Our 3rd annual celebration of surgery's top performers.

Here they are, the recipients of our 3rd annual OR Excellence Awards. After poring over many compelling nominations, these leaders emerged as the best of the best in 5 categories essential to facility-wide success: financial management, infection prevention, patient safety, patient satisfaction and pain control. But they don't work alone. Each winner represents a dedicated staff, a facility full of surgical professionals who strive to provide the finest surgical care. Please join us in saluting this year's winners and celebrating their outstanding accomplishments. We congratulate them and extend our appreciation to the incredible efforts of all our loyal readers.

— Editors of Outpatient Surgery Magazine

Financial Management
Gloucester County Surgery Center
Mullica Hill, N.J.
Diana Grasso, RN, BSN, CNOR
Administrative Director

Infection Prevention
Martha Jefferson Outpatient Surgery Center
Charlottesville, Va.
Margaret S. Lebo, RN, BSN
Quality Improvement and Infection Prevention Specialist

Patient Safety
Bozeman Deaconess Hospital
Bozeman, Mont.
Sara Mitchell, CST
Staff Safety Coach

Patient Satisfaction
Surgical Center of DuPage Medical Group
Lombard, Ill.
Dawn Dormitorio, RN, BS
Clinical Manager
Mary Olsen, RN
PACU Charge Nurse

Pain Management
Mackinaw Surgery Center
Saginaw, Mich.
Steve Corl, BSN
Administrator

Financial Management
Gloucester County Surgery Center in Mullica Hill, N.J., opened its doors in April 2009 after smoothly sailing through its first state inspection and AAAHC accreditation. Achieving business success, however, proved to be a more challenging goal than the center's early clinical successes were.

The obstacles to profitability were varied and not entirely foreseeable: a sluggish economy, a delay in getting Medicare certification and not getting the volume that the 19 surgeons who'd joint ventured with a hospital and an anesthesia practice predicted.

"I didn't comprehend what a challenging, time-consuming task it would be to attract physicians to build our case load," says Diana Grasso, RN, BSN, CNOR, the multi-specialty center's administrative director.

The center's leadership came to understand the urgent need to take fiscal action. "By the summer of 2010, we realized that without intense cost-saving measures, we could not survive," she says. It was time for Plan B, some tough choices and a dedication to shared sacrifice to trim costs and stay afloat.

Tightening the belt saves $300,000
Everything was on the table. The first step, and in Ms. Grasso's estimation, the most difficult one, was cutting the business office staff by 1 full-time employee and decreasing clinical staffing to a 36-hour workweek. Hours worked were tracked closely. On light-schedule days, employees were asked to clock out early. On busy days they worked short-staffed. The tight budget and a lack of sufficiently experienced candidates limited the use of per-diem staffing. In addition, staff were required to absorb an increase in their health benefit premiums. "These measures were very upsetting to endure, but the staff pulled together to make the best of a very difficult situation," says Ms. Grasso.

The facility's managed care contracts were scrutinized and their reimbursement fee schedules re-negotiated, with the addition of carveouts for cases using higher-priced implants and supplies.

Taming supply costs and improving inventory management were also major focuses of the profit plan. Ms. Grasso and the surgical tech tasked with materials management at the center developed a supply cost worksheet so they could track their orders on a daily basis to calculate — and set a budget for — surgical supply costs per case. They reviewed and re-negotiated their contracts with vendors to secure lower prices, networking with other centers' preferred vendor lists and switching companies for better pricing when necessary.

They started tracking the center's implant use, recording the costs of implants and comparing those amounts against insurers' reimbursement rates for the cases at the time they were scheduled, in order to determine whether it was financially beneficial to perform a procedure or to continue scheduling them. Orthopedic surgeons actively assisted Ms. Grasso and the materials manager in negotiating with vendors to reduce implant costs.

Other cost-cutting efforts included pruning inventory par levels and implementing a distributor's bar-coding system to automate the tracking and ordering of supplies. Ms. Grasso's team evaluated the percentage of inventory that implants represented, switching to consignment options whenever possible. And advance planning was encouraged to prevent the need for and extra cost of overnight shipping, except in the event of an emergency.

