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7 Top Tips for Fast-tracking
How to jump-start your clinical operations and improve your surgical throughput.
David Bernard
Publish Date: August 7, 2008   |  Tags:   Anesthesia

From staffing to scheduling to patient admissions and discharge, here's how a few of your colleagues are boosting their surgical throughput to keep their facilities speedy and efficient.

1 Build a can-do staff
Almost every facility cross-trains its pre-op, OR and PACU nurses, and with good reason, but do you cross-train your business staff? "All of our business office team members can schedule, verify insurance, produce claims, answer billing questions and complete other business functions," says Barb Draves, CASC, administrator at The Surgery Center in Middleburg Heights, Ohio. "Coding is the only area that has specific personnel responsible, and of course duties are segregated for internal controls, but we never hear the words ???I can't do that' or ???I don't know how to do that.'"

Additionally, all of the facility's nurses are ACLS- and PALS-certified, and 10 clinical staffers are certified for central supply processing, says Ms. Draves. "While these things cost more up front to get everyone trained, the overall savings down the road make the cost worth it."

Linda Vieira, RN, the administrative and technical coordinator for South Bay Endoscopy Center in San Jose, Calif., sees benefits in consistency. "The same RN follows the patient through her stay," she says. "We utilize the same RN for a patient's admission, procedure and recovery, thus saving time by not having to give a report at handoffs."

5 Keys to Good Cataract Case Flow

  • Have patients arrive at your facility one hour before surgery, says Ellen Lopez, RN, director of surgical services for the Southwestern Eye Center in Phoenix, Ariz. "We immediately check consents and paperwork and administer their dilating drops," she says. "Then the patients go back to the waiting room, which is dimly lit, so when they're called to the pre-op area, they're fully dilated."
  • Have patients lay on the gurney in their clothes and cover them with blankets. "We do not ask them to change clothes and put on a gown," says Ms. Lopez.
  • Prepare patients quickly. "We usually have two staff members, one of them an RN, hook the patients up to monitors, obtain their vital signs, assess their status, start their IV access and ready them for their blocks," says Ms. Lopez.
  • Turn the room over ASAP. After the surgeon completes a procedure, says Ms. Lopez, "discharge is minimal if the patient is stable and can tolerate fluids, which usually takes less than 10 minutes. The bed is stripped, remade and readied for the next patient within a minute or two."
  • Keep the patients flowing. "On days when our high-volume cataract doc is in house, we keep at least four patients ready in pre-op in order to keep the flow going in two ORs," says Robin Williamson, RN, clinical director at Stony Point Surgery Center in Richmond, Va.

2 Schedule smartly
An efficiently run schedule depends on realistic knowledge of how long your cases take, including room turnover, so as to avoid blocks full of holes. Linda Anderson, RN, the practice manager for Great Lakes Anesthesia in Elkhart, Ind., recommends conducting time studies to gain that knowledge. Then use it to your advantage.

"Do procedures first that are not ???iffy' in relation to time so that patients aren't waiting," she says. "Have your surgeons do their surgery center cases before their hospital cases, so they can start and end on time. Do procedures needing a longer recovery time early in the day to keep staff from staying late after cases."

Deborah Comerford, BSN, CNOR, CASC, director of clinical operations at Facility Development and Management in Orangeburg, N.Y., suggests symmetry in scheduling. "Book orthopedic cases together — all shoulders, then do the knees. Then rearrange the schedule so that the ???lefts' are all in a row, then the ???rights.' This saves time moving equipment around."

Or, says Ms. Anderson, "look at the anesthesia type as an aspect of scheduling. Do the axillary blocks in a row, having patients come in so that more than one can be done at a time and the blocks have time to set up. Generals and procedures that have regional for pain control can be done without setup time."

Dual room utilization can turn unused OR space into a plus. "We don't always fill all our rooms," says William Baumann, RN, BS, CNOR, director of surgical services at San Gorgonio Memorial Hospital in Banning, Calif. "When we have an open room, we bounce the surgeon back and forth, so as he or the RNFA is closing one procedure, another RNFA has already prepped and draped the next patient in the other room, creating ???negative turnover time.'"

3 Prepare the patient before the day of surgery
Several of your colleagues send patients their admissions paperwork via postal mail or e-mail well in advance of their scheduled procedure, giving them sufficient time to review and complete the forms while also speeding the check-in process. Some suggest that referring physicians distribute your packets of forms to patients.

Remember that "forms should be easy to complete," says Angela Blankinship, RN, BA, CASC, LHRM, the director of surgical services at San Luis Valley Regional Medical Center in Alamosa, Colo. "Check-off boxes work really well."

Many of your colleagues also emphasize the importance of pre-op calls to patients at two weeks to two days ahead of the procedure, not just to remind them of their upcoming appointments, but to confirm that all necessary lab tests, X-rays, EKGs and other history and physical components have been completed.

Whether you request that your patients arrive at your facility 30 minutes, 45 minutes or an hour before their scheduled procedures, remind the patient of the importance of arriving on time.

