The Appeal of Steel
Medical Center Opens Stainless Steel ORs
You know something innovative's going on when a surgical facility expands and the OR walls get all the attention. At the Spartanburg (S.C.) Regional Medical Center, which opened a new 12-OR surgical suite in September, the walls are light blue, powder-coated stainless steel.

Tonie Edwards, RN, BS, CNOR, the center's clinical director of surgical services, first encountered steel walls seven years ago, while researching OR tables at the equipment manufacturer Maquet in Rastatt, Germany. While they have become common in European hospitals in recent decades, they haven't yet caught on in the U.S.

"When I saw it, it just made sense to me," says Ms. Edwards, who'd seen the walls in Maquet's mock OR and in a German hospital. "The hospital was 25 years old, but the OR looked brand new."

The walls' durability is a large part of their appeal, she says. They don't show damage the way traditional sheetrock walls do after equipment bangs into them, and they're more thoroughly cleaned. In addition, the pre-fabricated modular panels — essentially sheetrock with a stainless steel laminate mounted on a track system and screwed to metal studs — can be easily removed, reconfigured and remounted for quicker repairs, expansions or equipment installations, and with less downtime and dust, than conventional walls. "They've already exceeded our expectations," says Ms. Edwards.

— David Bernard

Transportation Authority
Skyrocketing gas prices and love for the environment helped launch an employee carpool program at Banner Heart Hospital and Banner Baywood Medical Center in Mesa, Ariz. What began last year as a staff curiosity has developed into a money-saving and morale-boosting success for the healthcare system. Today 75 employees carpool while several others take public transportation or ride a bike to work, says Mary Fernandez, who manages the carpooling and alternative transportation programs. Quarterly $100 raffles and priority parking offered to carpooling employees, discounted public bus passes (the hospitals cover half of the monthly fees) and secured bike storage cages entice employees to sign up and remain involved in the commuter programs.

— Daniel Cook

InstaPoll Update
You'll find a new InstaPoll on www.outpatientsurgery.net every Monday morning. Here's a look back at the results of recent polls.

• Crocs OK in 4 out of 5 ORs. Even though footwear in the OR must be fluid-resistant, nurses in most surgical facilities are allowed to wear Crocs, the backless plastic clog with holes on top. Nearly four-fifths (78%) of our 102 respondents let staff wear Crocs. While Crocs has come out with a shoe without holes on the top, they're still backless.
• Obama or McCain? Republican presidential candidate Sen. John McCain scored a decisive victory over Democratic contender Sen. Barack Obama in Outpatient Surgery Magazine's online straw poll. Of the 69 surgical facility managers who voted, 49% chose McCain and 42% chose Obama. Another 9% were undecided.
• Parents of peds in PACU? In pediatric cases, can parents be present in the PACU when the child emerges from anesthesia? Nearly two-thirds (64%) of the 58 respondents don't allow this in their facilities. Slightly more than one-third (36%) do.

Stark Changes
Under Arrangements, Per-click Leases Prohibited
The Aug. 19 Federal Register included amendments to the Stark Law that prohibit financial arrangements which authorities view as potentially abused. The amendments, published as part of the Centers for Medicare and Medicaid Services' 2009 IPPS rule, include the following.

• Under arrangements, deals in which hospitals contract with external entities in order to outsource the provision of hospital services, have in most cases been prohibited. "Usually the subcontracted services are imaging services, but some hospitals have entered into under arrangements contracts with surgery centers, under which the surgery center provides all or part of the hospital's outpatient surgery," says Nora Liggett, a partner at the law firm of Waller Lansden Dortch & Davis in Nashville, Tenn. The hospital pays the surgery center a per-procedure fee for services and bills Medicare and other insurers at the hospital outpatient rate.

The benefits are obvious, she says. The hospital gains outpatient capacity, while the surgery center boosts its utilization and can reap higher fees than it would if it billed insurers directly. And under arrangements have flourished as their compensation relationships existed under the Stark Law's indirect compensation exception. In the government's view, though, they are a means for improperly sharing the hospital's revenue with referring physicians.

The amendments redefine "designated health service provider" to include both the entity that bills Medicare and any entity that furnishes services to the hospital. "This means that a physician who owns a company that provides services under arrangements to a hospital will be deemed to have an ownership relationship with a provider of designated health services," says Ms. Liggett, thus negating the indirect compensation exception. This change is scheduled to take effect on Oct. 1, 2009.

• Per-click equipment leases, in which hospitals contract to pay a physician lessor — such as a physician-owned lithotripsy company — a per-use fee will also be prohibited under the new Stark rules. "Formerly, that lease could fit the Stark lease exception as long as the per-use fee was fair market value," says Ms. Liggett. Under the new rules, though, "a per-click lease will not fit the exception, so a physician whose company has a per-click lithotripsy lease with a hospital will be prohibited from making Medicare or Medicaid referrals to the hospital," she says. This change also takes effect on Oct. 1, 2009.

— David Bernard

What Happens When You Don't Take a Time Out?
An investigation into a wrong-site surgery at Beth Israel Deaconess Medical Center in Boston provides some telling insight into how a simple failure to follow established protocols can lead to error. Although the correct surgical site was marked during pre-op, an investigation by the Massachusetts Public Health Department's Bureau of Health Care Safety and Quality describes several contributing factors that led to the error in the OR.

• The surgeon and surgical team were preoccupied with technical aspects of the procedure, which was complex and infrequently performed.
• The procedure room was still being set up when the patient was wheeled in.
• The surgeon didn't check the surgical site mark before positioning the patient, and the resident didn't check it before pre-washing the patient.
• The surgical team failed to conduct a pre-incision time out (existing policy did not state who was responsible for initiating the time out).
• The surgeon didn't notice that there was no mark on the site before making the incision, "because markings were sometimes washed off during surgical site area pre-wash and prep," and they weren't always made with a permanent marker.

The hospital developed a corrective action plan to prevent future wrong-site surgeries. According to the state report, the plan included directives to make more semi-permanent skin markers available in pre-op; place bright orange "Time Out" reminder cards in all ORs; require the surgeon performing the procedure to initiate the time out; add mandatory time out documentation fields in electronic intraoperative and anesthesia records; and re-educate staff about surgical site identification procedures. See "Zero Tolerance for Wrong-site Surgery" on page 34.

— Irene Tsikitas