDC guideline northe 1995 APIC guideline gave recom-mendations on artificial nails.

• The new guideline also recommendskeeping natural nail tips less than1/4-inch long (Category II).It does not make a recommendation

on nail polish. The literature review, how-ever, notes that freshly applied nail polishdoes not increase the number of bacteriaon periungual skin, but chipped nail pol-ish may support the growth of largenumbers of organisms on fingernails.

Whether the length of natural or artifi-cial nails is a substantial risk factor isunknown, because most of bacterialgrowth occurs along the proximal 1 mmof the nail adjacent to subungual skin. Anoutbreak of Pseudomonas aeruginosa in aneonatal intensive care unit was attrib-uted to two nurses—one with long natur-al nails and one with long artificial nails.

Guidelines and accreditationAt the briefing, CDC Director Julie

Gerberding, MD, MPH, was askedwhether she expects the new guidelinesto become part of facility accreditation.She answered that though the CDC isnot a regulatory agency, its guidelinesbecome a de facto standard of care.

She said she hopes the Joint Commis-sion on Accreditation of HealthcareOrganizations might accept the guide-line’s performance indicators as part of aquality promotion or patient safety pro-gram.

The guideline was developed by theHealthcare Infection Control PracticesAdvisory Committee (HICPAC), a feder-al advisory panel, in collaboration withthe Society for Healthcare Epidemiologyof America (SHEA), the Association forProfessionals in Infection Control andEpidemiology (APIC), and the InfectiousDiseases Society of America (IDSA). ❖

—Judith M. Mathias, RN, MA

ReferenceCenters for Disease Control and Preven-

tion. Guideline for hand hygiene inhealth-care settings. Morbidity andMortality Weekly Report. Oct 25, 2002;51:No. RR-16.

—www.cdc.gov/mmwr

Soap, alcohol rub OK for surgical scrubCDC categoryrankings

CDC recommendations are catego-rized as follows:

• Category IA: Strongly recom-mended for implementationand supported by well-designed scientific studies

• Category IB: Strongly recom-mended for implementationand supported by some scien-tific studies and strong theoret-ical rationale

• Category IC: Required forimplementation by federal orstate regulation or standard

• Category II: Suggested forimplementation and supportedby suggestive scientific studiesor theoretical rationale

• No recommendation, unre-solved issue: Practices forwhich there is insufficient evi-dence or no consensus regard-ing efficacy.


Hospitals will see Medicare out-patient payments rise an aver-age of 3.7% next year.

The increase for urban hospitals willbe slightly lower, 3.1%, and that forrural hospitals significantly higher, at6.2%. Teaching hospitals are expected toreceive a smaller increase of 2.7%,under the final 2003 rule for Medicare’soutpatient prospective payment system(OPPS), published Nov 1.

The changes are effective Jan 1.No pro-rata reduction will be need-

ed in pass-through payments next year.Pass-through payments are add-onsthat apply to certain devices, drugs,and biologicals.

The OPPS pays for hospital outpa-tient services according to a fee sched-ule of ambulatory patient classifications(APCs). APCs are groups of CPT codesthat are considered similar clinicallyand in their use of resources.

The final rule includes CMS’sresponses to comments from the pro-posed rule issued in August.

Here’s a look at the highlights.

Cost report penaltyThe Health and Human Services

Secretary will have authority to sus-pend Medicare payments if a providerfails to file a timely and acceptable costreport.

Inpatient-only listIn all, 43 codes for inpatient proce-

dures are being moved to outpatient-payable status for 2003. Among themare partial laminectomy or facetectomy,balloon valvuloplasty, and placement ofan epidural catheter with laminectomy.The list is on the OR Manager web siteat www.ormanager.com

Four procedures were added tothose proposed in August: two arthro-desis codes (CPT 22612 and 22614),pneumonostomy (CPT 32201) and mas-toidectomy (CPT 69502).

Needle biopsy of the liver (CPT47001) will be payable under OPPS,though it will be packaged with thesurgical procedure with which it isbilled.

If a procedure is on the inpatient-only list, hospitals receive no Medicarepayment if it is performed on an outpa-tient basis, even if the physician will bepaid.

Why does CMS insist on having an

inpatient-only list? Hospitals, physicians, and others

protest that the list should be abolishedbecause it interferes with the practice ofmedicine. Hospitals say the list causesconfusion because, if physicians canstill be paid even if they perform aninpatient-only procedure on an outpa-tient, physicians have no incentive toheed whether Medicare will pay thehospital. Medicare policy also can con-flict with private payers, who may payfor outpatient procedures Medicarewon’t pay for. Further, some point outthat the list is inconsistent withMedicare’s list of approved proceduresfor ambulatory surgery centers (ASCs).

But CMS says the list will stay,though it will continue to move proce-dures off the list when they meet CMScriteria. As for the conflict between hos-pitals and physicians, CMS considersthat a matter of education.

The final rule does clarify billingpolicies for emergency procedures onthe inpatient list that are performed onpatients before they can be admitted,some of which were modified from thedraft. Some instructions to fiscal inter-mediaries will be changed. There willbe a new modifier for cases in which aninpatient-only procedure is performedin a life-threatening situation, and thepatient dies before being admitted as aninpatient.

New technology issuesSeveral procedures are being moved

from new technology APCs to clinicallyappropriate (or regular) APCs becauseCMS now has enough data to make theAPC assignment. Among these are per-cutaneous breast biopsy, prostatemicrowave thermotherapy, cryoabla-tion of the prostate, and stereotacticradiosurgery.

In highlights of this section:• Stereotactic radiosurgery. CMS

agreed to continue to keep this pro-cedure under a new technology APCwhere the payment is higher thanunder the proposed APC 663.

• Preview Planning Treatment soft-ware. This has been moved back toAPC 975, which pays $625, ratherthan being reassigned to a lower-paying APC.New codes were created for:

• prostate brachytherapy

• observation care

• drug-eluting stentsIn other technology issues:

• For cardiac resynchronization thera-py, codes for left ventricular leadplacement are being placed in newtech APCs.

• Regarding laser surgery of theprostate, CMS decided to leave CPT52647 in APC 163, even though someadvocated placing it in a higher pay-ing APC because of a new lasersource involved in this procedure.

Outpatient payments to rise by 3.7% in 2003

Continued on page 8

Have a beef withinpatient-only list?

There is something hospitals anddoctors can do if they believe a proce-dure should be taken off the inpa-tient-only list. They can send CMSevidence, including operative reportsand peer-reviewed literature, thatshow the procedure can be per-formed safely for outpatients. Thereports can be from non-Medicarepatients.

The request should include infor-mation to demonstrate the codemeets five CMS criteria for paymentof outpatient procedures:

• Most outpatient departmentsare equipped to provide theservices to the Medicare popu-lation.

• The simplest proceduredescribed by the code may beperformed in most outpatientdepartments.

• The procedure is related tocodes already moved off theinpatient list.

• The procedure is being per-formed in numerous hospitalson an outpatient basis or

• The procedure can be safelyand appropriately performedin an ASC and is on theMedicare ASC list of approvedprocedures.

Requests can be sent to Director,Division of Outpatient Care, CMS,Mailstop C4-05-17, 7500 SecurityBlvd, Baltimore, MD 21244-1850.


• For neurostimulators, CMS madeadjustments to address a concernabout a large reduction in paymentfor APC 222. The status indicator forAPC 225 (implantation of neurostim-ulator electrodes) was changed to Sso it will not be subject to a 50%reduction when billed with APC 222(implantation of neurologicaldevice).

• Endometrial cryoablation. Someargued this code, CPT 0009T in APC980, should have a payment ratesimilar to prostate cryoablation. ButCMS did not agree because it saidthe endometrial procedure is shorterand requires fewer resources.

• Sling operation for stress inconti-nence. Some wanted this proceduremoved to its own APC because theysaid the current APC does not reflectthe true cost of the device. CMSdecided not to make the change butto present the suggestion to its advi-sory panel. CMS added that it doesnot create APCs for devices.

• Percutaneous breast biopsy. Com-menters noted that, because the pay-ment for CPT 19102 and 19103 waslower than for open biopsy, theremight be an incentive to performopen procedures rather than theless-invasive one. CMS notes thatthe percutaneous procedures alwaysare performed with an imagingguidance procedure, which can alsobe billed. CMS also said the openprocedure requires more resourcesthan the percutaneous one.

Drug-eluting stentsAs proposed, CMS is taking the

unprecedented step of creating a newAPC and payment codes for drug-elut-ing coronary artery stents, even thoughthey have not yet been approved by theFood and Drug Administration (FDA)for general use. The new APC is 656and the codes are G0290 and G0291.

The new codes create a billing mech-anism to keep hospitals from taking amajor hit when approval comes, andthere is a surge in demand.

The payment differential for thestent is $1,200, which some protestedwas too low and lower than the $1,800payment allowed under the inpatientDRG, which assumed an average of 1.5stents is placed in a session.

But CMS said that it is rare to place

more than one stent in an outpatientsession. Also, facilities can bill a sepa-rate code for each vessel in which astent is placed.

The new codes take effect April 1,2003. If the drug-eluting stents areapproved before then, they will be paidunder APC 104.

Ordinarily, additional payment on anew technology isn’t available until CMShas had a chance to collect charge dataon its costs, which typically takes 2 years.

Pass-through paymentsDrugs and devices that have been on

the pass-through list for at least 3 yearsare being removed and the paymentpackaged in with the APC.

Why are APC payments low? In comments to the August draft,

many said proposed payments werebelow their costs, especially for devicessuch as cardioverter/defibrillators,pacemakers, and neurostimulators, andmight keep them from providingpatients with expensive treatments.

To temper these effects, CMS read-justed APC weights to even out the pro-posed reductions, including those forAPCs where 80% or more of the cost isfor the device, and for blood and bloodproducts.

CMS says it is not able to raise pay-ments to cover hospitals’ full cost ofoutpatient services because OPPS wasset up by Congress to be budget neu-tral. That is, OPPS can cost Medicare nomore than the previous payment sys-tem, which paid 82% of hospitals’reported outpatient costs as shown oncost reports. ❖

The OPPS final regulation was in theNov 1 Federal Register, available at http://www.access.gpo.gov/su_docs/aces/aces140.html

Continued from page 7 ASC paymentupdate announced

Medicare announced this fall itwill raise ambulatory surgerycenter (ASC) payment rates

by 3% for the federal fiscal year Oct 1,2002, to Sept 30, 2003.

This is the first time in 5 years ASCshave received the full inflationaryadjustment, reports McDermott, Will &Emery, a Washington, D C, law firm.

2003 payment ratesGroup 1 $333 Group 2 $446 Group 3 $510 Group 4 $630 Group 5 $717Group 6 $826 ($676 + $150 for

intraocular lenses)Group 7 $995Group 8 $973 ($823 + $150 for

intraocular lenses)Group 9 $1,339

These are national rates. Actualpayment rates depend on geographiclocation.

The full adjustment took placebecause legislation expired that keptthe adjustment below inflation, andCongress did not act to renew thereductions before lawmakers left tocampaign in October. ASC tradegroups were working to make sureCongress does not take action to renewthe lower rates before the end of thesession.

A Group 9 was added to the pay-ment schedule. According to theFederated Ambulatory Surgery Asso-ciation, the group was originally creat-ed in 1991 but has not been used. Somenew codes are expected to be added tothe group for 2003, though whichcodes these will be was not known.

The Centers for Medicare andMedicaid Services (CMS) is preparingan extensive update of the list of proce-dures approved for ASCs, which isscheduled to be released before the endof the year. ❖

Check our web site for the latest news, meeting

announcements, and otherpractical help.

www.ormanager.com

New OR design web siteInvolved in an OR construction or

renovation project? Find helpful resources all in one place

on OR Manager’s new web site: www.ordesignandconstruction.com

OR Design & Construction

How your organization is surveyedby the Joint Commission onAccreditation of Healthcare Or-

ganizations will change dramaticallystarting in January 2004.

The process is being revamped to focusmore on continuous improvement andless on just getting ready for the survey.

In the project, called Shared Visions—New Pathways, JCAHO says the stan-dards are being rewritten to make themclearer and more relevant.

“We’ve reduced the number of stan-dards and increased the focus on safetyand quality,” JCAHO President DennisO’Leary, MD, said in an Oct 3 newsconference.

The new process will use automationto target areas to survey. JCAHO saysthis will allow surveyors to spend moretime on the most critical issues in eachorganization.

The standards will be in a new for-mat. In place of an intent statement willbe a rationale to explain why the stan-dard is needed and a list of elements tobe scored.

Organizations “will now know exact-ly what surveyors will be looking forwhen scoring compliance with the stan-dards,” JCAHO says.

Here’s what you can expect.

Self-assessmentHalf way through the 3-year accredi-

tation cycle, your organization will com-plete a self-assessment on a secureJCAHO web site, rating its compliancewith standards. The organization willhave 3 to 6 months to complete theassessment. There will be no on-site visitat the 18-month point.

“This shifts the ownership to theorganization,” Dr O’Leary said. “Experi-ence has shown us that organizations areat least as able to identify areas needingimprovement as we are.”

Critics say this will shift more work tofacilities, which will still pay the samesurvey fees.

If the organization finds it needs to takecorrective action, it will submit the planwith the self-assessment to JCAHO forreview and approval. The self-assessmentwill not affect the accreditation status.