Even the groups investing in the ASC venture played a part in its fiscal rescue. "I don't want to say 'Everyone took a hit,'" says Ms. Grasso. "But everyone participated in the cost savings. We tried to cut costs all across the board." For a 6-month timeframe, the center's ASC management firm and anesthesia group lowered their fees, while the hospital let the center pay its rent incrementally.

All told, the profit plan's cost-saving measures saved Gloucester County Surgery Center $300,000 for the year. It wasn't by any means easy. "You can imagine what a stressful year we had," says Ms. Grasso. "But we'd be a lot worse off if we hadn't. If we couldn't stay afloat, we were closing."

Not out of the woods yet
The work isn't over, either. The profit plan's initial stage concluded in March 2011, but many of its efforts are ongoing. "We've only made a dent in our spending, but it's really opened our eyes to how we could better manage inventory and cut costs," she says. "It's a learning curve."

Still, the center has been actively recruiting new physicians to its ORs — it credentialed 2 last month — and its existing surgeons have been steadily increasing their case volume. Per-diem nurses and surgical techs are brought aboard to meet the workload. Management and staff alike are "conscious all the time" of the lessons learned.

"Due diligence and cost-savings are now an everyday reality," says Ms. Grasso. "Without the collaboration of a wonderful, dedicated team, this could not have been possible. I am proud to say that I am the administrator of this surgery center."

— David Bernard

OR EXCELLENCE IN ACTION
Behind-the-Scenes Business
The Lakeland (Fla.) Surgical & Diagnostic Center has been in the business of treating patients in a range of specialties for 15 years. Behind the clinical team, unnoticed by most patients, stands a business office that keeps an eye out for solid revenues, cost-effective staffing and prudent spending in order to ensure the continued delivery of quality care. Tracy Rose, MBA, CPA, Lakeland's director of finance, and Wendy Neuman, CPA, its accounting manager, attribute Lakeland's sound financial footing — it has maintained a bad debt percentage of only 1% in recent years and its net days in A/R average 26 to 29 days — to a few routine steps.

• Outside looks. A quarterly coding and billing audit of a random selection of recent cases, conducted by an outside consultant, helps improve operational efficiency and makes sure the center is capturing the appropriate reimbursement.
• Consensus on expenses. A case-costing committee made up of business, clinical and materials management personnel collaborates in evaluating supply purchases (aiming to rein in spending without sacrificing quality) and capital expenditures (seeking wise investments when upgrading clinical technology and efficiency).
• Steady on staffing. The center carefully matches staffing needs to staff presence in order to control payroll costs. "We really have aggressive man-hour goals," says Ms. Rose. "Every 2 weeks, we go over the reports. If there's a department that's over its target, we'll let them know."
• Always watching. Monthly monitoring of key ratios helps to minimize debt. In addition to quarterly and annual audits, says Ms. Neuman, "we capture every bit of data we can and utilize it for our own detailed analysis."
• Safe and sound. Strong internal controls and a thorough approval process for payments virtually eliminate the possibility of error or fraud. Everyone is double-checked. "I prepare the financials, Wendy reviews them," says Ms. Rose. "Anybody can make a mistake."

Financial management requires constant follow-up and the cooperation of practically everyone on the business and clinical staff, say Ms. Rose and Ms. Neuman. But if it's done well and keeps a surgical facility in the black, it supports a greater mission: quality patient care.

— David Bernard

SSI Prevention
At Martha Jefferson Outpatient Surgery Center in Charlottesville, Va., an effort to reduce surgical site infections led to a staff-generated initiative that has ensured patients receive their pre-surgical dose of antibiotics on time more than 97% of the time.

Inside the QI study
Martha Jefferson modeled its SSI reduction efforts, in effect since 2007, on the multi-disciplinary Surgical Care Improvement Project (SCIP). Among its other guidelines, SCIP recommends that all pre-surgical prophylactic antibiotics be administered within 1 hour of incision to provide an adequate concentration of the drugs in the tissue of the targeted surgical area. (For fluoroquinolone and vancomycin, the window is 2 hours prior to incision in order to watch for any antibiotic-associated reactions.)

Eager to benchmark their practices on this front, the clinical staff conducted a quality improvement survey in December 2008. Nurses reviewed the pre-operative IV antibiotic orders in each patient's chart the day after surgery. They documented, in a written log in PACU, the time each antibiotic infusion began and the incision or tourniquet time, whichever came first. Any antibiotic doses that were missed or administered outside of the 1-hour range (or, in the case of fluoroquinolone and vancomycin, outside of the 2-hour range) were calculated as a variance.

