Planning on bringing a new procedure or surgeon to your center? Here's what's worked for me at my orthopedic surgery center.

From the word "go"
Because any additions will affect the entire perioperative process, from scheduling and pre-op to post-op and billing, start planning as early as you can. You'll need at least a month to prepare, and six weeks to eight weeks is ideal if you have the luxury of time. But you usually don't. Begin taking action as soon as you find out that there may be a new specialty or surgeon in the works. Keep your ears tuned for these possibilities at the scrub sink or in the OR. By the time it's official, the partners want the plan in action as soon as possible.

Your facility's board of directors must agree, of course, before you take any real action. If your physicians, like ours, come from all over and aren't usually at the facility at the same time, you'll want to be sure you haven't gotten mixed messages. So notify the board's members of the potential new addition as soon as you're aware of the possibility. Get them talking about it and gauge their views.

At one time, some of my orthopedic surgery center's partners wanted to open the facility to pediatric surgery. An informal poll at the scrub sink determined that the partnership wasn't completely in agreement on this proposal. We called a meeting and drew up a list of the pros and cons of adding pediatric services. The list included details on the cost of start-up equipment, staffing and patient concerns, and the block-scheduling requirements of pediatric surgeons. In the end, the partners voted to not add the specialty.

Background checks
If your partners do decide to add a new surgeon or surgeons, send out the credentialing packets and begin the verification process. It can take up to three weeks to obtain some of your primary-source verifications. In two days via the Internet and phone, you can complete the American Medical Association profile (www.ama-assn.org/AMAProfiles), National Practitioner Data Bank (www.npdb-hipdb.com/), Office of the Inspector General (www.oig.hhs.gov) and state license verification. Since verification by the Educational Commission for Foreign Medical Graduates (www.ecfmg.org) must be conducted through postal mail, though, it will take longer.

Once you've got the documents in hand, organize a credentialing committee meeting to review the documents and vote whether to recommend that the board of directors issue privileges to each candidate. (See "Better Ways to Credential Your Surgeons," November, page 28.)

Scheduling and staffing
To evaluate the addition's impact on scheduling and staffing, call each new practitioner to find out how much time he needs, which days he'd prefer to schedule his surgeries and, most importantly, whether he's available when your ORs are open.

Review the open and underutilized spaces in your block schedule, moving cases when possible to accommodate the new surgeon's requests. This is where diplomacy pays off. Once you've analyzed the usage of block time - how much of it particular surgeons use, how much they don't use - you'll have to approach them very carefully about changing their schedules to accommodate a new practitioner. If no one's willing to change his OR times, though, and if the new surgeon's availability is limited to days that are already blocked out, your center might never see his cases. Identifying potential scheduling conflicts before everything's underway can help to avert this sort of problem.

New procedures might not only necessitate changes in scheduling, but also in staffing. You may have to bring adequately trained staff on board to help perform the procedure. Find out if the new surgeon has a preferred assistant.

New staffing means additional verification. Our most recently added surgeon works with an RNFA, who we credentialed according to policy. If an RNFA, or any other position, hasn't worked in your center before, you may need to write a policy.

In terms of procedures, check the scope of your state license, too. New procedures may require additional licensing. When we added podiatry a few months after opening our center, our original license for orthopedic surgery and pain management required additional licensing and payment of a state licensing fee (for us in New Jersey, $2,000), before we could proceed.

Face time
Schedule a meeting with the new practitioner and your staff about three weeks before his first case. This will give the surgeon the opportunity to tour the facility and meet the staff. If your staff is knowledgeable and experienced, the meeting will serve to reassure the surgeon about his upcoming cases.

Take advantage of the opportunity to discuss the procedure he'll be performing. Shortly before our center began performing microdiscectomies, the staff and surgeon met to brainstorm the instruments, special equipment, positioning devices and medications would be required. We took notes and developed a punch list from this meeting. Also, ask the surgeon to bring a copy of his preference cards from his current hospital.

Tools for the job
Ordering new instruments, equipment, medication and other needed items should be your next priority. Instruments usually arrive in two or three days; however, you may have to back-order some special instruments, so place your orders as soon as you've developed an instrument list. Rely on your sales rep's wealth of knowledge - he's most likely been all over the region and seen the procedure you're adding done many times elsewhere - and meet daily with your purchasing agent to discuss the status of the ordered items.