Data-guided surveyAutomation will be used to focus sur-

veys on critical areas and help surveyorsbe more consistent.

Before the survey, JCAHO will use a“priority focus process” (PFP). An auto-mated tool will gather data about yourorganization from sources such as ORYX,JCAHO’s quality monitoring informa-tion, and demographic and statisticalinformation. For example, if the PFP dataindicates your hospital serves a largegeriatric population with a lot of medicaladmissions, it is likely many of thepatients are on multiple medications.Thus, medication issues are likely to be afocus during the survey. Other issuesmight be do-not-resuscitate orders andend-of-life care.

Tracking patient experienceDuring the 3-year survey visit, sur-

veyors will verify that the organizationhas implemented the corrective actions.They also will use another new processcalled “tracer methodology” along withthe PFP information to review care whileit is actually being given. They will pullactive patient charts and follow a patientthrough the process, observing and ask-ing staff about how care is delivered.

For example, one of JCAHO’s newPatient Safety Goals is to eliminatewrong-site surgery. Under the currentprocess, surveyors might ask what stepsare taken to prevent the problem and talkabout polices, education, and so forth

In the new process, “We’ll choose anopen record. We might find the patienthad surgery. Then we will trace theprocess through the organization,”explained Russell Massaro, MD,JCAHO’s executive vice president foraccreditation operations.

Say the patient had a fractured hipand came in through the ER. The survey-or would want to see how the patient

was assessed, how the x-ray was han-dled, and how the informed consent wasconducted. The surveyor would go tothe OR and ask the staff and physicians ifthe site was marked and if there was a“time out” before the procedure to verifythe site.

Using the geriatric example, if yourpopulation has a large number ofpatients who take multiple medications,and you had a previous Type I recom-mendation on medication use, medica-tion use would be identified as a criticalfocus area. The surveyor would random-ly choose active charts for patients takingmultiple medications and follow thesepatients as they receive care. This mightinclude interviewing staff, reviewingtheir credentials, and examining policiesand procedures.

If the surveyor finds a complianceissue and multiple charts show it is atrend, a Type I recommendation mightbe given. The surveyor is supposed toprovide education and guidance abouthow to meet the standard.

Scores may go awayAs part of its retooling, the JCAHO

Board of Commissioners is consideringdoing away with disclosing accreditationscores to organizations and the public.Too often, the commission says, scoresare used for competitive purposes. Thefocus has been on getting a high scorerather than on continuously improving.

Better-prepared surveyorsA common complaint is that survey-

ors aren’t consistent in how they surveyand focus on things that aren’t relevant.JCAHO is taking steps to reform survey-or training and oversight:• All surveyors will be required to pass

a certification exam. If they fail, theycannot be a surveyor of record andmust have remedial training. If theydon’t pass a reexamination, they can-not be a surveyor. They must be recer-tified every 5 years.

• All surveyors will receive educationand testing in systems theory andorganizational dynamics presented byuniversity graduate school faculty. ❖

For more information, visit www.jcaho. org


Joint Commission

Expect big changes in JCAHO survey process

“Surveyors will pullactive charts andfollow a patient

through the process.

“

each of your units; your managers;and your RNs, techs, and entry-levelworkers.

• Identify your retention problems.

• Develop a plan to address theseproblems.

Six indicators to measurestaffing

Mastering key statistics can help youfind trouble spots and make a case tosenior leadership about the need formore resources to improve recruitmentand retention (sidebar).

“You need to speak the language ofsenior management,” advises Sherman.“They will be after you for the returnon investment [from new employees]and cost per hire, and you have to beable to speak about the numbers.”

Managers should be able to get thenumbers from their human resources(HR) department or calculate the statis-tics themselves.

The numbers will paint a picture ofwhere your department is today.

“Then drill down to the specificnumbers for your department by disci-pline, by unit, by cost center, by specificmanagers—by anything that makessense for your organization,” Shermanrecommended.

To see how other ORs are faring, seethe staffing survey in the September ORManager.

Biggest retention issuesUse the key indicators and other

strategies to spot retention problemsthat need to be addressed. Among thetechniques JWT uses to diagnose prob-lems for its clients are exit interviews,new hire interviews, incremental inter-views, and “secret shoppers” who poseas applicants to see how the organiza-tion treats people who apply for jobs.

The most common retention prob-lems: inconsistent managers, lack ofsupport staff, no feeling of “cominghome,” lack of support and under-standing, poor patient-to-RN ratios,and little flexibility.

Problem managers. The number onereason staff leave? Their manager. Ifyou have retention figures by patientunits, such as the OR, postanesthesiacare unit (PACU), and GI endoscopy,

you can begin to see if this is a problem. Say the hospital’s average RN

turnover rate is 15%, but the turnoverin the PACU is 45%. If you documentthat fact, you can present the situationto the PACU manager unemotionally.

“You can say, ‘Look at these num-bers. Your turnover rate is high. What’swrong?” suggests Sherman.

Most likely, the manager was pro-moted because of strong clinical skillsbut has never been given training inteam leadership, communicating withdifferent generations, or being moreflexible.

Young nurses fleeing. Not only isthe RN population getting older, butyounger nurses are leaving at an alarm-ing rate.

“Last year alone, we ran 41% of theRNs aged 30 and under out of the pro-fession altogether,” Sherman observed.

The number of RNs under 30 hasdropped by 46%.

New hires don’t feel protected. “They feel they are being ground up.

They feel no one is listening, and theybelieve management is invisible.

“Your front-line managers have toomuch to do and don’t have enoughtime to spend with new employees,”she said.

Burning out staff. At what pointdoes the vacancy rate become a seriousproblem? At the point where theremaining staff is overworked enoughthat they burn out.

The magic number is 8%, Shermanhas learned from her work with clients.

“At 8%, you see more turnover,more sick leave, more accidents, andyour patient satisfaction scores plum-met.”

According to Sherman, RNs taketwice as much sick time as the averageAmerican worker, and the record is

about the same for other types of healthcare workers.

“The stress on the job is so difficult,that they have to find relief, so theytake more sick time. They also go parttime,” she said.

If nurses take twice as much sicktime as other workers, and an OR isnear the national average vacancy rateof about 10%, at any given time, 20% ofthe nurses are not working. That meansthese positions must be filled by over-time, PRN staff, or agency personnel.

Driving away entry-level appli-cants. Health care organizations loseentry-level workers to Wendy’s or Mc-Donald’s because fast food restaurantsare prepared to hire them today andput them to work tomorrow. They arebeing lured away by big hotel chainslike Marriott and Renaissance that offera good orientation and dignity.

“Entry-level people are the key toyour staffing, but we don’t make themfeel welcome,” said Sherman.

“Mafias.” Some units have a staffwhere everyone is alike in age, ethnici-ty, or some other characteristic. Theydon’t welcome newcomers and tend todrive them away.

“You need to diversify your units soyou don’t have a mafia anywhere,”Sherman said.

Develop a planAfter you’ve identified the prob-

lems, you can start identifying solu-tions.

Assign responsibility. Make reten-tion part of the expectations for unitmanagers and team leaders. Tie man-agers’ evaluations and bonuses to theirretention numbers.

Be clear about what you expect fromthe human resources (HR) department.

“You would be appalled at the num-ber of people who are lost in your sys-tem,” Sherman said. “The HR depart-ment is too busy, applications sit ondesks. Applicants are viewed as a nui-sance.

“If you don’t turn an applicationaround in 24 hours, you are going tomiss them.”

Develop managers as leaders. Ifyou have problem managers, they needto be given support, or they need to beredirected to new career paths.

Managers need to learn how to buildteams.



Continued from page 1

“Younger nursesare leaving at analarming rate.

“



“They must be constant [with theirstaffs] every day. They must communi-cate, they must involve employees indecisions, and they must embrace dif-ferences,” she said.

Provide mentoring. Pair new hireswith more experienced employees.

Many ORs do this through preceptor-ships. Ideally, the mentors should bestaff who have been there about 2 yearsand still remember what it feels like towalk in the front door.

“Make it an honor, not a chore,” sheadds. “If you can get [new employees]

through the first 3 years, the retentionrate skyrockets.”

Teach the language of all genera-tions. For the first time, four genera-tions are working side by side—theVeterans, the Baby Boomers, the Gen-Xers, and the New Millenniums.

“The Baby Boomers say about theGen-Xers, ‘You know, they just don’thave the same work ethic,’” Shermancommented.

“But if you look at their productivi-ty, it’s just as good as the BabyBoomers. They just want to do it morequickly and go home.”

Know what they’re thinking. Don’twait for employees to leave, then do exitinterviews. Instead, interview them about4 to 6 months into their employment.

RNs tend to turn over 9 to 11 monthsafter they start a job. That’s up from 18to 24 months previously. About 25%leave in that time period

By doing an interview sometimearound the fourth to the sixth month, amanager can retain 25% to 50% ofthose.

“It lets them know someone is listen-ing,” she advises. “It identifies prob-lems and uncovers bigger issues.”

Allow for different lifestyles. Someof your employees may be students,some may have young children, andothers may be caring for aging parents.

“Listen to your employees. Knowwhat’s important to them individually,”she advised. Foster an atmospherewhere staff are willing to support andfill in for each other.

Cultivate entry-level workers. “Exitinterviews tell us there is nothing moreimportant to the satisfaction of yourprofessional staff than having a fullcomplement of entry-level people,”Sherman said.

Any OR director who has faced chal-lenges with instrument processing inthe central service department canattest to that.

Remember the little things. Haveyour managers develop a file on thecare and feeding of each employee.

Remember what’s important tothem: A child graduating from highschool, a new baby, traveling, reading,riding their bike.

“We absolutely must take care of ouremployees the way we take care of ourinstruments and equipment.

“Remember what they are worth.” ❖

Days to fill positionsNational figuresRNs—General 47—Critical care 52—OR 43 Technicians 17Entry-level positions 11

DefinitionDays to fill = Date position posteduntil date offer accepted

Vacancy rateNational figuresRNs 10.8%

FormulaVacancy rate = Open positions divid-ed by total positions

• Remember to use bodies, notFTEs.

• Calculation may be done for theentire hospital, a department, ora job classification.

Turnover rateNational figuresRNs 16%Technicians 33%Entry-level positions 46%

FormulaTurnover rate = Departures from staffdivided by total positions

• Remember to use bodies, notFTEs.

• Include resignations and termi-nations.

• It is recommended to calculateturnover at the end of everymonth.

• Calculation may be done for theentire hospital, a department, ora job classification.

Cost per hireNational figuresRNs—General $7,038—OR $13,114—Cardiovascular $26,158—Critical care $22,782Technicians $842Entry-level positions $749

FormulaCost per hire = Total internal & exter-nal costs + 10% divided by number ofinternal & external hires

Internal costsSalaries—Total recruiter salaries—Total recruiter benefits (22%)—Total HR administrative salaries—Total HR administrative benefits

(22%)Office expense—Rent—Supplies*—Utilities*—Phone*—Equipment*Travel (eg, job fairs)

External costsAdvertisingBonuses (sign-on and referral)RelocationContract staffingConsultingCapital expenses

*Divide external costs by 3 becauserecruitment is typically one third ofthe human resource function.

Note: Do similar calculation forexempt and nonexempt employeesand for job families by allocating costsassociated with each group.

Six retention indicators

Source: JWT Specialized Communications Healthcare Group.


researcher who surveyed nurses on thesubject in the 1980s, defines verbalabuse as “any communication a nurseperceives to be a harsh, condemnatoryact upon herself or himself profession-ally or personally.”

Susan Araujo, RN, and Laura Sofield,RN, are replicating Cox’s study. Theirverbal abuse survey is posted on theInternet (www. nurseadvocate.org/nas-tudy.html). They define verbal abuse as“a concept that indicates some form ofmistreatment, spoken or unspoken, thatleaves you feeling personally or profes-sionally attacked, devalued, or humiliat-ed. It is communication through words,tone or manner that disparages, patron-izes, threatens, accuses, or is disrespect-ful toward another.“

The latest study on nurse-physicianrelationships, conducted by Alan H.Rosenstein, MD, MBA, vice presidentand medical director of VHA WestCoast, and published in the AmericanJournal of Nursing, defines disruptivephysician behavior as “any inappropri-ate behavior, confrontation, or conflict,ranging from verbal abuse to physicaland sexual harassment.”

Vertical and horizontalviolence

Verbal abuse can be vertical and hor-izontal. Vertical violence is between twopeople in different-status positions.Horizontal violence is between peers.

Verbal abuse from a surgeon to anurse is an example of vertical violence.Physicians have status and are seen asimportant because they bring moneyinto the institution; nurses are seen ashourly workers adding to labor costsand may be viewed in a subservientrole. Nurses have learned oppressedgroup behaviors, which make them eas-ier targets for verbal abuse, Sofieldexplained in an interview with ORManager.

In an atmosphere of regular abuse,nurses may begin to feel marginalizedand take on behaviors of the oppressor(the physician), losing their own identi-ty. This leads to negative feelings aboutoneself. Nurses get much of their pro-fessional recognition and self-validationfrom their relationships with physi-cians. When this relationship soursthrough verbal abuse, nurses find the

workplace unrewarding. They leave orbecome disgruntled employees.

Vertical violence creates a climate forhorizontal violence—verbal abusebetween peers. Horizontal violencethrives in the presence of vertical vio-lence but can exist without it.