The results showed a definite need for quality improvement. "In our initial audit, antibiotics were administered within the recommended time frame before incision only 80% of the time," says Margaret S. Lebo, RN, BSN, the center's quality improvement and infection prevention specialist. "Our goal was 97% compliance."

Impervious to schedule delays
A staff meeting was organized to discuss this shortfall and figure out ways to improve upon it. The participants soon identified the most common obstacle to on-time antibiotics: the inexact schedule. You can administer the drugs within an hour of the surgery's scheduled start time every time and still wind up with imperfect results when the surgical schedule, now and then, isn't an accurate predictor of OR time.

You can't wrangle unpredictability into submission, but you can change your methods to adapt to it. The solution Martha Jefferson's nurses developed works regardless of OR delays. No longer were pre-op staff tasked with starting IV antibiotics within an hour of the scheduled surgical start time. Instead, while readying the patient for surgery, they'd prepare the ordered antibiotic. They'd mark the bag with the patient's name, the dosage, their initials and the time they prepared it, and document the medication on the pre-op assessment form. They'd place a patient label on the bag and they'd leave it with the patient's chart.

Administering the antibiotic would then be the responsibility of the OR nurse who interviewed the patients before their transport to surgery, since delivering the drugs a few minutes before incision is within the acceptable range. The OR nurse verifies the physician's orders and starts the antibiotic infusion usually about 25 to 30 minutes before incision, documenting the time of administration on the pre-op assessment form.

Drug delivery was confirmed inside the OR as well. "Our time-out protocol was broadened to include patient allergies and if an antibiotic had been initiated pre-operatively," says Ms. Lebo. "This gave the surgeon a final opportunity to assess the need for antibiotic administration prior to incision. It also helped to identify when any ordered antibiotics may have been missed by the nursing staff."

As this new process was put into place, the daily chart review of on-time antibiotics continued. The desired results arrived fairly quickly, says Ms. Lebo. "There was an increase in our compliance after the first month of implementation of the corrective actions developed by our staff," she says.

Compliance with the small detail of on-time antibiotics has paid off. From 80% on-time administration in December 2008, the compliance rate rose to 90% the following month, 100% in February 2009 and 97% in March 2009. "Since February 2009, our compliance has been at our goal [of 97%] or better," says Ms. Lebo. And it's remained consistently above the Ambulatory Surgery Center Association's national benchmark, which generally registers between 92% and 94% month to month.

— David Bernard

OR EXCELLENCE IN ACTION
Enlisting Other Eyes for Infection Control Vigilance
The more people you involve in your investigations, the more effective your infection prevention efforts will be. At the Wooster Ambulatory Surgery Center in Wooster, Ohio, members of the business office join clinical teams in conducting monthly safety and environmental rounds to assess potential hotspots.

The value of including your business staff in infection control rounds, says Traci Sheipline, RN, the center's clinical nurse manager, is their different viewpoints on patient care areas, hand hygiene, personal protective equipment use, instrument reprocessing and the other practices and environments your clinical staff sees every day. "They don't have the clinical background, so it's more of a patient's or a consumer's presence during rounds," she says, and as they learn the hows and whys of infection prevention, they might as a result notice something that otherwise has gone overlooked.

The clinical staff also enlists surgical patients themselves for infection control surveillance, says Ms. Sheipline, following up each case with a post-op phone call 24 to 72 hours after their procedures. Among their other inquiries, the nurses will ask specifically if patients have noticed any signs of a surgical site infection, such as fever, wound drainage, a foul odor at the site or other symptoms indicating the onset of complications. If patients have noticed any of these symptoms, the nurses instruct them to contact their physicians — then they immediately contact the physicians' offices themselves.

In addition, every other month the center mails each of its surgeons a list of the patients they've recently operated on there, asking whether they have any knowledge of patients who have exhibited symptoms of, been treated for or been admitted to hospitals for post-op infections. On the rare occasion that an infection is reported, Ms. Sheipline says, Administrator and Infection Preventionist Tori Caillet, RN, revisits the patient's case record to determine possible causes and to correct gaps in prevention protocol.

