When new facilities open in your area, you have to work smarter to keep your doctors' business. Here's what worked for us.

• Be warm and personal. Your staff should start every conversation with surgeons on a personal note.
• Be accommodating with block time. The days of giving docs whatever time slots you still have open on your schedules are over. While you can't give everyone everything they want all the time, have a contingency plan. If someone requests a morning block that's unavailable (which happens often, because morning blocks fill up quickly), offer them a block that starts at noon - and let them have two teams in two ORs so they can switch from one procedure to the next. When someone cancels a block, offer it to other physicians.
• Be hospitable to newcomers. Start by visiting the interested physician's office and giving him a copy of your new physician's notebook. This includes what your guidelines are for every step of the process, from scheduling to dictation, as well as the services your staff offers and other clinical information. It lets the staffers know what you'll do and what they'll have to do.
• Escort new surgeons. Of course, a book can only show so much. Personally accompany the surgeon during his first three visits. Show him where the supplies are and help him navigate his way through PACU. By the end of the third visit, he'll be familiar with the way your surgical area is arranged. Your new physicians can now come in and concentrate on the procedures without worrying about finding what they need. Best of all, the time you spend as a guide will help you establish a personal rapport with them.

Susan Roland, RN
Administrative Director
North Florida Surgical Pavilion
Gainesville, Fla.
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First Come, First Served for Vacation Time
We all know that vacation days are worth more to some employees than a pay raise, and scheduling those precious days off is a top priority. One of our center's nurses grew so tired of being left with her second or third choices for days off after senior staff took first dibs on vacation time that she approached us with the idea of developing a first-come, first-served policy. Her ideas was to hang a dry erase board in the staff lounge that displays the year's calendar and tracks vacation requests.

Staff still submit vacation request forms before initialing the corresponding days on the community calendar. That creates an internal checks system for keeping track of vacation time: The calendar is in place for everyone to see and the request forms serve as written backup if someone decides to tamper with the big board.

When conflicts arise between employees who want the same days off, we have them discuss the matter and decide whose plans are more easily changed. In the end, we stick by the first-come first-served policy, and conflicting vacation requests always seem to be resolved. If you decide to implement this system, be sure to display the next year's calendar by September or October. Your employees will appreciate the opportunity to plan early for their time off so they're free for family vacations or their kids' school holidays.

Carolyn Skaff
Executive Director
ASC Durango at Mercy Regional Medical Center
Durango, Colo.
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Memo to Staff: This Is How We Do It
When nurses from several different facilities come together under one roof, they all know how to do everything, but they all do it differently - including how they practice and define infection prevention. No matter how long your nurses have been doing things their own way, here are five tips to get your entire staff on the same page.

• Conduct a mandatory staff meeting. This is for all central sterile processing staff, all nursing staff and housekeepers (so long as you give them ample notice, contracted housekeeping personnel will usually come in for training). Make a sign-in sheet and an agenda to document that this training took place and who attended. Ask staff to explain how they'd clean between cases, at the end of the day and terminally.
• Quiz them. When asking about cleaning between cases, ask staff which product they'd use to clean the OR table and other surfaces. Have them articulate each item in the room that needs to be cleaned between each case, at the end of the day and weekly. Ask them to state what product they'd use and the method they'd use to clean each one. Discuss mopping (yes, mopping). How do you fill the bucket? What product and amount of cleaning agent do you dispense into the bucket? How do you know you have the right concentration? What happens to the mop head after use? Where does it go? There are plenty of other details to review. Where does the garbage go? How do you transport the linen and garbage from the OR to storage?
• Stress the importance of consistency.

Remember, consistent infection control practices help reduce infections. Although your staff is experienced in surgical procedures and instrumentation, not every employee will be experienced in cleaning ORs and anesthesia equipment - this includes the BP cuff, the EKG cables, the pulse oximeter cable and the finger sensor - between cases. One area of care that may not be completely understood by even the most seasoned personnel is the importance of consistent infection control practices. Everyone thinks they know what the proper infection control practices are. They base their knowledge on previous places of employment. These preconceived beliefs might lead to inconsistency in infection control practices. Now's your chance to train every employee in your facility's infection control practices. You want hand washing, cleaning between cases and cleaning the facility at the end of the day to be done consistently by everyone. Have all cleaning products and equipment available to demonstrate use, reconstitution and disposal. Have staff practice live in the OR after the trial run of cases.

• Keep written policies handy. Use your written policies and manufacturer's instructions to teach staff how things are to be done in your center. Review the MSDS sheets for each cleaning agent. Keep these instructions together for easy reference. Make sure that the written policy is your actual practice so that your staff, for example, use only approved cleaning agents.
• Discuss handwashing. Hand hygiene compliance might be one of your biggest challenges. State your expectations that staff must wash their hands before and after any patient care. Have staff demonstrate their technique for hand washing. Remind them they should wash for 15 seconds - as long as it takes to sing "Happy Birthday" or the ABC's.

Debbie Comerford, BSN, CNOR
Consultant
Facility Development and Management
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Managing Hyperglycemia in Surgical Outpatients
Studies have shown that glucose intolerance and hyperglycemia commonly arise from surgical stress. Here's a sample, simplified approach to managing hyperglycemia in surgical outpatients, which we'll define as patients who are planning to go home on the same day as their procedures and who aren't already in a monitored setting where more comprehensive, ongoing diabetic management is taking place:

• Every known diabetic receives an HbA1c level test, ideally checked seven to 10 days before surgery. Every patient older than 30 receives a fasting blood sugar, or FBS, stick (if no fasting BG has been performed within two weeks before surgery).
• Unknown diabetics with an abnormal FBS greater than 200mg/dL receive a spot HbA1c test.
• If HbA1c is greater than 8 percent, the surgeon and anesthesiologist will discuss whether to delay or proceed with the case.
• Strongly consider canceling the case and referring the patient back to his primary care physician if the FBS is greater than 250mg/dL. All final decisions regarding case cancellation remain open to discussion between the surgeon and anesthesiologist.

The A1c value is an index of mean blood glucose over the past two to three months. This number is weighted to the most recent blood sugar levels. The HbA1c test result reflects the past 30 days as about 50 percent of the A1C, the preceding 60 days as about 25 percent of the value and the preceding 90 days as about 25 percent of the value. The body is continuously destroying and replacing red blood cells, so it doesn't take a full 120 days to detect a clinically significant change in HbA1c after a significant change in mean blood glucose.

Adam F. Dorin, MD, MBA
Medical Director
Grossmont Plaza Surgery Center
San Diego, Calif.
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