Red flag: When you cut costs, do you add risk?
Competency testing, product evaluation will help
Cut cost, not quality. Those are the watchwords of the '90s, and same-day surgery managers should consider this addendum: Be wary of risk management issues when you implement cost savings.
What are the possible hot spots when it comes to cost cutting? Same-Day Surgery interviewed risk management experts and same-day surgery managers and identified the following examples:
* Reusing disposable items.
Companies have emerged that will resterilize supply items that were intended for one-time use. That may be appropriate in some circumstances, says Brenda Johnson, RN, MS, ARM, a risk management consultant with the Benedict & Associates health care consulting firm in Pinellas Park, FL. For example, if the outer package but not the inner wrapping of sutures has been opened, or if products have remained on the shelf past the time-dated sterilization, resterilization may be cost-effective and safe.
But Johnson cautions: "You have to read the contract as to what measure of insurance they'll give you for the integrity of the product." In other words, they should stipulate that the product is as good as new.
If you use a single-use product in a way that varies from the label, make sure you verify your practice with the vendor, suggests Teresa Carter, RN, MBA, director of Hawthorne Surgical Center in Winston-Salem, NC.
"You are increasing your risk," Carter warns.
* Disinfection versus sterilization.
If you're sterilizing equipment for the first patient of the day, but using high-level disinfection for everyone else, can you justify that different standard of care? Whichever method you choose, you should be consistent, Johnson advises.
While the disinfection method may be perfectly safe, a different standard of care presents risk-management concerns, she says. If a patient contracts a post-surgical infection, "you'd be hard-pressed to show that the patient didn't get the wound infection from your [different] standard of care," Johnson warns.
* Unlicensed assistive personnel (UAPs).
Same-day surgery managers may debate the cost-effectiveness of using UAPs versus RNs, but one issue is clear: UAPs need to be well-trained, and managers need to document that training, same-day surgery experts advise.
Begin by defining the tasks involved in a patient care event, such as transferring a patient or providing instruments, equipment, and supplies, says Mark L. Phippen, RN, MN, CNOR, clinical educator at Valleylab in Boulder, CO, and chairman of the now-defunct Task Force on Assistive Personnel for the Denver-based Association of Operating Room Nurses.
Only a nurse can perform such cognitive duties as assessment and patient education, Phippen says. If UAPs are properly trained, they can implement tasks, such as positioning the patient on the OR bed. An RN would need to reassess the patient after positioning -- for example, to make sure there is no impaired breathing, Phippen says.
It is critical to validate UAP competencies, to adequately supervise UAPs, and to assess the patient's risk for adverse outcomes before deciding which tasks may be delegated to a UAP, he says. "If you do not take these steps, you are clearly heading to disaster in using UAPs," Phippen warns.
If a task is improperly delegated to a UAP and an adverse outcome occurs, the nurse involved in the case can be censured under the state nurse practice act, Phippen advises.
* Haste in the OR.
Make sure that your efforts to improve OR and turnaround time don't lead your staff to cut corners and ignore policies and procedures, says M. Jeanne Barkheimer, RN, LHRM, president of Primary Resources, a DeLand, FL-based consulting firm that specializes in ambulatory surgery center development.
Barkheimer recalls seeing a scrub nurse sterilize tubing for five minutes although the center's policy called for 10 minutes. Even if five minutes would be a safe standard, the discrepancy could lead to risk-management problems, she says.
"A patient might have gotten an infection that had nothing to do with that, but attorneys go back and question policies and procedures," Barkheimer says.
As a safeguard, Barkheimer suggests that same-day surgery managers implement core competency testing of staff at least once a year.
* Cheaper supplies.
Same-day surgery managers have found many ways to cut back on unnecessarily high supply costs. But if you switch to a cheaper product or a non-"name" brand, conduct a thorough product evaluation first, advises Barkheimer. (See sample product evaluation form, inserted in this issue.)
"The key is not to use anything on a routine basis until you have had an opportunity to evaluate it," she says.
Barkheimer recalls one nurse who switched to a new, cheaper solution for a phacoemulsification machine. About 100 patients were at increased risk of infection until she realized that she needed to put a filter in the tubing first. "She didn't evaluate the product thoroughly before she started to use it," says Barkheimer.
After switching to cheaper gloves or gowns, same-day surgery managers should closely monitor strikethroughs and tears, she says. You may also want to call a reference before using them. "Ask them if the integrity of the gloves held up well," Barkheimer suggests.
In general, quality and cost must always be balanced, says Carter. Hawthorne Surgical Center has assembled teams by specialty area of physicians, nurses, and administrators to consider cost-cutting measures. The teams meet at the end of the workday on an as-needed basis to consider such issues as new products or processes, Carter says.
"The total objective is to maintain quality," she says. "You've got to continue to give the patient value. To get that value, you can only cut costs so far." *
For more information about product evaluation, contact:
* M. Jeanne Barkheimer, President, Primary Resources, P.O. Box 2091, DeLand, FL 32721. Telephone: (904) 738-0405. Fax: (904) 738-1448.
For more information about risk management, contact:
* Brenda Johnson, Risk Management Consultant, Benedict & Associates, 6391 76th Ave. N., Pinellas Park, FL 34665. Telephone: (813) 544-5109. Fax: (813) 546-6034.
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