— David Bernard

Patient Satisfaction
Every day the staff at the Surgical Center of DuPage Medical Group in Lombard, Ill., feel proud and privileged to care for their patients. "We want them to have a good experience from the moment they walk in the door until they're wheeled to their car," says Mary Olsen, RN, the pre-op/PACU charge nurse at the 5-OR, physician-owned ASC.

Each and every one of the 12,000 or so patients who arrive each year at the 6-year-old facility for the unpleasant business of surgery are treated like royalty, their every need anticipated and met. They're cared for at every intervention, warmed before they're cold, fed before they're hungry, reassured before they're discharged. You can't measure this kind of going-out-of-your-way service in a patient satisfaction survey or get reimbursed for it. But it makes a huge difference. "We take the role of being a patient advocate seriously," says Ms. Olsen. "We want patients to be happy and comfortable. They are our No. 1 priority."

Clinical Manager Dawn Dormitorio, RN, BS, and Ms. Olsen outline the 8 ways the ASC strives to satisfy its patients. Notably, many of these niceties were implemented in response to comments patients made on satisfaction surveys.

1. 2-stick policy. The ASC's IV policy ensures that patients aren't stuck more than twice. After 2 failed attempts to start an IV, anesthesia is called in.

2. Warming. The ASC uses a warming gown on every anesthesia patient. "This decreases post-op infections, provides comfort to our patients and is a cost-saving measure on the use of blankets from our laundry service," says Ms. Olsen.

3. Privacy, please. After patients complained that the curtains in the pre-op and recovery bays offered too little privacy and let in too much noise, the ASC invested $33,000 earlier this year to install glass doors in front of each cubicle.

4. Value their time. Staff notify patients and their families of any delay to surgery (an infrequent occurrence given a 99% first-case on-time start rate). Depending on how the OR is running, staff may call patients at home to come in earlier or later. Staff also use pagers to alert the patient's family of any delays while the patient is in surgery or in PACU. "This alleviates any anxiety for the family," says Ms. Olsen. "People don't like to wait. Their time is as important as ours or the surgeons'."

5. Refreshments. The patient's family can repair to a fully-stocked kitchen to enjoy a snack and something to drink while they're waiting for their loved ones. There's even a selection of gluten-free snacks.

6. Gifts. Each pediatric patient receives a tote bag filled with crayons, a coloring book, a teddy bear and a pocket Etch-a-Sketch. Older kids get a water bottle. To decrease anxiety for children, staff transport them to the OR in a wagon instead of a cart or a crib.

7. Discharge instructions. Patients had expressed concerns of feeling pain, dizziness and sleepiness when discharged. The center developed a patient discharge form that lets patients know what to expect when they go home (download it at www.outpatientsurgery.net/forms). It explains that they may have pain upon discharge, but it should be manageable with pain medication ("We don't discharge a patient with a pain score greater than 3," says Ms. Olsen). It also reminds them that, due to anesthesia, they'll be dizzy and/or sleepy up to the next 24 hours and that there may be some nausea.

8. Thank-you cards. Every patient receives a thank-you card for choosing to come to the facility to have her procedure. From the front-desk receptionist to the Phase II nurse, each person who cared for the patient signs the card.

Selfless servants
It's little wonder that the Surgical Center of DuPage Medical Group is one of the busiest surgical centers in Illinois. Or that it's one of the friendliest. "It's all about loving our profession and enjoying our work," says Ms. Olsen. "You have to be a people-person to be in this profession. You have to like people and want to help them."

— Dan O'Connor

OR EXCELLENCE IN ACTION
A Surgical Center Designed With Patient Satisfaction in Mind

Penn SurgiCentre in Philadelphia, Pa., was designed with the patient in mind, says Alyson Cole, MPM, administrative director of operations of perioperative services for the Hospital of the University of Pennsylvania.

• Design. The SurgiCentre features large, private, walled bays for pre-op and recovery, complete with televisions and seating for family members before and after surgery. Patients travel to the reception area on a dedicated elevator directly accessible from the parking garage. Patients step on the elevator, ride 3 floors and step out into the middle of the reception area. "This is the same path taken on discharge, and is a great satisfier," says Ms. Cole.
• Registration. "Rather than have patients stop at a registration desk or wait in line, we brought the desk to them," says Ms. Cole. An admissions rep wheels a mobile cart to the patient's pre-op bedside and processes all paperwork while the patient is seated in a stretcher chair.
• Patient tracking. A patient tracking system lets family members follow a privacy-controlled name on large LCD screens in the lounge through the stages of surgery.
• Prescriptions. Upon discharge, patients can have their post-operative prescriptions delivered to the bedside so that there's no need to wait in line at the local pharmacy on the way home.

