Streamlining Pre-op
Pre-op efficiency improves patient satisfaction
Cost and staff productivity also affected positively
Fast, efficient service is one demand all customers make, whether the service is a hamburger purchased through a drive-through window or a surgical procedure scheduled through an ambulatory surgery program. This focus on efficiency means that many day-surgery program managers are taking a close look at their preoperative process and making changes that increase patients’ ease of access to pre-op testing, registration, and education.
"Not only is there a financial benefit when you make sure that surgeries start on time, reducing the amount of time the operating room is unused, but you also improve patient safety," says Jean Kirchner, RN, CNOR, director of patient access services at Munson Healthcare in Traverse City, MI.
By having the patient’s information on the chart at least the day before the surgery, you can verify that the patient has a ride home, as well as someone to provide home care if necessary. You also identify medications that the physicians need to know about, says Kirchner. You have time to order additional tests or stop medications, such as warfarin, without a disruption on the day of surgery.
The simplest way to streamline is to look at the physical setup, says Anthony A. Meyer, MD, vice chairman of surgery at the University of North Carolina (UNC) Medical School in Chapel Hill. "Don’t send people from one building to another to register and get the lab tests or X-rays they need," he advises. Patients of the UNC clinics come to a pre-care area to see the anesthesiologists and nurses for the pre-op visit and education. This visit can be scheduled as early as one month prior to surgery, so the patient can choose the time and day most convenient to him or her, explains Meyer.
Patients coming to pre-care have scheduled their surgery, registered, and taken care of their financial arrangements, often by telephone, says Meyer. Appointments are made for patients in the immediate geographic area. Because the clinics provide service to a large geographic area, the staff leave time for drop-in visits from patients who may have traveled a great distance to see the physicians.
At Munson Healthcare, the patient takes care of all pre-op processes in one department, says Kirchner. Because her department collects the information from all areas involved in pre-op, missing pieces can be identified the day before surgery.
"The nurses in the preadmission department check the charts 24 to 72 hours prior to surgery to make sure everything is complete, including the surgeon’s history and physical," she explains. Prior to set up of the preadmission department, about 10% of the charts were complete the day before surgery. Now 90% of the charts are complete. Completed charts mean surgeries start on time, she adds.
Munson Healthcare’s preadmission department is a one-stop center, with X-ray, EKG, lab, nursing assessment, financial pre-certification, and registration all taking place in the area. One-half of all preadmission visits are seen by appointment, but staff accept drop-ins who may have just found out they are scheduled for surgery, says Kirchner.
Tracking missing lab reports or X-rays can be time-consuming, but Kirchner’s facility has a special code on any test reports that are considered pre-surgical. When this code is entered by the department producing the report, the report is printed in the preadmission department. "We still chase paper, but this system has reduced some of the time we spend on this task," she says.
Because much of the information comes from the physicians, Kirchner involved representatives of the physician’s office staffs in setting up the preadmission program. (See story on setting up a preadmission department, at right.) "We used their input to design the flow of information, the timing of appointments, and the forms we use," she says. By having them buy into the concept during development, the office staffs were better informed and used the preadmission department more effectively from the beginning.
Take a look at what tests are being ordered, suggests Doug Davis, MD, senior staff physician at Scott and White in Temple, TX. After hearing cataract patients tell him that they hated the long pre-op day, Davis and the anesthesiologists devised a fast-track pre-op process that eliminated the visits to multiple departments.
"Although most of our cataract patients are older with some underlying disease process such as hypertension or diabetes, they are generally not sick people," explains Davis. "We are also now using a topical anesthesia that doesn’t carry the same risks as other anesthesia, so we don’t need as many screening tests." (See story on eliminating unnecessary tests, p. 117.)
Coordination of staff is key, says Meyer. "You must talk to physicians at conferences and rounds, and talk with other department staffs to make sure everyone knows what you’re doing and how the process should work," he adds.
To justify a separate preadmission department, attach cost savings to each aspect, advises Kirchner. "Look at the cost benefits of surgery starting on time in terms of staff and overhead costs."
Davis adds, "Although there is a cost-savings in a smoother pre-op process, you must remember the most important reason for changing the process. Any changes should be made to improve and add value to the patient’s experience."
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