RMV->) My move from surgical nurse to facility administrator was a real eye-opener. For one, I was perplexed when I'd overhear our schedulers turning down requests for cases while our block-scheduled ORs sat empty. I soon discovered that our 72-hour advance scheduling for block time policy had been in place for so long that folks were scared to change it, despite our steadily dipping case volume.

Without telling our surgeons blocked for time what I was up to, I asked our schedulers to reverse their course and accept all telephone requests for OR time. I also asked them to forward such requests to me. I rescheduled unused block time in two rooms. Physicians who used their block time 90 percent of the time had nothing to lose. I didn't touch their time. I gave away block time reserved for doctors who used their block time 50 percent of the time or less. I got burned a few times and had some explaining to do, but our volume shot through the roof.

Now we hold a physician's block time for up to six business days in advance if that physician uses at least 50 percent of his block time. When utilization of time falls below 50 percent, we release that block time 14 business days in advance. Doctors must release their block time at least 30 days in advance when they plan to go on vacation or take other extended absences. We schedule morning block hours from the bottom up, so that all cases by one physician run back to back.

Marietha Silvers, RN
Administrator
Physicians Surgery Center of Chattanooga
Chattanooga, Tenn.
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How We Improved Our On-time Starts
Not long ago, we had an abysmal on-time rate of 19 percent. We, as a staff, weren't on time and in turn had conditioned our surgeons to be late. We sent out a memo reminding everyone of the importance of being on time and of the cost of the OR minute. We also pledged to notify surgeons when we were running late. But none of that was enough to change behavior. We had to appeal to our surgeons' competitive nature. So we made on-time performance a game. We hung an on-time start board in the hallway just outside the surgeons' changing room. It serves as a scorecard, listing each surgeon's on-time percentage as well as our facility-wide quotient. The board, which also lists how late tardy doctors arrive, gets a lot of attention. Some docs are surprised to see how late they really were for a case. The board has also generated a new, friendly competition. No doctor wants his name on the late list. We also post a "We Made You Late" sheet that notes the reasons why the staff held up a surgeon. We want to be held accountable, too, for on-time starts. Instead of 15 to 20 doctors arriving late, now we only have a handful of stragglers. After the first month, we jumped to a 43 percent on-time rate. In May, we reached 76 percent.

Sandy Beers, BSN
Clinical Director
Surgery Center at Printers Park
Colorado Springs, Colo.
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A Simple Way to Improve Your Patient Handoffs
Patient handoffs are a particularly vulnerable time for communication failures among caregivers. To ensure effective and safe handoff communications, we follow the MAPS approach when transferring the care of a patient:

• M is for Medications. Which drugs did the patient receive, such as Versed in pre-op or general anesthesia in the OR?
• A is for Allergies. Relay information on all patient allergies.
• P is for Procedure/Pertinent Info. Report the patient's health history, the procedure done, the findings and the dressing.
• S is for Special Needs. Is the family waiting in the lobby. Crutches in the car? Communication concerns or disabilities?

Here's an example of a handoff between a pre-op nurse and an OR nurse: "Mr. Jones had 1g vancomycin and 2mg midazolam in pre-op. He is calm but not overly sedated (M). He is allergic to PCN (A). He is having a left knee scope with Dr. Smith and his knee is prepped (P). He needs glasses for any reading and they are in his clothing box. His wife went home and will need to be called when he gets to PACU (S)."

Terri Brickey, RN, LHRM, CASC
Administrator
Physicians Surgery Center
St. Petersburg, Fla.
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Last One Out, Get the Lights
We're always looking for ways to cut expenses and often this means getting staff to help with little things such as not wasting electricity. Even though we asked them to flip the switch when they were done in a room or for the day, we still saw lights left on. To focus folks, we held a contest. We put a notice on the bulletin board to announce that whoever could guess our electric bill for the month would get free movie tickets. After we collected the guesses, we revealed the bill's amount: almost $7,000, much higher than most of our staff thought it was. Showing the actual dollar amount helped put the issue in quantifiable terms for our staffers. They began to appreciate the need to turn off the lights. Our electric bill was much lower the next month.

Susan Roland, RN
Administrative Director
North Florida Surgical Pavilion
Gainesville, Fla.
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Watch Implant Invoices Like a Hawk
When you cut a deal on an implant price, do you assume it will show up on the invoice? Don't - you may be losing lots of money. I shudder to think what could have happened if my materials manager hadn't been on the ball. I was quoted one price for mesh, yet the invoice showed another. We caught it after the second invoice and worked out our credit for several hundred dollars, but with the price of each mesh varying from $50 to $1,500 depending on size, this could have snowballed into an astronomical problem if we had let it go longer. Discrepancies happen for lots of reasons. The sales rep may not communicate with the businesspeople at the company. The rep might leave or get reassigned to a new territory. Or the agreement may take too long to go into effect, and when you need product you can't wait. The key to our success is our strong materials manager. Having one person who deals with this daily, scours invoices and is privy to all vendor conversations is invaluable.

Kim Skerencak, RN, BSN, CNOR
Administrator
Ridgefield Surgical Center
Ridgefield, Conn.
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Better Bowel Preps Through Clearer Instructions
If you work in endoscopy, you know the problems that suboptimal bowel preps can create: missed lesions, delayed diagnosis and treatment, costly and time-consuming reschedules, dissatisfied doctors and patients.

While there's more than one factor that can cause suboptimal bowel preps, patients' poor comprehension of their pre-procedure instructions is a big one. Consider that one in five adults reads at or below a 5th grade reading level, that elderly patients' ability to comprehend instructions may be compromised by failing vision and hearing, and that many patients are hesitant to ask questions.

Now look at your facility's pre-endoscopy patient instructions. We regularly host seven or eight gastroenterologists and each one had compiled his own instruction sheet. Not only was there no standard version, but some were three pages long and full of complexly worded and poorly organized information.

We tested the effect of simplified patient instructions in decreasing suboptimal bowel preps. Our revision is one page, front and back (download it at www.outpatientsurgery.net/forms). We used a computer program to keep the instructions at or below a 6th grade reading level. It includes plenty of white space and the judicious use of capitalized, bold-faced and underlined words, since formatting helps in comprehension.

We'll determine whether increased comprehension means fewer suboptimal bowel preps this summer when we collect data on patients undergoing colonoscopies after reading our revised instructions as compared to patients who are using the existing ones. Our data analysis is scheduled for September.

In response to our study, one doctor argued that optimal bowel preps are simply a matter of compliance. But patients are much more likely to follow directions if they realize their importance and understand what is said.

Denise Kohler, RN, BSN, MSN
Endoscopy Nurse and Clinical Instructor
SHARP Grossmont Hospital, San Diego, Calif.
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The Virtual Business Office
To assist some of our staff in meeting their family and personal obligations, our surgery center recently implemented a virtual office for two of our five business office staff members that lets them work from home rather than traveling to the surgery center five days a week.

The clerical staffers that do the coding, billing and collecting of funds work three days a week at home and two days a week in the office. Hopefully in the near future that will become five days a week working at home, barring any meetings they need to attend in person. We're working on creating a public folder online where we can keep scans of transcriptions, explanations of benefits and CPT codes that our staff can access from home.

We've found that most of our patients aren't at home during the normal 8-to-5 work day, making it difficult for clerks to reach them about payments for their accounts. By giving our staff the flexibility to choose their own hours from home, our clerks can work some early evening hours when they can actually talk to patients without having to just leave a message.

Stuart Katz, FACHE, CASC
Executive Director
Tucson Orthopaedic Surgery Center
Tucson, Ariz.
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