— Dan O'Connor

Patient Safety
Pay attention to detail. Communicate clearly. Work with a questioning attitude. Speak up for safety. Never leave your wingman. Those are the 5 safety habits every surgical team member buys into at Bozeman (Mont.) Deaconess Hospital. "All healthcare workers are interested in patient safety," says Darci McCarthy Bentson, JD, MBA, CPHRM, the hospital's director of quality and risk management. "But it's easier said than done." She says many facilities often lack the tools needed to solve complex safety issues. Not so at Bozeman Deaconess. "We have a different tool box."

' Safety huddles. The surgical team meets each morning at 6:35 a.m. to preview the day's schedule and discuss potentially challenging cases, patients that require special attention (those with latex allergies, for example) and equipment needs. The huddles ensure safety concerns are resolved before they become issues, or worse, surprises in the OR.

That process is repeated each day at 8:15 a.m. during facility-wide safety check-ins. Most of the hospital's management team conducts a stand-up, 15-minute meeting to set safety expectations throughout each department. "We start each day with patient safety as the primary focus, to make every day a safe day," says Ms. Bentson. She says about 400 safety issues are addressed during a year's worth of daily check-ins. "Those are things we would have never discussed or not know about," she says.

' Speaking up. Speak Up for Safety is a program that promotes open discussions of patient and team safety without risk of retaliation. To publicize the program and its benefits, staff appear on educational posters hung throughout the facility. The posters show employees promoting safety-related practices. These familiar faces encourage their peers to speak up when patients are jeopardized.

The rate of reported events has risen significantly over the 2 years since the program's launch. "Our reporting of safety events has increased because fear of retaliation is diminished," says Roshelle Satterthwait, RN, MHSA, Bozeman Deaconess' director of surgical services. "A team member who reports a concern is looking for a solution."

' Safety coaches. All departments have assigned staff safety coaches who educate, encourage and reward safe behavior. Sara Mitchell, CST, Heather Davis, RN, and Rachel Pruitt, RN, CNOR, lead the safety charge in the ORs by adapting safety guidelines standardized at the facility level to fit the demands faced by surgical nurses, techs and surgeons. "The coaches understand the work processes in the OR and influence people at the point of care," says Ms. Bentson. "The directives are coming from peers, not from a glossy brochure."

"We don't seek to correct bad habits," adds Ms. Pruitt. "We praise and encourage the good habits. That's what drives our safety culture."

Changing the workplace culture is a clich?????? © often heard in surgical circles. Not at Bozeman Deaconess. They practice what they preach, one compliment at a time. "Sharing the positive stories, what people did right to protect patients, trickles down throughout the entire staff," says Ms. Satterthwait. "We'll see someone in the hall who was mentioned in a safety huddle and congratulate them on their success. People want to repeat behaviors that get them recognized."

— Daniel Cook

OR EXCELLENCE IN ACTION
Checklists Make Everyone Accountable
Linda Prister, RN, MSBA, rests a little easier each night knowing the comprehensive checklists used at the Dearborn (Mich.) Surgery Center help her staff catch near-misses before they turn into devastating safety breaches. The center's executive director says all staff members involved in a patient's care — from the registration desk to the PACU — fill out the checklist, marking that they've completed tasks required by regulatory agencies. "Our checklist is significantly more comprehensive than other centers' approaches," says Ms. Prister.

What makes an effective checklist? Flexibility, says Ms. Prister, so you can expand it as needed (to add new quality indicators, for example). Make checklists user-friendly so staff can fill them out quickly. Ms. Prister's checklists are color-coded, cueing staff to the sections they're responsible for completing.

Audit your checklists so you can track what actions you're taking to protect patients and addressing concerns that are overlooked. When ASCs will be required to submit quality safety measure data to CMS in 2014, points out Ms. Prister, you'll already be in compliance.

