Be competitive by getting the ambulatory mindset
Be competitive by getting the ambulatory mindset
Hospital-based told to think like ASCs
Fast, focused, friendly. That is the formula for success in ambulatory surgery centers (ASCs). And that is the mindset managers at St. Francis Hospital in Tulsa, OK, say their staff must adopt in the main OR, which is about 50% outpatient.
"If you want to keep your outpatient services, you better be sure you do the best job in town," says Denise Geuder, RN, MS, CNOR, director of cardiovascular and surgery services.
St. Francis opened a freestanding surgery center in 1992 in response to heavy competition in the ambulatory surgery market. "Because we didn't have systems that were outpatient-friendly [at the hospital], physician offices and for-profit centers were skimming off the cream of the crop [of cases]," says Sue Banschbach, RN, CNOR, clinical manager of surgery and outpatient surgery.
Although the hospital handles an outpatient population that is generally less healthy and involved in more complex procedures than at the surgery center, the main OR still can benefit from that ASC mindset, Banschbach says. Gradually, practices that began in the ASC are moving into the hospital, making the main OR more patient-friendly and efficient, she says.
St. Francis has found the ASC mindset in the following areas:
* Pre-op visit.
With the support of anesthesiologists, St. Francis has created strict criteria for patients who can skip the pre-op visit, says Banschbach. Unlike the patient population of the ASC, which is generally healthy, many of the patients in the main OR have complicating illnesses, such as diabetes or heart disease, she says.
"It is really quite a coup for us to admit any patients without a pre-op visit," Banschbach says. "We wouldn't have been able to get anesthesia to agree to that if they hadn't seen it work in the ASC."
Less than 10% of the hospital outpatients are admitted without a pre-op visit, she says.
Meanwhile, the hospital made the pre-op visit more convenient, with such changes as moving a mini-lab near the pre-admit area, she says.
Be willing to change
* Supplies and equipment.
Nurses in the ASC were the first to stop wearing shoe covers except in cases that involve a high potential for blood exposure. That policy was in keeping with recommended practices of the Denver-based Association of Operating Room Nurses.1
Still, it took time before the nurses in the main OR cut back on their use of shoe covers, Banschbach says.
"We continued to cling to the idea that we needed to use them all the time," she says. "In the ASC there was more of a willingness to accept change, to be a leader in doing that."
Yet the "ambulatory mindset" is increasingly taking hold in the main OR at St. Francis, which has adopted such cost-effective policies as standardization.
Geuder and Banschbach presented cost information on endoscopic devices to the all-physician Operating Room Committee. "You don't have to tell them [what to do]," says Banschbach. "They naturally assume you have to cut it back."
The physicians agreed to standardize their equipment choices in order to lower prices. St. Francis now has a primary vendor that provides 80% of the endoscopic devices and a secondary vendor that provides the other 20%, which allowed the hospital to obtain bulk discounts.
Addressing unlicensed assistants
* Role redesign.
St. Francis once used a team of surgery assistants, transporters, and nurse technicians to turn over rooms. Now multiskilled nurse technicians are certified in an in-house training program to hold retractors, pick supplies, open sterile supplies, and assist with prepping, in addition to transporting patients and cleaning rooms.
The main advantage: Higher-paid nurses and certified surgical technicians are now free to do tasks that require their greater level skills, Geuder says. "It was our answer to the unlicensed assistive personnel issue," she says.
* Paperwork.
St. Francis has unified its paperwork so that one "perioperative flowchart" follows the patient through the system, from admitting to discharge, Geuder says.
"Make sure your paperwork has the ambulatory focus that it is based on patient needs, not facility needs," advises Geuder. "That is the hallmark of the ambulatory mindset: fast, focused, friendly, and flexible."
Reference
1. Association of Operating Room Nurses. Recommended practices for surgical attire. Standards & Recommended Practices 1996;142. *
For more information on how a hospital OR can adopt an ambulatory mindset, contact:
* Denise Geuder, Director, Cardiovascular and Surgery Services, St. Francis Hospital, 6161 S. Yale Ave., Tulsa, OK 74136. Telephone: (918) 494-1993. Fax: (918) 494-1922.
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