Herbert Dunn, RN, MS, a periopera-tive nurse at New York PresbyterianChildren’s Hospital who has studiedhorizontal violence, explains that verti-cal violence is usually open—conduct-ed in front of others. Horizontal vio-lence is closed or secret; it often is notconducted in the open nor directed tothe intended victim. In an interview,Dunn described horizontal violence asthe inability or insecurity to confrontothers about workplace problems. Thebest example, he says, is lounge talkwhere nurses may “trash” fellow nurs-es who aren’t present.

Nurses may perpetuate horizontalviolence when they begin to feel deval-ued; have little to say about their prac-tice; and have unhealthy relationshipswith physicians, executives, and theirown managers.

Nurses are exposed to other sourcesof verbal abuse as well. Araujo andSofield found verbal abuse could comefrom patients (56%), their families(48%), and, surprisingly, immediatesupervisors (16%).

How prevalent is verbal abuse?Dr Rosenstein says he was surprised

at the frequency of the problem, whichin his study ranged from once or twicea month to weekly. Disruptive behav-iors cited were yelling, raising thevoice, disrespect, condescension, berat-ing colleagues and patients, and use ofabusive language.

When Araujo and Sofield askednurses how many times in 1 monththey experienced verbal abuse, 74%

reported 0 to 5 incidents, and 15%reported 6 to 10 incidents. After herstudy, Cox wrote, “Verbal abuse is soprevalent in nursing that it is surprisingthat any of us stays in the profession.”

Causes of verbal abuseWhen Rosenstein asked nurses to

identify what precipitated verbal abuseby physicians, they said it occurredwhen nurses were placing a call tophysicians, questioning or seeking toclarify physician orders, when physi-cians thought their orders were notbeing carried out correctly or in a time-ly manner, after perceived delays incare, and after a sudden change inpatient status.

He thinks nurses could eliminatemany incidents of verbal abuse by hav-ing all of the information about apatient available before calling the doc-tor and speaking in a clear and compe-tent manner. Competency is a deflectorof any type of disruptive behavior.

Can verbal abuse be managed?Verbal abuse in surgical suites can be

managed, but it takes the time andcooperation of key physicians andadministrators, says Barbara Pankratz,RN, MS, director of surgical services atthe University of Wisconsin Hospitaland Clinics, Madison.

After an initial survey of employees,Pankratz realized the impact the prob-lem had on staff morale and retention,so she joined with key leaders andother experts in the organization todevelop a policy.

The key to their success was educa-tion. Pankratz and selected physiciansworked to educate other physicians byattending all surgical specialty divisionmeetings.

In a postpolicy implementation sur-vey she conducted to see if the policywas working, 90% of the staff said theynow knew how to deal with problemswith physicians, and 75% felt progresswas being made. About one third feltthe feedback process on how the prob-lem was being solved needed improve-ment.

Pankratz took that feedback to theProfessional Conduct Committee, and aprocess was developed to make surethe staff member initiating a complaintwas provided with the appropriate


“Are we willing to tell a surgeonhe isn’t welcome

on staff?

“





Ten ideas for preventing verbal abuse

These ten suggestions for foster-ing permanent changes that canhelp prevent or reduce disrup-

tive behavior are from MargaretThornborough, MFT, a psychothera-pist who has worked extensively withprofessional clients, including physi-cians and nurses.

One of the most important skills isto learn to check emotions at the door.Being emotional prevents a personfrom being able to see the situationclearly. Helping the victim cope withan abusive situation while it is occur-ring is powerful but requires learningnew ways of dealing with conflict.

1. Know the abuserMost nurses know who the abusers

are and what will “set them off.”Instead of being afraid or angry, try toeliminate triggers of abuse.Competence and effective communi-cation skills are essential. Providinginadequate service to the physician asa payback for his or her behavioraggravates the situation.

2. Free the oppressorDuring an abusive incident, the vic-

tim gets hurt, and this makes theoppressor angrier. If a person canlearn to free the oppressor, abusiveincidents will subside. Here’s anexample. If a surgeon is abusive to thescrub nurse, the circulating nurse’sinstinct is either to ignore theexchange or try to defend the scrubnurse. If the circulating nurse choosesto stand up for the scrub nurse, thismay make the situation worse.Freeing the oppressor happens whenthe circulating nurse pays attention tothe surgeon by talking to him and try-ing to help him understand a betterway to handle his frustration. Thistype of intervention must be learned.

3. Build a response repertoireHumor is a good way to deflect and

redirect a potential verbal abuse situa-tion. Nurses and physicians frequent-ly engage in “OR banter,” which oftenescalates, with nurses giving up as thebanter becomes more toxic. The nursebecomes angry, but the physician

doesn’t realize the rules of the gamehave changed. Creating a professionalatmosphere by speaking judiciously,clearly, and professionally.

4. It takes two to abuseTwo people are needed to create a

verbal abusive situation—an abuserand a victim. A person on the receiv-ing end must decide not to become avictim.

5. Learn patience and respectIn today’s remote-control society,

we have been taught that if we don’tlike something, we can click it awayrather than learning the communica-tion skills to ask for what we wantand being patient while we get it.Abusers believe it is their right toblame someone if they don’t get whatthey want. Learning to respect thosewho help us get what we need andwant is a powerful skill.

6. Abuse versus powerA victim’s misconception is that the

abuser is powerful. Just because aperson speaks abusively to someoneelse doesn’t give that person power. Ifa victim believes the abuser is power-ful, the victim is powerless to act.

7. Explore the ego and self-speak

We often get bent out of shapewhen we are talked to in a way wedon’t like. Our ego is quick to remindus we don’t deserve to be treated thisway, and we have a right to feel hurtand angry. This is the ego talking, pre-venting victims from achievingawareness and clarity.

Negative self-speak is something allof us do. When someone vocalizeswhat we think about ourselves, wefeel offended. For example, a physi-cian may say to a nurse, “You are areal jerk,” and the nurse feels offend-ed. But the nurse may have said thatto herself several times that day with-out realizing she is abusing herself.She might have dropped a sterilepackage when she is in a hurry andsaid silently, “You are such a jerk,”but when someone else says that to

her and she reacts, she becomes a vic-tim.

8. Create win-win situationsMost nurses create win-lose situa-

tions by not dealing with the verbalabuse at the moment. They wait tospeak to the manager, file a complaintwith the union, or, worse, hold theirfeelings in and suffer the effects ofprolonged anger. The victim’s hope isthat someone else will solve the prob-lem. Verbal abuse must be dealt withat the time it occurs.

9. Realize life is stressfulThe world is a difficult place; peo-

ple are on edge. The world of healthcare for physicians has changed;many feel trapped with little controlof their practice. Nurses feel devaluedbecause they have been considereddisposable by their employers. Thisgerminates an atmosphere that is ripefor abuse. Getting to know each otherand creating connections help nursesand physicians relate to one anotherin a more effective way.

10. Learn about yourself.Most of us act from constructs

formed in our early lives; both victimand abuser bring these to the workplace. Removing these constructs andlearning to deal with one anotherhuman to human will decrease verbalabuse situations. Learning how to bepatient, understanding, and compas-sionate is important. Abusers mustnot assign blame when somethingbad happens to them, and victimsmust learn not to accept the blame. Ifa nurse finds he or she is alwaysbeing abused, a good question is,“What is it about me that causes thisto happen?” Victims give off negativeenergy, and abusers pick this up.

To contact Margaret Thornborough,call 310/828-3611.


information during the process.

Culture of collaborationGail Avigne, RN, BA, CNOR, nurse

manager of the OR at Shands Hospital,University of Florida, Gainesville,believes verbal abuse must be managedand behavioral expectations clearlydefined so physicians and staff knowabuse will not be tolerated. For exam-ple, merit pay increases are based onbehavior, customer focus, team build-ing, problem solving, developing oth-ers, and adapting to change.

Avigne has fostered a culture of col-laboration for about 5 years through aDiversity Work Group (OR Manager,July 1999). This group of 15 to 20employees, representing about 23 jobclassifications and various ethnicgroups, meets once a month to talkabout issues in the OR.

Avigne says it has taken a long timeto help employees realize they mustbring problems forward to solve themin a respectful way. Committee mem-bers also act as department cheerlead-ers and, along with key physicians andadministrators, were helpful in educat-ing coworkers and physicians when thenew disruptive behavior policy wasintroduced. (A copy of the Shands poli-cy is on the OR Manager web site atwww.ormanager.com)

Deborah Eiben, RN, BS, NP, a staffnurse at the Kaiser FoundationHospital in Walnut Creek, Calif, saysthe hospital’s Violence in the Workplacepolicy makes her and other staff nursesfeel safer because they know the policywon’t allow abusive physicians or peersto succeed. Eiben, the union representa-tive for her department, has seen thepolicy work. She emphasizes that aclear and well-stated policy has beenessential to solving and reducing abuseproblems.

What should the OR managerdo?

After interviews with OR managers,administrators, and physician execu-tives for this article, we found thatthose who thought they had a success-ful policy agreed on these points:

Have a strong policyThe written policy must say clearly

that there is zero tolerance for disrup-tive behavior. Key physicians must sup-port the policy. Dr Rosenstein saysinstitutions must ask, “Are we ready totell a surgeon who brings in $2 milliondollars a year that he isn’t welcome onstaff because he is verbally abusive?”

If institutions aren’t willing to getserious about their policy, they should-n’t write one and should be prepared tosuffer the consequences of high staffturnover or employees who performmarginally.

Promote a code of ethics and acode of behavior

Codes must be more than words ona piece of paper to meet a JointCommission on Accreditation ofHealthcare Organizations requirement.They should act as a template for cour-tesy and respect for everyone whoenters the facility and should guide allinteractions. (Examples of codes of con-duct are on the OR Manager web site.)

Educate, educate, educatePhysicians need to be taught how

powerful they are in creating meaning-ful workplaces. Rosenstein says mostphysicians are unaware of or are insen-sitive to the verbal abuse issue. Iftaught about how influential they are,most change immediately. During theeducational process, physicians need tounderstand the steps of the process andwhat will happen if their abusivebehavior is reported.

Doing nothing is not an optionIn light of a significant nurse short-

age, turning a blind eye to disruptivebehavior is costly. The cost to hire anew OR RN is over $13,000, not includ-ing orientation, according to JWTSpecialized Communications Health-care Group. If a newly hired nurse

leaves in 6 months because he or she isunhappy, costs mount up.

Writing an effective policyA policy and procedure should be

written only after discussions with keyphysicians, administrators, humanresource professionals, mental healthspecialists, legal advisors, and otherpersonnel. Each institution must ask ifit is ready to deal with a physician whois reported as a verbal abuser. DrRosenstein, Avigne, and Pankratz agreethat a good policy should:• Be well written. Make the policy

short, clear, and to the point. Thepolicy should be distributed toeveryone. Physicians should sign acode of behavior during the privileg-ing or the reprivileging process.

• Be supported by everyone. Theremust be physician champions whotake the message to their colleagues.Administrative support is impor-tant, but if the physician leadershipdoesn’t sign onto the policy, it willnot be effective.

• Have teeth. Staff and physicians alikeneed to know that if an incidentoccurs, action will be taken and con-sequences or sanctions applied if nec-essary. If an incident occurs, and noth-ing is done about it, the physician andthe nurses will distrust the policy andefforts to address verbal abuse.

Develop a processEach institution must determine the

procedure for handling a complaint.Usually, a multidisciplinary committeeis appointed. A discussion with a legaladvisor and union representatives iscritical to ensure protection of confiden-tiality and individual rights. A goodprocedure should explain how to:• Record the event. The event should

be documented as soon as possibleafter it occurred using factual andobjective language. Confidentialityof reporting and managing theprocess should be maintained.Anyone should feel safe in recordingand reporting an event.

• Report the incident. Several indi-viduals should be authorized toreceive a complaint. Names and con-tact information should be includedin the procedure and on the record-ing form.



“Codes must be more than

words on a pieceof paper.

“

• Delineate the process. Once a com-plaint has been filed, the process forevaluating the complaint should bedelineated. Identify member(s) ofthe multidisciplinary committeewho will review the complaint. Afterreviewing the complaint, the desig-nated committee member shouldmeet individually with the partiesinvolved to ascertain the scope ofthe problem. The committee membershould then give a full report to themultidisciplinary committee anddetermine the next step.

• Identify remedial options. Optionscan include taking a course on angermanagement, improving communi-cation skills, and/or counseling witha mental health professional. Thelevel of the offense and number ofoccurrences determine which optionwill be selected. Interventionsshould be graduated depending onthe offense; for example, repeatedoccurrences would be treated moreseverely than a single minor inci-dent.

• Identify consequences or sanctions.The type, level, and number ofoccurrences determine the conse-quences. Sanctions can range fromlosing early-morning surgery starttimes to losing privileges.

• Provide a feedback loop. Definehow the person reporting the inci-dent will be told how the problem isbeing addressed. This is importantto gain nurses’ trust.

Most physicians unawareDr Rosenstein says physicians’ dis-

ruptive behavior ranges from mild andinfrequent to highly disruptive, withmost falling in the middle. He believesmost physicians are unaware of theeffect they have on a nurse’s workday.In VHA hospitals, he has found that50% to 60% of physicians who have hadan intervention take care of the problemimmediately; another 40% might need ageneric course to help them betterunderstand the impact they have on theworkplace. About 25% don’t get themessage, and sanctions may be needed.

