After seeing disruptive day-of-surgery cancellations rise over four years, we created a new position in our facility, the clinical nurse liaison, whose job is to improve patient pre-op education and help us get as much information as possible about patients before they arrive at the center for their procedures. The thinking is that the more informed patients are and the more we know about them before they arrive, the less likely they'll cancel on the day of surgery. Since we created the position in 2006, the number of day-of cancellations has fallen 31 percent, from 55 in 2005 to 38 in 2007. In the first quarter of this year, we've had only six cancellations.

Part teacher, part diplomat
The clinical nurse liaison is our center's link to patients and the referring physicians' offices from the time a procedure is scheduled until the patient arrives on the day of surgery. The liaison spends about 40 percent of her time on the phone, making first contact with patients and gathering information from the referring physicians' offices.

As early as two weeks before surgery, the liaison contacts each patient and goes over all the pre- and post-op information during a 15-minute conversation. If the patient comes by the surgery center before the day of surgery, the liaison goes over the information in person. During the conversation, the patient learns about the anesthesia process, PONV and how he may feel when he awakens after surgery. The liaison and patient also discuss medications he may need to buy and, if necessary, where to get crutches or other post-op supplies. Whenever possible, the liaison also talks with family members so that they know what to expect when the patient returns home.

Talking with the patient as early as possible lets us identify any issues that need to be dealt with before surgery and, if necessary, reschedule the procedure with sufficient notice. The liaison asks patients about medications and conditions such as high blood pressure or diabetes that may require additional tests before surgery. The liaison makes sure that the patient has a ride home and someone to take care of him when he gets there. Not having a ride home and someone to care for the patient at home are two common causes of day-of cancellations.

The liaison's conversations with the physicians' offices have helped decrease staff frustration that results from scheduled patients that are either poor candidates for an ambulatory setting or lacking the right documentation or medical clearance for surgery at the scheduled time.

In the past, a referring physician's office staff was often the target of a surgeon's frustration due to the expectation that physicians would take care of all the paperwork and details before the patient arrived. The physicians' offices now have a contact person and number they can call to have their questions answered before scheduling surgery.

These conversations help the surgery center, which can refer information about a patient with a complicated medical history to the medical director or an anesthesiologist in advance. This lets surgical staff devise a treatment plan, which sometimes means sending the patient to a hospital for surgery. Prior knowledge of higher acuity patients helps decrease the time needed on the day of surgery for the pre-op interview and the anesthesia assessment. It also decreases surgery delays, turnover time and last-minute cancellations.

How to sell it
Because of the cost of creating a new position, I had to sell the idea to the physician-owners on our center's board of operations. I explained that as volume increased, patient satisfaction had waned and the number of day-of cancellations had gone up. Creating a clinical nurse liaison position would address these two issues and link the surgery center with the patients and the referring offices. The physicians bought into the concept immediately. They agreed that their offices weren't giving patients referred to the surgery center the needed education before surgery and a liaison would help.

We decided that the clinical nurse liaison should be clinically and socially skilled. We wanted an RN with at least two years of pre-op and post-op experience and good people skills. The job requires the nurse to be an educator and a good listener, since patients and their families are anxious and sometimes upset. Although the majority of the liaison's contact with patients happens on the phone before the day of surgery, she still introduces herself to many patients and family members in the waiting area, pre-op or PACU. Patients and family appreciate it when they can match a face to familiar voice.

Long-term goals
As the liaison's job evolves, so will her tools. With the help of our center's medical director, we plan to develop an in-depth pre-op nausea and vomiting assessment tool and protocol. We're also working on creating a pre-op pain assessment tool for nurses and anesthesia providers to individualize pain management treatments. Patients will receive a follow-up questionnaire related to pain and nausea control for the two days following surgery.

For the center's business office, we plan to create process improvement forms for tracking improving office relations and patient satisfaction. Finally, the liaison will develop and implement a new post-op follow-up survey form for measuring patient satisfaction. Now that we have a liaison, we have someone to address clinical concerns found on our patient satisfaction surveys. We don't know what we'll find, but we're better prepared to deal with it.