No time to measure quality? Use a nurse!
Monitoring, education are their primary roles
Same-day surgery managers often face daily crises that sap the time and energy they need to devote to monitoring patient education and quality care. Quality and education can take a distant role while efforts go into "putting out fires" on a daily basis.
To address the problem, some same-day surgery programs are designating a nurse to have primary responsibility for quality, including appropriate patient education. Ddesignees ensure physicians and other staff keep quality at the forefront, and they provide valuable outcomes information for obtaining managed care contracts. Same-Day Surgery has talked with two facilities that keep quality a priority by designating a nurse to oversee.
Officials at Fairview-University Medical Center in Minneapolis wanted a "quality champion" with accountability. The nurse manager of departmental performance is an advocate and resource for quality improvement, outcomes measurement, education, orientation, and regulatory compliance.
"The buck stops here," says Carol Hamlin, RN, MSN. "I'm considered to be held responsible to be the expert on what quality should look like in perioperative services." Performance is not just outcomes measurement, she emphasizes. "If you have good education going on, you're well on your way toward good outcomes. That's not the whole answer, by any stretch of imagination. But if you put some effort into teaching and helping people to learn, the chances of having a quality outcomes are greatly enhanced."
Hamlin oversees quality, outcomes, and education at three surgery sites, and the educators report to her. She monitors turnover times, block times, first case delays - "the things that plague effective operations," she says.
Information is shared through a perioperative services newsletter distributed biweekly to perioperative staff and senior administrators. In addition, Hamlin co-chairs a quality committee that is heavily composed of bedside clinicians. The group meets every month to discuss outcomes.
Monitoring isn't done simply for accreditation, she stresses. "If we can't do anything that can actually improve the perception or outcomes of care, we have done ourselves a massive disservice."
Patients called 30 days post-op
At Veterans Affairs Medical Center in White River Junction, VT, quality is monitored with a 30-day postoperative call from the preadmit certification nurse. Patients are asked about the staff's courteousness and whether they were attended to in a timely manner when they came in for their pre-op workup. They also are asked about pre-op education: Was the information informative and easily understood? Were the discharge instructions clear or too complex? (See form, p. 96.)
In recovery, patients are asked whether they felt pain and to rate their pain control on a scale of poor to excellent. The hospital has begun to track pain control outcomes in relation to the type of procedure to determine if there's a correlation. Patients also are asked about their incisions, signs of infection, problems such as fever and chills, and whether they've made follow-up appointments with their physicians. Physicians follow up on any potential problems.
The response to the calls has been positive, says Lisa Hodge, RN, preadmission certification nurse. "Patients say . . . 'No one's ever called me that far after surgery to ask how I've been doing,'" she says. "They sometimes have questions about their follow-up appointments. Person al contact makes it very beneficial to the patient."
She tallies negative comments each month and relays them to nurses who work in that area. So far, the outcomes information has indicated a potential problem with pain control, she says. "That's not unusual, because it's very subjective." In addition to examining the type of procedure the patients had, she tracks whether patients with complaints have a history of chronic pain. Infor ma tion about tracking pain trends was part of a presentation given during a Joint Commission survey.
Hodge gets involved in the pre-op process before problems develop. She examines the list of patients scheduled for admission after surgery to determine if they might be more appropriate for outpatient discharge. That process involves education of patients and physicians, she says. For example, she contacts the doctor and points out that the procedure scheduled doesn't typically require inpatient admission unless there are complications. "I ask, `Does this patient really need to stay?'"
The goal is to reduce acute care admissions and lengths of stay. If the procedure isn't normally done on an inpatient basis, but the patient has travel difficulties or lives far from the hospital, an intermediate care unit is available. Patients in this unit don't require acute care assistance or monitoring. Also, patients who are self-sufficient can stay in a "lodge" in the hospital. "It's like a hotel within the hospital," Hodge says. "They're on their own, and we provide meals and a bed at no charge."
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