My Philosophy for Providing Surgical Care.

The following is a talk I first gave in 1997 as the Keynote speaker at the Pennsylvania

Association of Nurse Anesthetists annual meeting. I was the inaugural Medical Director

of the Health Campus Surgical Center, we had been open 4 years, and I had the team I

wanted firing on all cylinders. My Chief Nurse Anesthetist, Susan Seda, was the

President of the Association and asked me to speak about what made the service we

delivered so special. I was honored to do so. It was all about teamwork. Medicine tends

to be a “black box” for patients. Surgery and anesthesia are especially frightening

because of the unknown. I believe that properly presented education is the best anti-

anxiety drug available and used that philosophy to build our process. I still smile when I

think about those days :)

Scott F. Stieber, M.D.

The Ambulatory Surgical Team Relay

10/1997

Providing ambulatory surgical care at the Lancaster General Health Campus Surgical

Center(HCSC) is like running a relay race (4X400). Each leg of the race is equally

important, and while speed may appear to be the most important part, the race is often

won or lost on the “baton pass”. As Medical Director, I am the coach of our team.

Before running the race there are a few tenets affecting the strategy of the race which I

feel are important to discuss.

As in most relays there are four separate “races” within the race. The four runners in our

race are: Lead-off leg: Pre-Anesthesia Clinic (PAC); second leg: Pre-op; third leg: O.R.;

and the anchor leg: Post Anesthesia Care Unit (PACU) and post-op stage 2.

To run this race most successfully, it is important to recognize who we are running this

race for and what they consider important. I believe we have 2 main customers whose

interests we need to value.

1. Our external customer is the patient. This customer has varying levels of expectation for the experience and often a high level of anxiety, most of it based on fear (bad previous experience, old-wives’ tales, media, etc.). There is no business in the world where the opportunity for customer service is greater. Consistent, orchestrated education to create expectations which are then met is the form this customer service should take. All team members contribute to this customer service, but I view the PAC as my external customer service specialist.

2. Our internal customers are our surgeons. This customer is a lot easier to understand and more difficult to satisfy. They expect all patients ready, all equipment available and working, good anesthesia, short turnover time, staff who anticipates their needs, etc. They often expect we can read their minds. To give us the best shot at “mind reading”, we need to have staff who get to know these customers as intimately as possible. Consistent surgical teams and a scheduler who can interface between the office and O.R. are a requirement to maximize this customer’s satisfaction. Again, all team members are involved in providing this customer service, but I view the surgical scheduler as the internal customer service specialist.

Prior to each “race”, our scheduler gathers the pertinent information for this case: time,

date, procedure, surgeon, etc. and fits it in with our other races running that day (other

surgeon’s schedules) ensuring that it will not produce conflicts (time, equipment, etc.)

and that each surgeon’s O.R. is organized in the most efficient way. The scheduler has a

tremendous impact on our success and should be close enough to the daily execution of

the schedule to know what worked and what didn’t. Surgical scheduling is significantly

more nuanced than any other type of medical scheduling. The more intimately involved

the scheduler is with the product they create, the better positioned they will be to support

that product.

I also have a philosophy on which customer is more important. While I consider my

surgical colleagues as friends, admire their abilities, and recognize that surgery cannot

occur without them, I do not think that maximizing their satisfaction should be our

primary goal. If we concentrate on the patient and maximize the patient’s satisfaction, all

our surgeons will be generally happy. I am not sure the inverse would hold true.

On to the “race”

PAC runs the lead-off leg.

• They need to start far enough ahead to comfortably accomplish all their tasks in an organized and unhurried fashion. They are the first contact the patient has with our facility and have the opportunity to create the first impression. I want that impression to be calm, competent, and compassionate.

• They obtain the pertinent medical, surgical, and anesthetic history. Their most important responsibility is to ensure that each patient is an appropriate ambulatory candidate for the proposed procedure at our facility and is medically cleared for the event. The PAC must begin this process far enough in advance to allow for consults/additional testing to occur without impacting the surgical date. A triage of the upcoming patients into high-risk groups facilitates this task.

• They provide education. They start an orchestrated, consistent, graded process of communication to create expectations and by doing this allay anxiety. They give an overview of the surgical day and address the issues of NPO requirements, transportation, first night surveillance, post-op pain, pre-op nerve blocks, etc.

• They administer the Nausea/Vomiting risk assessment tool and the Pediatric Separation Anxiety assessment tool. Not only do these tools provide information for the staff and drive resolution protocols, they provide tremendous customer service to the patient by letting them know that these issues are very important to us and we have them covered.

• During their interface with the patient, they identify situations which require review: high risk for separation, prior difficult airway, angina, difficult living arrangement which may not support post-op requirements, morbid obesity, etc. They bring these issues to the attention of the Anesthesiologist who provides the leadership to resolve them in advance of the Day of Surgery (DOS).