Avigne and Pankratz say they valuethe support they have received fromkey administrators and surgeons.Pankratz believes that the more physi-cians are involved in formulating a pol-

icy, the more likely it is to be successful.Avigne says strong human resourceprofessionals are important. Everyoneinvolved in policy development andimplementation must be available tointervene promptly when an incident isreported. Avigne emphasizes thatphysician-nurse relationships are ofparamount importance for recruitingand retaining staff. Often, what physi-cians do not think is a big deal is a hugedeal for nurses, and managers find outtoo late why they are leaving.

Don’t rely just on a policy to solvethe problem. Offer classes that teachrespect and conflict management skills,and promote personal awareness andgrowth. Creating a work environmentthat is honest and respectful is the bestoffense. (See sidebar for suggestions.)

SummaryEmployees and their work perfor-

mance determine the success of anybusiness. Permitting verbal abuse andother disruptive behaviors is bad man-agement.

Well-written policies, physicianchampions, strong executives, and thewillingness of OR managers to try newapproaches to assist the staff to developnew skill sets will help to create healthi-er workplaces where everyone knowswords don’t hurt. ❖

—Suzanne Ward, RN, MA, MN,CNOR

Suzanne Ward is a perioperative nursewith extensive experience in both educationand management who writes on operatingroom management.

ReferencesCox, H. Verbal abuse in nursing: Report of

a study. Nursing Management. Novem-ber 1987: 18 (11): 47-50.

Cox H. Verbal abuse in nursing practice.Nursing Management. November 1988;19(11):58-63.

Cox, H. Verbal abuse nationwide. Part I:Oppressed group behavior. NursingManagement. February 1991, 22(2):32-35.

Cox H. Verbal abuse nationwide: Part II:Impact and modifications. NursingManagement. March 1991;22(3):66-69.

Linney B J. Confronting the disruptivephysician. Physician Executive. Septem-ber-October 1997; 23(7):55. www.acpenet.org/Forums/Positional/Vpma/Articles/Linney.htm

Rosenstein, A. Nurse-physician relation-ships: Impact on nurse satisfaction andretention. American Journal of Nursing.June 2002; 102 (6):26-34.

Stroma, BT. Impaired and/or disruptivephysicians. Presentation at annualmeeting of American Health LawyersAssociation, June 19, 2000. www.vin-son-elkins.com/publications/health-care/presentations/impaired.pdf



Have an idea?Do you have a topic you’d like to

see covered in OR Manager?Have you completed a project youthink would be of help to others?

We’d be glad to consider your suggestions.

Please e-mail Editor Pat Pattersonat [email protected]

Web sites onverbal abusewww.betterendings.org

A web site to stop verbal abusewith children.

www.dr.irene.com Information on verbal and emo-

tional abuse, signs and symptoms,and what to do about it.

www.nurseadvocate.org A site specifically for nurses. Take

the verbal abuse survey and readinformative articles.

www.mtoomey.com The Liberation Psychology Home

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What can a car maker teachhealth care organizations? APittsburgh-based initiative is

applying principles from Toyota to makerapid improvements in care processes. Itis saving nurses’ time and improving thequality of care and services.

The Pittsburgh Regional HealthcareInitiative (PRHI) was launched by theJewish Healthcare Foundation and USTreasury Secretary Paul O’Neill. O’Neillapplied the Toyota Production System(TPS) to improve worker safety while atAlcoa in Pittsburgh. Implementing TPSin the Alcoa workplace caused dramaticsafety improvements. The lost-dayinjury rate for Alcoa workers is now1/18 that of health care workers,according to PRHI. After TPS wasapplied to manufacturing, costs felldramatically as well.

The Toyota principles were devel-oped after years of study by SteveSpear and Kent Bowen of the HarvardBusiness School.

Today PRHI focuses on three areas: • patient safety

• clinical initiatives

• use of TPS to redesign health careorganizations through the PerfectingPatient Care System. PRHI’s members include hundreds

of clinicians, 35 hospitals, four majorinsurers, over 30 major and small-busi-ness health care purchasers, and dozensof corporate and civic leaders.

The learning lineA central concept of TPS is the

“learning line.” The line is where work-ers learn how to design, operate, andimprove their work using TPS princi-ples. A key approach is to solve prob-lems one at a time in the course ofwork. The goal: an ideal where patientcare is delivered:• on demand

• defect-free

• one by one

• immediately

• without waste or error

• in an environment that is physically,emotionally, and professionally safe.

Will OR managers some day estab-lish TPS “learning lines” in theirdepartments to get patients what theyneed, reduce waste, and create happier,

more involved workers? Examples of how the system is

working in related areas suggest thecarmaker’s philosophy holds promisefor any department.

Correcting a chart snafuAt Western Pennsylvania Hospital,

Dave Sharbaugh is the PRHI educatorfor a TPS learning line in the preopera-tive holding area.

To participate, a hospital must freeup one full-time person to serve as ateam leader. At West Penn, that personis Gloria Teichman, RN, formerly thecharge nurse. Workers come to her firstwhen they have a problem doing a jobor meeting a patient’s need. First, sherestores the system by quickly address-ing the problem. Next, she and otherson the learning line solve to the rootcause by asking ‘why?’ five times toreach the underlying design principleand then applying the agreed-upon setof principles to fix the problem.

A chart snafu is one of the first prob-lems the learning line at West Pennhelped unravel. The preop departmentdiscovered many charts came back tothe holding area without Address-ograph stamps on all of the pages. Ittook about 2 minutes for a nurse to fixthese defective charts.

“We had to redesign the process sothe workers building the charts couldpass on defect-free work to the cus-tomers, ie, the nurses in the holdingarea,” says Sharbaugh.

By getting extra stamp machinesinto the hands of the workers whoneeded them, the number of chartswith stamping problems—about 30 to35 charts a day—fell to just one or twowithin a week.

“That saves about 70 minutes perday of RN time in the holding area,”says Sharbaugh.

One of the TPS principles holds thatthe people who do the work should bethe ones to design and improve theirwork. Initially, workers recommendedthat just before the chart returned to theholding area, the secretary should fixthe problems. That failed because thesecretary couldn’t keep up, althoughproblems decreased to 16 per day.

“Then we said, why should we letthe chart become defective at all—let’skeep it perfect. That’s when we decidedto get the stamps to the people whowere adding materials and make surethe card that’s embossed stays with thechart,” says Sharbaugh.

Problem solved in 5 minutesTeichman uncovered a number of

problems when she used TPS principlesto solve an order mix-up with a physi-cian’s office. Rather than approach theproblem in the traditional way, with thephysician’s office having to refax theforms and frustrations mounting in thechart room, Teichman and the secretaryfrom the chart room walked to thephysician’s office. They quickly discov-ered the office had the wrong fax num-ber, the wrong form, was sending oneform instead of two, and thought thehospital preferred to have the patientgo for testing on the day of surgeryrather than in advance.

“In 5 minutes, we were able to dealwith all the problems and change thesystem,” says Teichman.

“You learn by doing on the learningline,” says Sharbaugh. “You can’t sepa-rate learning and system change.”

Lacking labelsSeveral other Toyota principles—

work should be done on demand, andpeople’s work is valuable—were borneout in a label problem. Occasionally,charts lacked the labels nurses neededto put on patients’ specimen bottles,registration forms, etc. The nursescouldn’t print more labels because theprinter was busy printing the labelbatch report—sometimes for patientswho wouldn’t come in for several days.

“This goes against the principle ofwork on demand, and there was a lot ofwaste in producing the labels if the casegot cancelled, or the dates changed, forexample,” says Sharbaugh. “We foundthat for a 2-week period we wouldthrow away a 4-inch-thick stack of

Borrowing from Toyota to improve quality

“In 5 minutes, we were able todeal with all the

problems.

“

labels. Now the secretary prints thelabels just when the patient shows upfor the procedure. It’s not quite ondemand, but it’s close.

“In the course of the year, we’veprobably saved about $300 worth oflabels. The real cost is somebody’s time.Further, Toyota principles are thatevery worker deserves the right to suc-ceed. If we take their work and throw itaway, what are we saying about theirvalue?”

Saving nurses’ timeShadyside Hospital in Pittsburgh

has established an eight-bed learningline on a surgical unit. Leading theeffort are Debra Thompson, RN, UPMCHealth System teacher/trainer for thePerfecting Patient Care System; JudyShovel, RN, program manager, UPMCShadyside process improvement; andSue Martin, RN, program manager for-mer UPMC Shadyside nursing clinicaldirector who is now involved in clinicaldesign improvement. The latter twotrained under Thompson at UPMCSouth Side Hospital as “lend forwards,”employees freed up to learn from alearning line and bring TPS back home.

Detailed observation is a key tech-nique for the team leaders. Since earlyNovember 2001, they have spent weeksobserving how nurses do their workand solving problems with the nursesto ensure that they can spend moretime addressing patient needs. Oneproblem they observed was the timenurses spent searching for the singlekey to the narcotic pumps when theyneeded to change the setting forpatients’ pain medication. (Manage-ment had a backup set as well.)

The leaders figured nurses spentabout 49 minutes in every 24-hour peri-od looking for the key. The solution wassimple: Give every nurse a key at thebeginning of a shift and collect them atthe end. A pharmacy policy had to bechanged, and the TPS leaders consultedtheir compliance experts to make surethey were following regulations andstandards.

Why had the single key policy stoodfor so long? “Pretty much because oftradition,” says Thompson.

“The learning lines allow you to haverapid, frequent experiments under thedirection of a team leader, with addition-al input from educators, PRHI, thenHarvard, and Toyota. But we also havewhat we call vertical pathways for assis-tance through the operational health

chain, where you can pull people in forrapid problem solving. The team leadercan serve as a bridge builder to get reso-lution to problems very quickly.”

TPS for the OR?How do these TPS pioneers in health

care envision the process working inthe OR?

“The challenge is for OR managersto get out from behind the desk, walkbeside the scrub techs and circulators,and see what they do, who they talk to,who their customer is, who their sup-plier is,” says Martin.

“One of the things we’ve observed isthat people do a lot of ‘work-arounds,’”says Thompson. “Then the next ques-tions to ask are: How does the workerknow what to do? What is the connec-tion piece? Where does he or she getinformation? How do workers knowthey have everything they need to dotheir work?”

Detailed observation offers a win-dow into the “current condition.” Thenworkers and the leader can begin tosolve problems and do experiments.“You must always have some kind of

test,” says Thompson. “How manyminutes of the nurses’ time is spent onthis task, and if we eliminate it, thenhow many minutes are saved—that’swhen the ‘Aha!’ comes in.

“With traditional quality improve-ment, we would solve a problem in theconference room rather than observingit on the site. One chart or medicationerror may tell you a great deal aboutwhat’s happening all over.”

Another important issue for the OR isincluding physicians in the vertical path-way, say the Shadyside TPS leaders.

“When we’ve included our physi-cian partners in observations, theysometimes admit they never reallyknew the impact of their decisions. Wehave a couple of key physicians whohave signed on to be the liaisons for theconnection issues between the staff andphysicians,” says Shovel.

Although the process is detailed, thepace isn’t slow. In one morning, nineproblems had been brought to theattention of the Shadyside team leaderon the learning line.

“This is not about assigning blame,”stresses Thompson. “The process helpsus get back to the ideal of what do thepatients need and how can we redesignwork to get them what they need so it’sless hard for everybody.” ❖

—Susan Klann

Susan Klann is a freelance writer inDenver.

More information on the ToyotaProduction System and the PRHI Initiativeis at www.prhi.org.


“You can’tseparate learning

and systemchange.

“

Needles are single-use items andshould not be reused on the samepatient or from patient to patient.

This warning from the AmericanAssociation of Nurse Anesthetists(AANA) was prompted by an Okla-homa case in which more than 50 peo-ple may have been infected with hepati-tis C after a nurse anesthetist in a painclinic allegedly reused needles andsyringes on multiple patients.

According to the state’s epidemiolo-gist, the nurse drew enough medicationinto a syringe to treat multiple patientson the same day. He then used thesyringe with the same needle to injectmedication into patients’ IV ports. Since

patients’ blood can back up into IVports, needles are supposed to be usedonly once to avoid the risk of diseasetransmission.

In a Sept 23 letter to its members,AANA said reuse of needles andsyringes is a clear violation of its infec-tion control standards as well as thoseof the American Society of Anesthesi-ologists. AANA urged clinicians toreview standards, guidelines, and codesof ethics to assure practice follows thestandards.

The New York Times reported Oct 10that privileges of both the anesthetistand the anesthesiologist running theclinic had been suspended. ❖

Anesthetists warn on needle reuse

A quarterly column on technologytrends for surgical services.

If you’re designing new operatingrooms, equipment planning is a criti-cal part of the project, whether it

entails new construction or remodeling.The opportunity to build an OR

suite doesn’t come often, and planningfor new technology is complex. For thatreason, teams often look for expertisefrom an equipment planning consul-tant. One of the planner’s most impor-tant roles is to provide the vision andguidance for technology aspects of theproject. Equally important is an equip-ment planner ’s role in creating aprocess for decision making on medicalequipment planning issues. The plan-ner should be brought in as early aspossible to coordinate and participatein these decisions to help avoid con-flicts between equipment and otheraspects of design.