— Daniel Cook

Pain Control
You know patients who undergo surgery are going to experience pain. "So why wait until they're recovering to treat it?" asks Steve Corl, BSN, facility administrator of the multi-specialty Mackinaw Surgery Center in Saginaw, Mich. Mackinaw's pain control regimen has reduced patients' complaints of post-op discomfort by 35%, resulting in better patient satisfaction scores, decreased discharge times and medication cost containment. "We've learned that treating pain should not be a one-time thing," he says, "but a continuum of care throughout the perioperative setting."

Proactive approach
Each patient presenting for surgery at Mackinaw receives Motrin in pre-op (as long as it's not contraindicated). Following surgery, patients are given an appropriate dose of Demerol by injection. Those steps are taken with aims of attacking pain before it becomes an issue and letting patients awake from surgery pain-free.

During pre-op phone calls, staff ask Mackinaw's patients if they're currently experiencing pain and what they consider acceptable levels of discomfort (based on a 10-point scale). Pre-op nurses and anesthesiologist Craig Bohnoff, MD, who has worked with the center to develop pain control protocols based on national data and trends, review this phone assessment with patients on the day of surgery.

They ask patients if their acceptable pain score has changed since the phone interview, which lets Dr. Bohnoff and the pre-op staff tailor the center's pain-control regimen to specific patients' needs. "That helps dictate which medications patients receive in pre-op, during surgery and afterward," says Mr. Corl. For example, patients who admit to having a low pain tolerance receive the standard oral dose of Motrin before surgery for long-term pain relief (PO medications remain in the body's system longer, explains Mr. Corl), but are also given intramuscular injections of Demerol (which linger longer than medications delivered through an IV, points out Mr. Corl) to help control breakthrough pain.

Mackinaw's pain control protocol also involves an aggressive perioperative nerve block program. "Not only has this been successful for typical block procedures performed on the extremities, it has been hugely beneficial for hernia repairs and lap choles, 2 painful surgeries," says Mr. Corl. Patients are informed of a pain block's ultimate benefit — several pain-free days following surgery — and most elect to receive one, according to Mr. Corl.

Moving past pain
Mackinaw is proactive in its approach to pain control, attacking pain before surgery to avoid giving high doses of medication in post-op (which can lead to longer recovery times and dissatisfied patients).

But controlling patients' pain isn't only about pumping up patient satisfaction scores. "It also helps keep costs down," says Mr. Corl. By establishing a solid pain control protocol, you'll discover which medications work, and just as importantly, which ones don't. "Narrowing down your options to certain pain control medications will reduce your pharmaceutical costs," explains Mr. Corl, who says Mackinaw has consolidated its narcotic use to mostly Dilaudid and Lortab. Zeroing in on effective ways to maintain patient comfort also means patients meet discharge criteria faster, which keeps them moving through your facility, points out Mr. Corl.

"During follow-up phone calls to patients a day after surgery, if our regimen works correctly, they'll have no discomfort whatsoever," he says. "We move past pain altogether."

— Daniel Cook

OR EXCELLENCE IN ACTION
Staff Leads Charge in Improving Pain Control Program
Staff at High Pointe Surgery Center in Lake Elmo, Minn., knew they had to revamp their pain control protocols when less than 90% of their patients were satisfied with how their pain was addressed and managed. In 2010, the center's newly formed "pain team" was charged with bringing pain control satisfaction scores above the 94% national average. They looked at improving every factor that contributed to controlling patients' discomfort: how pain varied by procedure, length of surgery, patients' expectations and types of intervention used.

"Educating patients before surgery won't change the pain they experience," says Diane Lulic, RN, High Pointe's pre- and post-op nurse manager, "but it will set their expectations at realistic levels." Ms. Lulic helped develop a letter for patients and their families that discusses post-op pain and the steps they can take at home to help control discomfort: rest, elevation and consistently taking pain medications.

High Pointe developed specific medication directives that match patients' pain experiences and expectations. "They'd administer morphine, Dilaudid or fentanyl — there was no consistency," explains Ms. Lulic. Nurses now know to give patients in moderate discomfort a certain type of medication and assess its efficacy before moving on to the next and more aggressive step in the facility's pain-control algorithm.

The improvements worked. In the first 4 months of 2011, High Pointe's overall patient satisfaction scores with respect to pain control improved to 95%.

— Daniel Cook