Lynda Dowman-Simon, RN, the OR manager for St. John's Clinic: Head & Neck Surgery in Springfield, Mo., notes that some early patient teaching can streamline the day of surgery. "We give patients pre- and post-op instructions when they schedule surgery," she says. "This allows them to be familiar with the instructions and decreases teaching time." Ms. Dowman-Simon's facility has also posted the instructions on its Web site.

4 Be on time, every time
A little preparation goes a long way in terms of start time, says Dana Yocum, RN, BSN, CASC, the administrator of Mid Rivers Ambulatory Surgery Center in St. Peters, Mo. "All items for every case are pulled the day before, before anyone leaves for the day," she says. "This allows our turnover time to stay between six to eight minutes."

Sure, you call your patients to remind them of their upcoming procedures, but what about your staff? Martha Potter, RN, CNOR, MHCA, administrator of the Southern Delaware Surgery Center in Rehoboth Beach, places calls to her surgeons to remind them of their scheduled start times.

5 All hands on deck
The way in which your colleagues staff their ORs for procedures seems to have a valuable impact on workflow efficiency. "Having dedicated teams seems to make the most difference in the OR," says Sally Patterson, RN, BSN, CNOR, the director of perioperative services at St. Joseph Hospital in Bangor, Maine. "That way, each staff member is familiar with the surgeon's pre-op, intra-op and post-op preferences."

Ms. Dowman-Simon recommends rotating surgical staff members by case. "Two surgery techs are assigned to a room. One is always processing instruments, pulling the next setup, assisting with patient transfer and room turnover. They alternate scrubbing in for cases."

Once a procedure is completed, the more hands on deck for patient transport, the better. "Everyone participates in the transport of patients, even the clinical nurse director," says Steven D. Williams, MD, FACS, medical director of the Riverside Ambulatory Surgery Center in Bourbonnais, Ill.

"On days when everything is working right," says Melissa Waibel, RN, BSN, CNOR, administrator of the Creekwood Surgery Center in Kansas City, Mo., "any free people come to help when they hear a patient is moving into or out of a room, regardless of their ???job.'" (Ms. Waibel adds that her circulator begins cleaning the room and moving equipment for the next case into position as the physician closes the patient.)

Enlist other personnel already in the room for double duty. Says Robin Williamson, RN, clinical director at Stony Point Surgery Center in Richmond, Va., "Instead of the circulator helping to transport the patient to post-op after a MAC anesthesia procedure, the CRNA does so, thereby leaving the circulator behind to help turn over the room with the scrub tech. The CRNA will then bring the next patient back to the OR."

Or, says Jo Ann Dower, RN, MGA, an assistant vice president for Virtua Health in Marlton, N.J., ask personnel who are on their way to the room anyway. "Environmental services are part of the team, and come into the room to help move the patient," she says. "They then stay to do the turnover, so there is no waiting to clean the room."

Above all else, recruit experienced and qualified staff members with good attitudes and foster a positive environment to retain them. This, say your colleagues, is the best way to boost workflow, since low turnover maintains a high efficiency

6 Shorten time in PACU
Each patient's recovery time and discharge schedule is unique to her own case, but here are some tips to smooth the way to the door.

"In recovery, we have the family member wait in an extra chair next to the recliner where the patient will return," says Linda Jenkins, BSN, MSA, administrator of the Truvista Surgery Center in Troy, Mich. "This helps us save time in getting the family for the doctor to speak with, and helps the recovery nurse in delivering discharge instructions more efficiently for a quicker discharge."

Lynne Pinkham, nurse director of surgical services at Mid Coast Hospital in Brunswick, Maine, recommends establishing "surgeon pre-approved discharge criteria" for some procedures, "so the nurses can discharge patients when they meet the criteria instead of waiting for the surgeon to see the patient."

Additionally, don't discharge patients without seeking their views on the surgical experience. "Each of our patients receives a survey," says Ms. Dowman-Simon. "One of the questions is, ???How can we improve our surgery center?' Many of our patients' suggestions have been incorporated into our setting. We send those patients a gift certificate for dinner at a local restaurant."

7 Encourage continuous improvement
Keep your eyes open for improvement opportunities every working day and let your staff know you're open to suggestions.

"We review processes with the staff after exceptionally busy days to see what we can change or streamline to assist in efficiency," says Annette Bak-Lopez, administrator of the Bald Mountain Surgical Center in Lake Orion, Mich.

"Staff members have to know that if they have an idea, they can express their thoughts," adds Ms. Blankinship. "Their suggestions have to be looked at and honestly evaluated. After all, they are the experts at what they do."

Carolyn McKee, RN, the bariatric coordinator for Clark Memorial Hospital in Jefferson-ville, Ind., suggests sharing information to motivate your staff. "I feel it all starts with the culture of your facility," she says. "Keeping the team informed about patient satisfaction scores, physician scores, area competitors, who your customer is and where your revenue comes from are valuable things to communicate to your team."

Remember, of course, who else has the power to change processes at your facility — particularly if they're the obstacle to efficiency. "The only thing that holds our facility up are physicians themselves," says Michael S. Fitzgerald, clinical manager of surgical services for Holy Family Medical Center in Des Plaines, Ill. "If peer pressure is made upon the physicians by other physicians, however, this is the best way to gain physician compliance. The physicians respond best to each other."

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