Vision is essential. Whether the pro-ject involves new construction or reno-vation, the planning and design teamwill want to reexamine the flow ofpatients and supplies and determinehow surgical procedures are changing.Which specialties are growing ordeclining? Which procedures does thefacility expect to increase or decrease?Which technologies will make proce-dures less invasive? Which will be donein an outpatient setting?

Equally important is coordination. Aplanner coordinates equipment-relatedissues with all parties, including thesurgical team, architect, contractor,facilities engineers, and others. Forexample, an OR has many technologiesthat generate heat. How will theseaffect the heating and air conditioningsystem? Also important are structuralissues. What supports will be neededfor equipment and utilities? Becausemany new technologies rely on infor-mation systems, what coordination isneeded with the rest of the hospital’sinformation network?

If you’re planning a minimally inva-sive surgery (MIS) OR, you may plan toinstall equipment booms that involve avariety of services and vendors.Equipment planning must consider allof these parties. In one situation, an OR

project was headed by a well-knownMIS surgeon who had good ideas aboutequipment planning. As the team start-ed to draw up plans, they realized theyhad not consulted with the anesthesiol-ogists. Leaving out a crucial team mem-ber can have costly implications fordesign and construction plans and bud-gets.

A planner also coordinates currentequipment inventory with new equip-ment needs. In an MIS OR, for instance,can you use existing electrosurgicalunits or will you need to upgrade? Towhat extent will you standardize equip-ment?

Questions to ask equipmentplanner

Key questions to ask when selectingan equipment planner include: • What is the planner’s level of exper-

tise? How much experience does theplanner have with projects similar toyours?

• What resources does the plannerrely on? How does the planner mon-itor new and emerging technologyand assess its efficacy?

• Does the planner have agreementswith certain vendors? Is the plannerfree to consider other vendors aswell?

What is the surgical servicesdirector’s role?

Surgical services leaders should beclosely involved in all phases of designand construction. They bring an impor-tant clinical perspective because theywill use the suite every day. Theyshould not hesitate to provide inputand ask questions.

They and their staffs know whatworks well in the current ORs and whatthey want to change. They understandhow equipment is used and how itaffects the workflow. They have experi-ence with various brands of equipmentand know about service, reliability,ergonomics, and educational issues.

Equipment planning processHere is how an equipment planner is

involved in the design and constructionprocess: • Early in the project, meet with clini-

cians, the architect, and administra-tors to gain a vision of the new spaceand how it will be used.

• Consult with the architect as thearchitect develops a space program,which is a “blueprint” of how thespace will be organized.

• Develop an equipment budget. ECRIuses its own database, which hastemplates for equipment for varioustypes of rooms, for example, anorthopedic OR.

• Inventory current equipment andrecommend how it should be allo-cated to the new facility based notonly on its current condition butwhether it will meet long-termneeds.

• Consult with the architect duringdesign development as more de-tailed drawings are made. Meet withclinicians to make more specificdecisions about equipment needsand refine the template. Begin tozero in on manufacturers and mod-els while monitoring the budget.


Equipment planning for a new OR suiteTechnology in Surgery

New technologiesNew technologies affecting OR

planning:• picture archiving and commu-

nication systems (PACS), com-puter-based data storage andretrieval systems for digitalimaging, which allow a varietyof images to be displayed oncomputer screens, including CTscans, MRI, nuclear medicine,angiography, ultrasound, andradiology

• anesthesia data managementsystems used for documenta-tion and cost tracking

• advanced guidance systems forneurosurgery, otolaryngology,and orthopedics

• increasing use of minimallyinvasive procedures, includingrobotics, with greater use ofspecialty equipment and equip-ment booms

• new imaging technologies,including intraoperative MRI,C-arms, and ultrasound.


Consider issues such as weight andutility and information technologydemands.

• Continue to consult with the archi-tect before construction documentsare prepared so decisions can bemade about fixed equipment, whichmay require structural support.

• Develop detailed equipment liststhat include new and existing equip-ment for the architect and contractor.Coordinate with other members ofthe design team to review drawingsand plans.

• Assist in the hospital decision makingand procurement process, includingcoordinating requests for proposal,vendor negotiations, time lines fordelivery, and acceptance testing.

• Continue to be a resource for thehospital’s team, the architect, andcontractor as phases of the projectare completed. Operating room construction or ren-

ovation is a complex and detailedprocess. A good equipment planner canmake the difference between an unor-ganized, over-budget project and onethat fulfills the team’s original visionfor a new OR suite. ❖

—Jay TicerHealth Devices Group

ECRI, Plymouth Meeting, Pa

Jay Ticer can be reached at jticer@

ecri.org. ECRI, a nonprofit organizationsometimes called the Consumer Reportsof health care, is known for its objectiveapproach to medical device evaluation.

WorkplaceKaiser nurses make big gainsin new contract

Nurses at Kaiser Permanente’s 17Northern California hospitals have rati-fied a new contract that bans mandato-ry overtime, increases pensions andhealth benefits, and boosts wages 26.5%across the board over the next 4 years,according to the Oct 23 Sacramento Bee.

In the Sacramento area, hourlywages for new nurses will go from$25.90 in the first year to $39.69 in thefourth year of the contract. In the BayArea, hourly wages will increase from$30.47 to $41.34.

Kaiser agreed to end all mandatoryovertime shifts by Jan 1, 2003. Forretirement benefits, Kaiser agreed toreplace current 401(k) plans with adefined benefits plan. Participation inthe fund will nearly triple currentretirement benefits, offering a retire-ment income comparable to that pro-vided by other major California healthcare systems.

The new contract also gives nurseswho retire at age 55 and who have atleast 15 years of service the chance to

buy family and dependent health cov-erage through Kaiser’s HMO plan at areduced premium.

—www.sacbee.com

Health care drives awaypotential leaders

More than half of health care CEOsbelieve their profession drives awaypotential leaders, according to a new sur-vey from Witt/Kieffer, an executivesearch firm specializing in health care.The survey, sent to nearly 1,600 CEOsnationwide, also found that nearly two-thirds believe there is a short supply ofhealth care leaders for the future. Theresponse rate was 11%.

Three-fourths say they miss opportu-nities to mentor effectively, and 67%report they create short-term manage-ment roles for their potential leaders, notleadership career paths. In addition,57%of respondents say they may missthe best potential new leaders by failingto screen and evaluate them effectively.Fifty-four percent say health caredemands unreasonably long work hours,

which discourages potential leaders.—www.wittkieffer.com

California holds hearings onnursing ratios

Public hearings were underway thisfall to invite comment on regulations tocarry out a state law passed in 1999 tomandate nurse-patient ratios in acutecare hospitals. The hearings were sched-uled for Nov 15 and 19 and Dec 4.

The ratios will be a minimum stan-dard that varies by hospital unit. Theproposed ratio for the OR and postanes-thesia care unit is 1:1 for patients underanesthesia and 1:2 for patients postanes-thesia. (A minimum 1:1 ratio for OR RNsis already in state regulation.) For med-surg units, the ratio will be phased inover a year from 1:6 to 1:5.

The ratios must take effect by January2004. Five years after they are adopted,they must be reviewed by the state with areport to the legislature. California is thefirst state in the nation to mandate ratios.

—California Department of Health Services.www.dhs.cahwnet.gov

SNOMED CT® in the surgical suite: An example

Source: SNOMED International.

SNOMED was misspelled in this graphic, which originally appeared in the August issue.SNOMED is the Systematized Nomenclature of Medicine, which some are using for nam-ing surgical procedures. OR Manager regrets the error.

SNOMED CT ID:63185002

Laparoscopywith biopsy

73632009Laparoscopy

274313004Endoscopic

biopsy

86273004Biopsy

37270008Endoscope

83670000Peritoneal

cavity structure

Is a Is a

Procedure site

Uses

Method


What’s the best way to reward staff?

“So when are we going to get ourChristmas bonus this year?”When an employee walked into

his office and asked him this on a sun-ny October day, Steven Robinson, COE,knew it was time to change the incen-tive program.

He and physician owners ofProfessional Eye Associates, based inDalton, Ga, were frustrated that theircurrent bonus program had turned intomore of an entitlement.

“It was becoming an expected rewardrather than an earned one,” says Robin-son. “We wanted to come up with a planthat would reward people who havehelped to make us profitable.”

Many ASC managers share his senti-ments. They are looking for a plan thatwill reward “hustle,” yet is objectiveand easy to administer.

Robinson started over and built anew bonus program with rewardsbased on a combination of seniority,salary level, and employees’ scores on apersonnel evaluation tool completed bytheir peers, managers, and physicians.

Simplest systemPerhaps the simplest system is to

have two incentives: a bonus tied tovolume or financial targets as well asmerit increases to reward individuals

based on their performance evaluation.Bonuses are more common in sepa-

rately licensed freestanding surgerycenters than in hospital outpatientdepartments, where there are issues ofequity with other units.

For the bonus, “You would take atarget volume for the quarter, andemployees would get a reward if thetarget is met or exceeded,” says SusanHollander, senior vice president foroperations for Aspen Healthcare,Boulder, Colo, a consulting firm thatdevelops and manages surgery centers.

If the target isn’t met, it’s a goodidea to carry it from quarter to quarterfor a year to give employees somethingto strive for, she adds.

The bonus amount is budgetedannually by the board, usually as a per-

centage of operating or net income. Thebonus is then divided among allemployees, including clinical, ancillary,and business staff, based on seniority.

“It’s just as important to reward yourregistration clerk who has been with youfor 5 years and sets a positive tone withyour patients as it is for the RN who hasbeen there a year,” she says.

An even simpler method is to givefrequent and inexpensive rewards, likemovie tickets, to individuals who dosomething noteworthy.

In Robinson’s program at Profes-sional Eye Associates, the bonus is part-ly tied to individual performance. Theplan draws on his 30 years in the Armyand 14 years as a practice manager. Heis now modifying the program for anew surgery center the practice is open-ing, using Performance Now softwarefrom a company called CCHKnow-ledge Point (www.knowledgepoint.com).

Under the current plan, bonuses arepaid twice a year based on a percentageof the practice’s profits.

“When we decided to base thebonus on part of the profits, it changedthe entire outlook,” he says. “Suddenly,we had people saying, ‘Maybe I canwork another patient in,’ or ‘Maybe wedon’t need that new piece of equip-ment.’”

The bonus money is split as follows:• 20% is based on longevity. For each

month of service, a certain value, say$1, is assigned. Thus, a person whohas been employed 180 months (15years) receives a larger percentage ofthe 20% than a person who has beenthere only 12 months. This part ofthe bonus applies to employees whohave completed their probation andwork more than 24 hours a week.

• 20% is based on salary level. A per-son who earns $40,000 a year, forinstance, receives more than some-one making $20,000.

• 60% is based on the staff’s scores ona personnel evaluation form. People

Gwendolyn Grothouse, RNAdministrative directorApple Hill Surgical CenterYork, Pa

Barbara Harmer, RN, BSN, MHADirector of surgical servicesFlorida Hospital, Celebration HealthCelebration, Fla

Jerry Henderson, RN, BS, CNORExecutive directorThe SurgiCenter of BaltimoreOwings Mills, Md

Diana Procuniar, RN, BA, CNORNursing administratorWinter Haven Ambulatory Surgical

CenterWinter Haven, Fla

Donna Gelardi-Slosburg, RN, BSNNational surgery specialistHealthSouthSt Petersburg, Fla

Rhonda Tubbe, RN, CNORAdministratorThe Surgery Center of NacogdochesNacogdoches, Tex

Ambulatory Surgery Advisory Board

“Basing the bonus onpart of the profitschanged the entire

outlook.

“


AmbulatorySurgery

with the highest scores receive alarger share than those with lowerscores.

Scoring performanceThe evaluation form scores perfor-

mance on 17 questions relating to quali-ty of work, reliability, cooperation,knowledge base, teamwork, and soforth. Employees rate their peers andmanagers on a 4-point scale from unsat-isfactory to outstanding. Employeesalso are scored by their manager andthe physicians.

(A copy of the personnel evaluationform is on the OR Manager web site atwww.ormanager.com. Look under theOR Manager’s Tool Box.)

In larger organizations with morethan 40 employees, Robinson suggestsdoing the evaluations by department.

He has found most employees ratetheir peers fairly. If an employee’sscores for a peer seem out of line, hewill ask the employee for a narrativevalidating the score.

In one case, an employee gave his bossa superlative score in every category.

Robinson called him in and said, “Soyou’re saying this person really has noroom for improvement? I’d like you tojustify these scores in writing.” Theemployee came back with a more realis-tic evaluation.

Robinson tracks the bonuses using aspreadsheet with built-in formulas.

“Once you get the spreadsheet setup, it doesn’t take long to figure out,”he says.

There is a line on the spreadsheet foreach employee where Robinsonupdates months of service, currentsalary, and the evaluation score, and thespreadsheet calculates the bonus.

Robinson updates employeesmonthly on how the practice is doingfinancially with an overview of totalcharges, write-offs, collections, andexpenses.

“The first time I shared these num-bers with the staff in an open meeting,they were blown away by the smallamount that was left over from theseemingly large charge total,” he says.

A plan to retain staffWhen a valued scrub nurse left a

couple of years ago because she wasn’tworking enough hours, owners of theOregon Eye Surgery Center in Eugeneasked what could be done to keep thatfrom happening again.