• They then create the baton, which in this case is the medical chart. They ensure that all paperwork is completed and that the permit, H&P, and orders are signed, dated, timely and crosschecked against the schedule. They confirm that any special requirements are noted, arranged, or confirmed (DOS testing, x-rays, pathology, antibiotics, etc.). The baton they pass is a completed chart requiring no additional work or, infrequently, has clearly documented issues to resolve on the DOS.

The second leg of our race is run by Pre-op. They are the members of the team

who make the first face-to-face contact with the patient and are responsible for the

(second) first impression.

• Their primary role for this leg of the race is to provide emotional support and service to the patient. I would prefer that their care appear to be more of a personal than a medical nature. To facilitate this appearance, all the important medical issues must be resolved before the D.O.S. The quality of our medical care is paramount and is best ensured via an effective PAC process. If the Pre-op staff is confident that the first leg of our race is always well run, they will be much more effective in providing the patient what they need.

• They confirm a few pertinent issues prior to admitting the patient: what procedure, which surgeon, NPO status, allergies, any recent change in medical status?

• They start the I.V. with local anesthesia, do the prep, place the pleget, give the pediatric pre-med, assess the blood sugar, obtain the antibiotics, provide the blanket, etc.

• They continue the process of education by reinforcing the teaching done by PAC and introduce pertinent post-op education.

• They then pass the baton (which is now a completed chart with a prepared patient) to the O.R. circulating nurse.

The third leg of the race is the Intra-operative care. This is the time when our

internal and external customers are brought together. I often think of myself as

the host of this party. This leg is the culmination of the efforts of the PAC and

pre-op, and its success is dependent on the scheduler and the anesthesia

department as well.

• The circulating nurse meets the patient in pre-op and re-confirms the surgical procedure, surgeon, allergies, and NPO status, reviews the surgical paperwork for completeness and ensures the surgical marking has been properly performed. This is done in a way that communicates to the patient that we are already aware of these items but follow a process with important redundancies to ensure their safety.

• The patient is escorted to the O.R. by the circulating nurse, introduced to the other members of the surgical team, and asked to verbally confirm his/her identity, surgeon, and procedure to the team. We have our patients walk, if possible, to empower them to be in control.

• The patient gets on the operating table and participates in positioning to ensure that all pressure points are padded, neck is supported, and they are comfortable before anesthesia is induced.

• The circulating nurse, with active involvement from the anesthesia department and surgeon, ensures that the final time out is performed prior to surgical incision.

• In addition to supporting and participating in the above, the O.R. staff must ensure that all equipment is available for the planned procedure, that ancillary needs are arranged (special support people, x-ray, pathology, etc.) and that an appropriate amount of time is allocated to each case. These issues can be facilitated by our surgical scheduler, who is the only member of the team in direct contact with the internal customer’s representative (our surgeon’s scheduler).

• The O.R. team also promotes internal customer satisfaction by expediting turnover, communicating to resolve discrepancies, and leading the process of quality improvement so that each issue is faced only once.

• At the end of the procedure the O.R. nurse and anesthesia provider escort the patient to the PACU and pass the baton (which is now a recovering patient and the supporting paperwork) to the PACU nurse. This handoff has traditionally been referred to as the “report”.

The final leg is post-op care and discharge.

• The patient is admitted to PACU, monitors are applied, and medical stability is assessed. The Report is given. The PACU nurse ensures the patients’ comfort by addressing any N/V or pain, making sure the patient is warm, etc. They communicate with families if necessary (sleeping kids, longer stays than usual, etc.). They allow each patient to dictate how long a stay in PACU they require, again to cede control to the patient. They then deliver a comfortable patient to Stage II at the appropriate time.

• Stage II provides the cabin service (snack, drink), deals with the scripts, provides the final education, and discharges the patient in a timely fashion.

• While most relays have their “fastest” performer last, in this particular relay the final leg should resemble a stroll if the first 3 legs have been run successfully! I always say that my goal is to have every patient leave the facility looking like nothing happened. While the surgical procedure may interfere with this goal, continuous process improvement should be ongoing to maximize each patient’s “Discharge Snapshot”.

All patients receive a post-op phone call to assess:

1. Pain

2. N/V

3. Satisfaction. What could we have done differently?

Any trends or dissatisfiers are addressed, resolved, and integrated into process

improvement.

What role does the computer play in this process?

1. Allows for the production of clean, clear, concise data which can help us measure

what we do and help determine if process improvement is needed and if it was successful.

2. Does block time assessment, procedure costing, etc.

3. Creates a snapshot of the patient. Many of our patients are repeat customers and

it would be more efficient to not redo much of the chart with each intervention.

4. It MUST make us better!!!