Keep in mind that you don't have to purchase every needed item. Trials and loaners are economical means of obtaining equipment for the first case. In addition, order minimum amounts of the needed medication for the first case to keep costs down and to avoid the budget risk of having large quantities expire on your shelves.

When the new instruments arrive, don't open and sterilize them immediately. Instead, secure them in storage until the case is officially booked and sterilize them a day or two before the case. Why? Because you can usually return unopened items to the vendor. Processed instruments aren't returnable.

Ascertain your staff's level of competency with the new instruments, equipment and medication. An in-service may be in order for those who are unfamiliar with or haven't used an item recently. Even seasoned OR staff may benefit from the refresher course.

Insist on having all electrical equipment on site at least two days before the first scheduled case so that biomedical has time to inspect the equipment before it's used on a patient. The two-day window is also an opportunity to make sure all of your equipment's parts are on hand and functioning properly. Once, we discovered that a Midas Rex drill we'd gotten on loan was powered by nitrogen pressure - and we didn't have an adaptable nitrogen cord because our center mostly used electrically powered equipment. Because we noticed this during the practice run, we were able to order a quick connect fitting and cord in the remaining time, averting a big problem on the day of surgery. You'll always discover something during a dry run.

In the worst-case scenario that some needed item is impossible to obtain or won't arrive on time, contact the surgeon's office immediately. Oftentimes you'll find that a substitution can be made.

Paperwork and patient care
Reach out to the new surgeon's scheduler. Send over your pre-admission testing requirements, chart forms and booking forms, directions to the facility, business cards and other patient literature. Don't wait for the surgeon's office to ask you to send them.

Obtain a copy of the surgeon's post-operative instructions, if applicable. Then you can print them out on your center's letterhead, and patients will have your center's name and contact information in addition to the surgeon's in the event of any concerns.

The surgeon may want to review your center's consent form. If he requests changes to the form, submit the changes or his new form to the board of directors for review.

If your center uses a dictation service, call the service a day or two in advance to register the new surgeon's name and add another dictation number. I usually ask the surgeon what dictation number he uses at the hospital and set that one up with our center's service. This makes it easy for the surgeon to remember when he starts practicing here or if he only visits occasionally. Even if his hospital uses the same dictation service, there won't be confusion, because each facility has its own ID number.

Among all your other preparations, don't forget the patient. On the day of the procedure, after all, your center's focus should be on patient care, not just instruments and clerical details. Careful planning ahead of time will assure that your patient receives the best care possible on the day of the procedure - and that he avoids sharing in the staff's preparation-related stress, delays and other difficulties. You don't want them to feel as if they're a test case.

A new procedure may involve additional patient needs. If there will be a longer recovery time, order a meal for the patient. For our discectomy patient, we set up a quiet recovery area away from our other post-op patients. We laid a sheet of egg-crate foam on the stretcher and placed a television in the recovery area. Small details like these contribute to a positive surgical experience for the patient and his family members.

Day one, and beyond
On the day of the case, arrive early to greet your new surgeon. Have a locker and a set of scrubs waiting for him. If it's a morning case, bring in breakfast; if midday, lunch. These little extras go a long way toward making a newcomer feel welcome and confident at your center. You should be easily accessible during the case to answer any questions about the facility. When the case is concluded, orient the surgeon to the dictation area.

Before the new surgeon leaves the center on his first day, make sure you talk with him about the case. Ask what went right - which, given your careful planning, should be almost everything - and what didn't go as well as expected. Ask him to assess the staffing, instruments, equipment and medication, and note what items he'll need for the next case. Be sure you fill those needs before he returns.

Your evaluation of the new addition shouldn't stop there. Call patients one business day post-op and ask for their input, noting any positive or negative comments. Meet with your staff, not only to hear their views, but also to thank them. Planning for a new procedure and surgeon can be stressful, and everyone appreciates recognition for their roles in making the process work.

Review all the charts for the new procedure, keeping an eye on completeness and compliance, for one year. Develop a quality assurance tool for documenting the review and provide a quarterly analysis to the board of directors during that year.

The growth of a surgery center is without question a challenge for everyone involved, but drawing up and carrying out a step-by-step plan in the months and weeks before you add surgeons or specialties can make these complicated processes more manageable, not to mention successful.