In response, the center’s manager,Ginny Pecora, RN, and her team devel-oped three types of incentives: • a rating system for RNs used in

determining the pay scale and allo-cating merit increases

• a minimum-hours plan to smoothout peaks and valleys of a fluctuat-ing case volume

• cash bonuses paid once a year basedon the center’s profits and allocatedaccording to scores on the evaluationform developed by Robinson. The center has two ORs, performs

about 3,000 procedures a year, and has40 employees.

A point systemA point system was developed to

recognize RNs’ skills and contributionsto the center. RNs are scored from 1 to 5in these areas:• how long they have worked in nurs-

ing

• how long they have been at the cen-ter

• how many areas they have cross-trained to

• extra projects they have participatedin, such as maintaining materialsafety data sheets or being responsi-ble for fire safety or employee healtheducation

• scrub skills, ranked from entry levelto expert.Each nurse was rated when the sys-

tem was first set up, and the ratingswere used to set up a wage scale.Managers found out what competitorswere paying and gave the owners aproposed pay package. That year, all ofthe RNs received a 10% to 20% payadjustment.

“We were able to get everyone into arange that was fair. Also, everyone hasaccess to the tool so they know howthey are rated,” says Pecora.

The RNs are rescored each year todetermine how pay increases will beallocated, but pay is not reduced if thescore goes down as long as the employ-ee is performing well.

Minimum-hours planThis plan addresses RNs’ dissatisfac-

tion about fluctuating hours. In setting up the plan, Pecora first

determined an average number ofhours worked per week based on thecenter’s historical case volume. For RNswho were most seriously affected, theowners agreed to supplement their payif the case volume dropped below theaverage for a short time. Seven employ-ees currently participate.

In return, on days when the surgeryschedule ends early, the nurses areexpected to work on projects such aschart review or reorganizing the med-ication cabinet. The project does nothave to be in their job description.

After the first year, money paid outwas less than had been projected by acouple of thousand dollars.

“If you looked at what our costwould be if they went elsewhere, itwould be more,” Pecora comments.

Attitude countsThe Harmony Ambulatory Surgical

Center, LLC, in Fort Collins, Colo, has aquarterly incentive plan for both clini-cal and administrative employees.Employees can increase their annualsalary by 5% if they meet all of the cri-teria.

“With a quarterly payout, there is


“There is areminder that

‘my hustlecounts.’

“


more immediate gratification and areminder that ‘my hustle counts,” com-ments Harmony’s administrator,Rebecca Craig, RN, CNOR.

Bonuses are based on the physician’sdistribution, with the staff receiving upto 5% of the total distribution amount.For example, if the annual distribution is$500,000, the employees receive 5%, or$25,000, divided among them. The centeris a joint venture between Poudre ValleyHospital and local physicians.

“Everyone knows that curbingexpenses will increase the total distrib-ution,” Craig notes. “For example, if wedecide to buy a $10,000 microscope,that will increase expenses and reducethe distribution. The staff and physi-cians are very careful about what theyneed. If it’s necessary for patient care,they will say to buy it. Otherwise, theymay decide they don’t need it.”

Each employee’s payout is based onhow well the person meets criteria, with50% based on attitude and behavior(sidebar). Attitude and behavior are eval-uated by the manager, who documentsinformation such as reports from physi-cians and team leaders about skill andwillingness to help get the work done.

Meeting financial, qualitygoals

Staff can increase their annual payby up to 10% through an incentive planat Children’s West, a freestandingambulatory center affiliated withChildren’s Hospitals and Clinics inMinnesota’s Twin Cities area.

The center has four ORs, 52 employ-ees, performs about 4,000 procedures ayear, and is not unionized.

The incentive program, firstdescribed in the July 2001 OR Manager,is based on the center meeting goals for:• profitability

• quality

• customer satisfaction

• patient safety.The patient safety goal was added

this year.The incentive amount is the same

percentage for all employees. Employ-ees can also receive an annual meritincrease.

The profitability goal is based onachieving the budgeted patient volumeand/or net income.

The center determines its financialtargets each year. If the financial targetis attained, the staff receives up to 5% oftheir salary. The payout depends onhow much actual performance exceed-ed the threshold. The financial goalmust be met for the staff to receive apayout on the other three goals.

A maximum of 5% of salary is paidfor the remaining goals. A threshold, tar-get, and maximum are set for each goal.Performance is gauged by responses tothe center’s customer satisfaction survey,which is given to all of its patients andhas a 45% return rate.

On quality, the aim is to have 90% to94% of families answer they are “verysatisfied” on questions nurses havecontrol over, such as being available,responding to questions, and givinghelpful discharge instructions.

Customer satisfaction is measuredthrough one question: Would you rec-ommend this facility to others? “Onehundred percent of families have saidthey would come back or recommendthe center to others,” says Jane Price,RN, MBA, CNOR, senior director forChildren’s Hospitals and Clinics.

Patient safety is assessed by askingfamilies to check on the survey or writein if they have had a concern abouttheir child’s medical safety while at thecenter.

Survey data are tabulated by the sys-tem’s marketing department. Price esti-mates it takes 8 hours of a manager’stime twice a year to administer the pro-gram in addition to the marketingdepartment’s time.

For the first half of 2002, employeesreceived 9% of their first 6 months’earnings. This was the center ’s four-teenth consecutive payout. Payouts arepossible twice annually and have aver-aged 7.7% since the plan was started.Price says she is confident the plan hashelped the team achieve a high level ofcommitment, quality, and outcomes. ❖

AmbulatorySurgery


Criteria forincentives

Harmony Ambulatory SurgicalCenter’s criteria for staff incentives:

Clinical staffAttitude and behavior 50%

Meeting benchmark for paid non-physician clinical hours/per casefrom Federated Ambulatory SurgeryAssociation (FASA) (applies to allprocedure rooms plus preoperativearea, postoperative units, and extend-ed recovery) 25%

Accounts receivablecoordinatorAttitude and behavior 50%

A/R posting completed by secondbusiness day of following month 25%Posting error rate <5% per month 25%

Biller/insurance coordinatorAttitude and behavior 50%

Days in A/R (no more than 67) 25%Cash collections for month abovebudget 25%

Outpatient coding specialistAttitude and behavior 50%

Average days from date of service toposting (8 days) 25%

Average days from date of service toclaims submission for primary insur-ance (8 days) 25%

Medical records clerkAttitude and behavior 50%

Communication, resolution of issues(eg, helping physicians meet policy ofdictating operative report within 24hours of procedure) 50%

Receptionist/schedulerAttitude and behavior 50%

Meeting same FASA benchmark asclinical staff 25%

Patient satisfaction above 95% 25%

Even though the doctor may say oth-erwise, Barbara Riley of Santa Fe,NM, knows for the patient there is

no such thing as routine surgery.“Other surgeons know what it means

when a doctor says it’s routine,” Riley, aretired hypnotherapist and founder of asupportive approach called TeamSurgery, says.

“But when the patient hears it’s rou-tine, he or she might think, ‘Why getworked up over it?’ and miss an oppor-tunity to be really prepared.

“Research proves that people whohave prepared themselves have a betteroutcome,” Riley notes. “Even showingthe patient the floor plan of the hospitalhas been shown to positively change theoutcome of the surgery.”

Passion of preparationPreparing patients (and their fami-

lies, employers, and friends) for surgeryis Riley’s passion, her personal and pro-fessional response to the damage shesaw in people’s lives when they did notsufficiently prepare themselves emo-tionally or logistically for even the most“routine” case.

In the mid-1990s, she spent 2yearsvolunteering at Santa Fe’s St VincentHospital, working with a medical librari-an, Beth Saltzman, and a surgical ser-vices clinical nurse specialist, Mary LouJackson, RN, to develop an interdiscipli-nary free class for anyone havingsurgery. Jackson continues to offer the 2-hour class at least twice a month, work-ing around the schedules of surgerypatients if necessary.

According to Jackson, who routinelyadjusts the class content and the accom-panying booklet she prepared withRiley based on patient and physicianfeedback, taking some time in advanceof the surgery to tour the facility, meetwith preop nurses, anesthesiologists,and discharge planners; practice stressmanagement; learn about preoperativeand postoperative nutrition; and otheraspects of the surgery have significantlyreduced the anxiety she is accustomedto seeing among preop patients.

Jackson notes that her class is “ageneric class, I can’t give you specificinformation about your specific surgery,”but with the additional opportunity tomeet various staff members and createeven a brief relationship, the impact is

greater than if they simply offered theclass on video.

A personal strategyWhile creating the class at the hospi-

tal, Riley continued to offer presurgicalcounseling in her hypnotherapy practice.When Doug Stewart, Boston Red Soxteam psychologist and a neighbor, cameto her office with a workbook he had puttogether for his pending prostate surgery,the pair decided to collaborate, and TeamSurgery was born.

Going into far greater detail than theclass model Riley had set up at St.Vincent and specific to each individual’smedical, work, and family situation,Team Surgery is both a product (a work-book/CD set Riley and Stewart are seek-ing to publish) and the approach Rileyuses in consulting with individuals.

Riley narrows the concept of TeamSurgery to three primary components forthe patient: • developing deep relaxation tech-

niques

• identifying reputable information inan understandable vocabulary

• organizing self, family, and friends inadvance for logistics and support.Riley bases relaxation techniques on

the classic book, The Relaxation Response,by Herbert Benson, MD, as well as theconcept of exceptional patients fromBernie Siegel, MD. There are differentways to develop relaxation techniques,from simply counting to 10 or takingdeep breaths to delving into spiritualbeliefs, Riley notes.

“I try to be practical. There are few ofus who haven’t done really hard thingsreally well at least once; I want to knowwhat worked for that person then and gofrom there.”

When information gathering, Rileysays she considers it crucial that patients

take a friend or family member to thedoctor’s office to catch whatever infor-mation the patient might miss.

“It’s often very difficult to take in allthe information,” she says. “I alwaysinsist a patient be accompanied by afriend to take notes. There is no wayeven under the best of circumstances totake this information in. Medical infor-mation is sometimes hard to translate,and that’s not always apparent.”

An opening to healThe third component of the Team

Surgery approach echoes Riley’s beliefthat no one undergoes surgery alone.

“I look at what is required in the 2 to 3weeks before and after surgery, some-times including a giant wall calendarwith the surgical date in the middle.

“I look at everything that needs to becovered in one’s life: who’s going to takethe dog to the vet, who’s going to takethe kids to and from school, who’s goingto pick up the prescriptions. Friends andfamily are ready to help, but they don’twant to have to figure out what needsdoing, and you don’t want to figure itout after your surgery.”

Riley also recommends a family meet-ing to determine a designated phone per-son to handle all communicationsbetween the patient, the team of support-ers, and the doctors.

“When you have a strategy and ateam, then you can prepare,” she adds.“A hospital is set up for procedures, notfor people. It’s your responsibility tomaintain yourself, to be a person, to goin with your resilience intact, to be whoyou are, not someone so off-balance thatyou can’t use your usual strengths.

“The guiding principle of TeamSurgery is that surgery is an opening toheal,” Riley comments.

“The question is, how do you wantto use it? We all have choices abouthow to do our lives. This is one.” ❖

—Candelora Versace

Candelora Versace is a freelance writer inSanta Fe, NM.

For more information on Team Surgeryand to contact Barbara Riley, go towww.teamsurgery.com. Mary Lou Jacksoncan be reached at St Vincent Hospital inSanta Fe, NM, at 505/983-3361.


Helping patients prepare for surgery

“When you have astrategy and ateam, then you

can prepare.

“

December 2002

Health Policy & Politics

FDA finds one fourth of hospitals reusesingle-use devices

A survey conducted before the Food and DrugAdministration’s guidance on reuse went into fulleffect found 24% of hospitals were reusing single-use items.

The most commonly reused items were:• sequential compression sleeves 16%

• drill bits, saw blades, or burrs 7%

• biopsy forceps, snares 6%

• endoscopic/laparoscopic scissors, graspers, dis-sectors, or clamps 6%

• electrophysiology catheters 4%.Large hospitals were more likely to be reusing

single-use devices. In all, 45% of those over 250beds were doing so, compared with 12% of hospi-tals with fewer than 50 beds..

The phone survey was conducted betweenDecember 2001 and February 2002 with a responserate of 79%.

—www.fda.gov/cdrh/reuse/survey-execsum.html

FDA will charge for medical devicereview

Medical device companies that want theirdevices reviewed by the FDA will pay a user feeunder a new law signed by President Bush Oct 26.The funds will help speed the FDA review process.

During 2003, companies will pay $154,000 for apremarket application and $2,187 for a 510(k).Small businesses will pay less.

Congress also authorized the FDA to accreditthird parties to conduct some of its inspections sothe FDA can focus on higher risk inspections.There are strict conflict of interest provisions.

Frequently asked questions on the new law areon the FDA’s web site.

—www.fda.gov/cdrh/mdufma/faqs.html

Labeling of single-use devices requiredAs of Jan 25, 2004, any reprocessed single-use

device introduced into interstate commerce mustbe labeled as follows: “Reprocessed device for sin-gle use. Reprocessed by [name of manufacturerthat reprocessed the device].”

Congress approved the labeling requirement aspart of the new user fee law described above.

In addition, the FDA will issue stricter rulesregarding which devices are exempt from regula-tions governing single-use devices. Fewer deviceswill be exempt, and more validation data will berequired.

—www.fda.gov/cdrh/mdufma/faqs.html

JANUARY THROUGH NOVEMBER, 2002

VOLUME 18

ACCREDITATIONBig changes in survey process, Dec:9

AMBULATORY SURGERYASC payment update, Dec:8ASCs and JCAHO guidelines, Apr: 25Consolidating ASC software vendors,

Jun: 25Diminishing returns for ASCs, Apr: 34Disaster plan checklists, Nov: 24Documentation errors review, Oct: 40Handling mass casualties, Nov: 23HIPAA & business associates, Jul: 28Joint ventures Q&A, Sep: 40Obesity surgery in ASCs? Aug: 26Outpatient RNs training, Mar: 30PACU eliminated in surgery center,

Jan: 27Pain management in ambulatory care,

Mar: 33Patient clothing, a survey, Mar: 34Patient right to interpreter, Aug: 24Physician distributions, Jan: 29Plastic surgeons take safety steps, Jun: 29Pondering HIPAA action, May: 25Practice guidelines & JCAHO, Feb: 28Procedures mix Q&A, Jul: 26Providing limited ER services, Mar: 29Staff key to surgeon satisfaction, Apr: 29Staffing a 5-room ASC, Sep: 35Surgeon’s “safe harbor” Q&A, May: 29Toughest JCAHO standards for ASCs,

Feb: 242002 Salary/Career survey part 2, Oct: 1What’s best way to reward staff? Dec:22Why build an ASC, Q&A, Nov: 26

AMERICAN NURSES ASSOCIATIONShortage spurs call to act (HP), May: 30

ANESTHESIAAnesthesia standards improve safety,

Apr: 32New postanesthesia guidelines, Jan: 21Preanesthesia evaluation, Jan: 20

ANESTHESIOLOGISTSAAs value debated, Mar: 20Licensure bill on move for AAs (HP),

Mar: 38Shortage delays surgery, Sep: 18

ANESTHETISTSAnesthetists warn on needle reuse, Dec:19NAs lawsuit can proceed (HP), Mar: 38

BENCHMARKINGBenchmarking supply costs, May: 18

BOOK REVIEWSCore Curriculum new edition, Aug: 29

CARDIOVASCULAR SURGERY - SEE HEARTSURGERY

CDC (CENTERS FOR DISEASE CONTROL &PREVENTION)Draft guidelines on processing, Jun: 7Knee allograft infections, Jan: 8

More West Nile evidence, Nov: 5Soap, alcohol rub OK for scrub, Dec:6US case of VRSA reported, Aug: 15

COLLECTIVE BARGAININGCalif strike averted (WP), Jul: 22Kaiser nurses make gains (WP), Dec:21

COMMUNICATIONOvercoming verbal abuse, Dec:1Patient right to interpreter, Aug: 24Preventing verbal abuse, Dec:13

COMPETENCEAcing JCAHO competence survey, Jun: 14Competence assessment myths, Jun: 16New RNs’ declining competence, Jul: 12Staff competence & JCAHO, Jun: 1Staff competency Q&A, Aug: 20Tips on competence standard, Jun: 15

COMPUTERS & SOFTWAREConsolidating ASC software vendors,

Jun: 25Consolidation of OR IS market eyed, Jul: 10

COSTS & COST CONTROLSBenchmarking supply costs, May: 18Decision to outsource instruments, Nov: 11Dropping GPOs pro & con, Mar: 1Editorial, Nov: 3GPO practices probed, Jun: 1Hospitals driving costs, Nov: 7 MD buy-in on cost control, Jun: 20Value analysis tightens chain, May: 1

DESIGN & CONSTRUCTIONBuilding project survival (pt 2), Jan: 1Considering an MIS OR? Aug: 21Construction monitoring checklist, Feb: 17Design key decisions (pt 2), Jan: 15Equipment planning for new OR, Dec:20Healing environment in surgical suites,

Mar: 14Healing environments, what’s known?

Mar: 17Infection risk part of construction, Feb: 19Lessons learned from renovation, Feb: 21Making healing part of OR suites, Mar: 1OR functioning during construction

(pt 3), Feb: 1ordesignandconstruction.com, Nov: 28Substerile area—a new look, Jan: 22Two models for healing environment,

Mar: 16

DEVICES - SEE SUPPLIES & EQUIPMENT

DISASTER PLANNINGBioterrorism checklist (HP), Oct: 46Disaster plan checklists, Nov: 24Handling mass casualties, Nov: 23RN response teams recruited, Nov: 28

DISPOSABLES & REUSABLESFDA questions single-use items, Sep: 1Resterilization practices survey, Nov: 1

ECONOMICSBusiness case for stable workforce,

Aug: 13

Health care cost crunch (HP), Aug: 30Trauma center closures a trend? (HP),

Aug: 30

EDUCATIONDistance ed an answer to shortage?

Apr: 1HHS awards grants (HP), Jul: 30Kaiser awards scholarships (WP),

May: 24Kids in health careers (WP), Apr: 28Med school applications fall (WP),

Nov: 19Nursing education shake-up (WP), Jul: 22Outpatient RNs training, Mar: 30Planning management transitions,

Mar: 24School enrollments up (WP), Feb: 30Web-based staff education, Jun: 17

EFFICIENCY - SEE PRODUCTIVITY

EMPLOYMENTBottom line on staff shortages (WP),

Aug: 28Business case for stable workforce,

Aug: 13Developing a plan to retain, Dec:1Editorial, Jun: 3Foreign nurse recruiting (WP), Jul: 22Legally defensible interviewing, Jul: 18Recruitment, what works, Aug: 1Selecting the best, Jul: 1Temp agencies edged out (WP), Jan: 242002 Salary/Career survey part 1, Sep: 12002 Salary/Career survey part 2, Oct: 1What do you offer? Aug: 12Will recruits be competent? (WP), Apr: 28

ERRORS - SEE TREATMENT ERRORS

ETHICSEditorial, Jul: 3

EYE SURGERYWho’s appropriate for LASIK? Jul: 27

FDA (FOOD & DRUG ADMINISTRATION)Action on two tissue banks, Oct: 9CD on reprocessing available, Aug: 27Charge for medical device review (HP),

Dec:26Concerns about suture packs, Aug: 25DEHP, PVC exposure notice, Oct: 15Droperidol warning, Jan: 18Genetic bone graft approved, Aug: 7Labeling of single-use devices required

(HP), Dec:26Needed: info on unused devices (HP),

Oct: 46Requiring more device data (HP), Aug: 30Survey on single-use devices (HP), Dec:26Tissue banking grows, Jan: 1

FIRBIN SEALANTSSealants from patients’ blood, Jul: 21Sealants likely to stick around, Jul: 20

GASTRIC BYPASSBariatric increase sees surge in legal cases,

Feb: 10Bariatric surgery special needs, Feb: 1Bariatric surgery techniques, Feb: 13Editorial, Feb: 3


OR Manager Subject Index 2002

Obesity surgery at a glance, Feb: 8Obesity surgery in ASCs? Aug: 26Personal view from OR director, Feb: 9

GUIDED IMAGERYImagery reduces stress, costs, Oct: 32

HANDWASHINGAlcohol as effective as scrub, Oct: 5Soap, alcohol rub OK, Dec:6

HEALTH CARE REFORMEditorial, May: 3

HEART SURGERYTrauma system for heart attacks? Jun: 5

HIPAA – SEE PRIVACY & CONFIDENTIALI-TY

HOSPITALSCan’t buy way out of shortage (WP),

Nov: 19Costlier hospitals for patients, Jul: 9Editorial, Oct: 3Hospitals driving costs, Nov: 7Leaders turn staffing around, Sep: 20Niche hospitals controversial (WP),

Oct: 45Positive for working mothers (WP),

Nov: 19Potential harassment liability (HP),

Oct: 46Proposed OPPS rates, 2003, Oct: 11Why build an ASC, Q&A, Nov: 26

IMAGENurses rank high in poll (WP), Feb: 30

INFECTION CONTROLCryoLife receives warning, Aug: 7Graft infection lessons, May: 7Infection risk part of construction, Feb: 19Knee allograft infections, Jan: 8Loaner instruments process needed,

Jul: 24Making your own kits? May: 22Packaging wish list, Sep: 29Substerile area—a new look, Jan: 22

INFORMATION SYSTEMSConsolidation of OR IS market eyed,

Jul: 10Perioperative IS ratings, Jul: 11

INSURANCEUninsured health care workers soar (WP),

May: 24

JOB SATISFACTIONDissatisfaction tied to shortage, Jul: 13Staff satisfaction survey, Nov: 15Staying happy in tough times, Aug: 18

JOINT COMMISSIONAcing JCAHO competence survey,

Jun: 14Alert on wrong-site, Jan: 7ASCs and JCAHO guidelines, Apr: 25Big changes in survey process, Dec:9Competence assessment myths, Jun: 16Getting H&Ps before surgery, May: 1JCAHO safety goals begin in January,

Sep: 30JCAHO safety goals Q&A, Nov: 20

Practice guidelines & JCAHO, Feb: 28Securing anesthesia drugs, Jan: 26Shortage threat to safety, Sep: 8Staff competence & JCAHO, Jun: 1Staff competency Q&A, Aug: 20Staffing compliance and JCAHO, Apr: 1Tips on competence standard, Jun: 15Toughest JCAHO standards for ASCs,

Feb: 24Web-based staff education, Jun: 17

LAW & LEGISLATIONBariatric increase sees surge in legal

cases, Feb: 10Bill seeks workplace “best practices”

(HP), Jun: 30Calif suit filed over unpaid breaks

(WP), Jun: 28Nurse Reinvestment Act (HP), Sep: 44

MANAGED CARESupporting managed care contracts, Jul: 1Three shifts in managed care, Jul: 7

MATERIALS MANAGEMENT - SEE SUP-PLIES & EQUIPMENT

MEDICAREASC oversight lacking (HP), Apr: 36ASC payment update, Dec:8Friendlier ABN forms (HP), Jan: 30Growth estimates questioned (HP),

Mar: 38Inpatient payments lag (HP), Jun: 30Medicare broken OMB says (HP),

Mar: 38Medicare H&P rule clarified, May: 11New pain code (HP), Feb: 30Outpatient payments for 2003, Dec:7Outpatient rates postponed (HP), Feb: 30Paying too much for supplies (HP), Jul: 30Proposal to relax EMTALA (HP), Jun: 30Proposed OPPS rates, 2003, Oct: 11Proposed payment rates, 2003 (HP),

Sep: 44

MEETINGSClara Adams-Ender keynote, Apr: 5Comedy troupe plays, Aug: 22Finance reports seminar, May: 5Intuitive side of managing, Aug: 5Managing the mix key to business, Jun: 6“Managing Today’s OR Suite” conference

coverage, Nov: 16“Managing Today’s OR Suite” moves to

single meeting, Sep: 5Standard for costing procedures, May: 20

NEEDLESAnesthetists warn on needle reuse, Dec:19

NEUROSURGERYSoaring liability curbs cases, Nov: 14

NOMENCLATUREWhat to name our procedures? Aug: 10

NURSE-PHYSICIAN RELATIONSOvercoming verbal abuse, Dec:1Preventing verbal abuse, Dec:13

NURSING SHORTAGEDissatisfaction tied to shortage, Jul: 13Distance ed an answer to shortage?

Apr: 1

Ex-nurses sought to fill gaps (WP), Apr: 28

House, Senate act (HP), Feb: 30Leaders turn staffing around, Sep: 20Military faces shortage (WP), May: 24160 hospitals study shortage (WP),

May: 24Push for legislation (HP), Jan: 30RN growth slowest in 20 years (WP),

Apr: 28RN staffing linked to quality, Jul: 5RN turnover rate at 21% (WP), Mar: 27RN turnover survey, Apr: 7Shortage threat to safety, Sep: 8

OPERATING ROOMSDesign key decisions (pt 2), Jan: 15Lessons learned from renovation, Feb: 21Making healing part of OR suites, Mar: 1OR functioning during construction,

Feb: 1Preference cards in OR, Aug: 1Technology roadmap for OR, Apr: 27

OR MANAGERSBuilding project survival – pt 1, Jan: 1CLUES® of personality, Jul: 15Golden Scalpel Award, Oct: 30Legally defensible interviewing, Jul: 18Managing the mix key to business, Jun: 6OR Manager of the Year, Oct: 7Planning management transitions, Mar: 24Preference cards as tool, Aug: 11Recruitment, what works, Aug: 1Selecting the best, Jul: 1Staff satisfaction survey, Nov: 15Staying happy in tough times, Aug: 18Stubborn devotion to quality, Oct: 25Supporting managed care contracts, Jul: 1

ORTHOPEDICSArthroscopy & osteoarthritis, Sep: 32Implant costs rise, Nov: 10orthonurse.org, Apr: 38

OSHA (OCCUPATIONAL SAFETY &HEALTH ADMINISTRATION)Ergonomic plan outlined (HP), May: 30OR rules at osha.gov (HP), May: 30Sharps lessons (HP), Nov: 22

PAINPain management in ambulatory care,

Mar: 33

PATIENT CENTERED CAREEditorial, Mar: 3Healing environment in surgical suites,

Mar: 14Healing environments, what’s known?

Mar: 17Making healing part of OR suites, Mar: 1Two models for healing environment,

Mar: 16

PATIENT RIGHTSPatient right to interpreter, Aug: 24

PATIENT SAFETYDEHP, PVC exposure notice, Oct: 15Office surgery & safety, Sep: 42Patient safety bill progress (HP), Nov: 22Plastic surgeons take safety steps, Jun: 29



PATIENT SATISFACTIONEditorial, Aug: 3

PHYSICIANSER MD shortage seen (WP), Aug: 28Med students shun surgery, May: 8Physician shortage looms (WP), Mar: 27Staff key to surgeon satisfaction, Apr: 29

POSTANESTHESIA CARE UNITNew postanesthesia guidelines, Jan: 21PACU eliminated in surgery center,

Jan: 27

PREOPERATIVE CARECardiac risk guidelines, Mar: 9Getting H&Ps before surgery, May: 1Helping patients prepare for surgery,

Dec:25Medicare H&P rule clarified, May: 11Preanesthesia evaluation, Jan: 20Pregnancy testing policy, Mar: 34Readable patient consent form, Apr: 22

PRIVACY & CONFIDENTIALITYAHA protests rule delay (HP), Jan: 30Final HIPAA rule, Oct: 12HHS: optional privacy consent, May: 16HIPAA & business associates, Jul: 28HIPAA snapshot, May: 26Right to privacy at zoo? Jun: 18To-do list for HIPAA, Jun: 26

PRODUCT ACQUISITIONDropping GPOs pro & con, Mar: 1GPO practices probed, Jun: 1GPOs & codes of conduct, Sep: 10GPOs probed again (HP), Nov: 22NY Times critical of GPOs, Jun: 10Third option in purchasing, Jun: 11

PRODUCT RECALLBronchoscope recall failure, Apr: 20Editorial, Apr: 3Recalls; what you should know, Apr: 21

PRODUCTIVITYClean chart project, Nov: 18Outsourcing surgical instruments, Nov: 1Preference cards in OR, Aug: 1

PROFESSIONALISMAgenda for the decade (WP), May: 24discovernursing.net (WP), Mar: 27

PROGRAM PLANNINGTechnology roadmap for OR, Apr: 27

PROSPECTIVE PAYMENTAPC rates in effect (HP), Apr: 36ASC payment update, Dec:8Changes protested, Jan: 5Outpatient payments for 2003, Dec:7Proposal frustrates AHA (HP), Nov: 22Proposed OPPS rates, 2003, Oct: 11

PUBLIC RELATIONSEditorial, Sep: 3

QUALITYBorrowing from Toyota, Dec:18Clean chart project, Nov: 18Developing a clinical indicator, Apr: 11Stubborn devotion to quality, Oct: 25

RECRUITMENT & RETENTION – SEEEMPLOYMENT

REIMBURSEMENTASC payment update, Dec:8Outpatient payments for 2003, Dec:7

REUSE - SEE DISPOSABLE & REUSABLES

RISK MANAGEMENTGraft infection lessons, May: 7

SAFETYAnesthesia standards improve safety,

Apr: 32JCAHO safety goals begin in January,

Sep: 30JCAHO safety goals Q&A, Nov: 20Office surgery & safety, Sep: 42Plastic surgeons take safety steps, Jun: 29

SALARIES & BENEFITSBidding wars for nurses (WP), Aug: 28CRNAs salaries top MDs (WP), Jun: 28MD superstars recruitment, Jul: 27RN, LPN salaries up in 2002 (WP), Oct: 452002 Salary/Career survey part 1, Sep: 12002 Salary/Career survey part 2, Oct: 1What’s best way to reward staff? Dec:22

SCHEDULING & UTILIZATIONThree rules for elective cases, Jul: 9

SENTINEL EVENTS - SEE TREATMENTERRORS

STAFFINGBidding for shifts online (WP), Jan: 24Bills would ban mandatory overtime

(HP), Jan: 30Calif ratios delayed (WP), Feb: 30California hearings on ratios (WP), Dec:21GI RN position statements, Oct: 35ICU complications rise (WP), Jan: 24Leaders turn staffing around, Sep: 20New association for RNs (WP), Mar: 27New ratios proposed in Calif, Mar: 5Nurses freeze admissions (WP), Jul: 22RN staffing linked to quality, Jul: 5Shortage threat to safety, Sep: 8Staffing a 5-room ASC, Sep: 35Staffing and patient mortality, Dec:5Staffing compliance and JCAHO, Apr: 1

STERILIZATION & DISINFECTIONCompressed air inappropriate, Mar: 23Draft guidelines on processing, Jun: 7Drills, other power equipment, Nov: 21Making your own kits? May: 22Packaging wish list, Sep: 29Resterilization practices survey, Nov: 1Scope guidelines coming, Aug: 19Substerile area—a new look, Jan: 22What is being resterilized? Nov: 6

STRESSStress at work pervasive (WP), Oct: 45

SUPPLIES & EQUIPMENTBenchmarking supply costs, May: 18Considering outsourcing? Nov: 9Decision to outsource instruments,

Nov: 11GPOs & codes of conduct, Sep: 10MD buy-in on cost control, Jun: 20

Outsourcing surgical instruments, Nov: 1Packaging wish list, Sep: 29Seamless outsourcing process, Nov: 13Third option in purchasing, Jun: 11Tighten product-entry process, May: 17Value analysis success factors, May: 15Value analysis tightens chain, May: 1

SURGERYBariatric surgery special needs, Feb: 1Bariatric surgery techniques, Feb: 13

SURGICAL TECHNOLOGISTMedPAC holds to nonreimbursement

(HP), Sep: 44

SURVEYSASC manager salaries, Oct: 36Automation a way of life, Oct: 26Average annual salaries, Oct: 19Canceling surgery, Sep: 11Diminishing returns for ASCs, Apr: 34Golden Scalpel Award, Oct: 30Macro view of shortage, Sep: 14Manager recruiting, Sep: 20OR manager characteristics, Oct: 24Profile of ASC manager, Oct: 36Resterilization practices survey, Nov: 1RN turnover survey, Apr: 7Salary/recruiting, Sep: 16Skill mix unchanged, Oct: 21Staff satisfaction survey, Nov: 15Surgical services director, Oct: 12002 Salary/Career survey part 1, Sep: 12002 Salary/Career survey part 2, Oct: 1Vacancies, temps, Sep: 11

TECHNOLOGYConsidering an MIS OR? Aug: 21Equipment planning for new OR, Dec:20Technology roadmap for OR, Apr: 27

TISSUE BANKSAction on two tissue banks, Oct: 9Banking resources, Jan: 12Editorial, Jan: 3Tissue banking grows, Jan: 1

TISSUE CULTURECryoLife receives warning, Aug: 7Graft infection lessons, May: 7Knee allograft infections, Jan: 8

TREATMENT ERRORSAlert on wrong-site surgery, Jan: 7Bill to protect whistleblowers (HP), Jul: 30JCAHO safety goals begin in January,

Sep: 30NY State probes deaths, May: 13VHA program to curb wrong-site surgery,

Mar: 7

WRONG SITE - SEE TREATMENT ERRORS



Managing Today’s OR SuiteStarting in 2003, Managing Today’s OR

Suite will become a single conference.Future dates are:2003 Sept 17 to 19

Manchester Grand Hyatt San Diego2004 Oct 6 to 8

Hyatt Regency Chicago


A multi-specialty Ambulatory Surgery Center (ASC) in NorthPlatte is seeking the following positions for immediate hire.

Candidates must have a health care background with a college degree. Important skills include: leadership, physician relations, third-party payer contracting, personnelmanagement, business operations and financial management.

Candidates must be an RN with surgery center experience.Other requirements include supervisory experience, asuperb work ethic, excellent interpersonal/communicationskills, and a positive attitude. Candidate should enjoy managing the fast-paced environment of a dynamic, service-oriented, high-quality surgery center.

We offer a competitive compensation and benefits packagecommensurate with experience. Please mail/fax/email yourconfidential resume, including salary history to: Johnson &Johnson Health Care Systems Inc., Consulting andServices, Attn: Michael Peabody, 1100 McCaslin Blvd.,Suite 200, Superior, CO 80027; Fax: (720) 304-9070; orEmail: [email protected]. No telephone inquiries,please. EOE

First probable variantCJD case in US resident

The Centers for Disease Control and Prevention (CDC)reported in October on the first likely case of variantCreutzfeldt-Jakob disease (vCJD) in the US. The case, involv-ing a 22-year-old Florida resident, was originally reported tothe CDC in April.

The patient, who was born in the United Kingdom in1979 and moved to Florida in 1992, grew up in the UK whenbovine spongiform encephalopathy (BSE), or mad cow dis-ease, was increasing and when the risk for human exposureto BSE was at its peak.

It is likely that the patient was exposed to BSE beforemoving to the US and that the interval between exposureand onset of illness was 9 to 21 years, consistent with knownincubation periods, according to the CDC.

The patient sought treatment for depression and memoryloss in November 2001. By January 2002, the patient was hal-lucinating and had speech abnormalities, bradykinesia, andspasticity. The patient was evaluated in the UK, and a tonsilbiopsy demonstrated the presence of protease-resistant prionprotein with the characteristic pattern of vCJD.

The patient is unlikely to have transmitted the disease toothers because the patient did not have surgical proceduresthat involved manipulation of infectious tissue. The diseaseis not communicable by usual personal contact. ❖

—Morbidity and Mortality Weekly Report. Oct 18,2002;51:927-929. www.cdc.gov/mmwr

31

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At a Glance


Periodicals

Government should setstandards, pay for quality

The federal government should takethe lead in setting health care qualitystandards, starting with six governmenthealth programs, the Institute of Medi-cine recommended Oct 30.

The report recommended that thegovernment give financial rewards todoctors and hospitals that improve qual-ity. It also advocated making data avail-able to the public for comparing pro-vider quality.

The institute urged the US Depart-ment of Health and Human Services, theDepartment of Defense, and the Depart-ment of Veterans Affairs to work togeth-er to forge current fragmented effortsinto standardized performance mea-sures. Since better information systemsare needed, the report urged the govern-ment to strongly support developmentof computerized patient records.

The report called for 5 performancemeasures next year and another 10 by2004. The institute proposes that by 2007providers be required to submit data onsafety and quality as a condition of par-ticipating in Medicare, Medicaid, theState Children’s Health InsuranceProgram, the Defense Department’s TRI-CARE programs, and the Indian HealthService. The programs provide care forabout one third of Americans.

The report, requested by Congress, isthe third in a series on health care quali-ty. The first report, released in 1999,seized headlines by citing that up to98,000 patients a year die because oferrors. The second, Closing the QualityChasm, called for a national effort toimprove quality and patient safety.

—www4.nationalacademies.org

AAAHC teams for lithotripsyaccreditation

The Accreditation Association forAmbulatory Health Care (AAAHC) hasjoined with the American LithotripsySociety (ALS) to form the AccreditationProgram for Lithotripsy Organizations(APLO). The program will provide vol-untary accreditation for organizationsoffering lithotripsy services.

Organizations will be reviewed forcompliance with AAAHC standards andALS requirements that address lithotrip-sy services. Organizations found to besubstantially compliant will be awardeda combined AAHC/ALS accreditation.

On-site reviews will be conducted byAAAHC surveyors.

—www.aaahc.org

ECRI issues alert on somethoracic catheters

ECRI issued a critical alert Nov 12about a potential patient safety threatfrom some thoracic catheters inPharmaseal thoracentesis trays distrib-uted by Allegiance Healthcare Corpora-tion. The catheters may be brittle and canfragment in the patient’s pleural space.Because the catheter is exposed onlyafter it is inserted in the patient,providers cannot examine the flexibilityor strength of the catheter before inser-tion. Possible complications from frag-mented catheters are foreign-body reac-tions, infection, and the need for surgeryto removed the fragments.

After receiving a report from a mem-ber hospital, ECRI investigators deter-mined that catheters from trays with thesame lot number L1N094 were found to

be broken or brittle. Another incidentwas reported to the FDA for lot numberL1K058. “The problem may be moreextensive than those particular lots,” cau-tions ECRI’s Mark Bruley.

ECRI is a nonprofit organizationfocused on health care technology.

—www.ecri.org

CABG mortality higher in stateswithout certificate of need

Medicare patients have a greater like-lihood of dying after coronary arterybypass graft (CABG) surgery in stateswithout certificate of need (CON) regula-tions, according to a study of more than900,000 Medicare CABG patients in morethan 1,000 hospitals.

CON regulation began in 1974 to con-trol health care costs and help ensurequality of care by limiting the number offacilities performing complex medicalprocedures.

Since the federal government bowedout of the program in 1984, many stateshave limited or eliminated their CONregs.

The study found that unadjustedmortality was 5.1 % in states withoutCON, 4.4% in states with continuous reg-ulation, and 4.3% in states with intermit-tent regulation.

Risk-adjusted mortality remainedhigher in states without regulation com-pared with states with regulation.

Mean annual volume per hospital forCABG surgery was 84% lower in stateswithout regulation, and more patientsunderwent surgery in low-volume hos-pitals.

—Vaughan-Sarrazin M et al. JAMA.Oct 16,2002;288:1859-1866. www.jama.com

the monthly publication - or manager...2002/12/05 · patient deaths increases by 31%, or 20,000...

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