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Health Care Industry

Sacred cows revisited

AORN Journal, Dec, 2004 by Michael P. Ryon

Common practices, such as wearing cover gowns or shoe covers; scrubbing hands for three, five, or 10 minutes before a surgical procedure; or using time-related sterility storage, have been dubbed "sacred cows" by perioperative staff members. Many caregivers revere these practices, regardless of their contribution to quality health care or patient outcomes, and these practices have generated much discussion among perioperative staff members. The existence of sacred cows has dwindled in ORs throughout the United States because of multiple performance improvement initiatives by OR managers and evidence-based research regarding their value. Although it still is necessary to determine whether these practices are useful for patient care, perioperative nurses also must focus on practices that make ORs valued by health care organizations.

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BACKGROUND

Before perioperative departments can evolve into highly efficient, profitable revenue centers within health care, perioperative staff members must deal with the issue of sacred cows. Health care organizations are looking for ways to end profitless growth, a situation in which beds are full and resources appear to be fully used but profits remain stagnant. One cause of this profitless growth is the variability of services, processes, and products. Most hospital departments, including the surgical services department, do not adequately monitor and correct inefficiencies and cost overruns. (1)

I recently conducted an informal clinical survey of 50 US hospitals to ascertain current OR efforts in the areas of cost reduction, use of information technology (IT) systems, and performance improvement initiatives. The results provide insight into how perioperative nurses view the sacred cows they have been dealing with for years. The primary contact for the survey was an OR clinical educator, if there was one at the facility. A secondary contact was the OR supervisor. I made initial contact by telephone, and then sent a 25-item questionnaire via e-mail to the contacts. Respondents returned the questionnaires via e-mail.

REDUCING COSTS

Survey results vary widely, with some hospitals making great efforts to reduce costs. Current recommendations in the literature suggest that a major factor in reducing variable costs is via standardization of surgical services instrumentation and supplies. (2) The term surgical services instrumentation refers to all individual instrument sets used for each procedure and any implants that may be used.

When asked their first choice for reducing costs, most respondents chose standardization of services and supplies. The second most common answer was reducing turnover rates and increasing OR use. The survey also asked whether the hospitals had attempted to standardize individual surgical services instrumentation and supplies, what percentage of services they had standardized, which service was easiest to standardize, and which service was the most difficult to standardize. A majority (ie, 77%) of the respondents said they had attempted to standardize individual surgical services instrumentation and supplies. The percentage of services standardized ranged from all services to only one service. The service indicated by the majority of hospitals as the easiest to standardize was general surgery, and the most difficult was orthopedics.

Lack of physician collaboration was regarded by survey respondents as a primary barrier to service and supply standardization. The question, "Have you experienced resistance from surgeons to standardize?" elicited multiple responses, but 100% of the respondents said they had encountered surgeon resistance. Several even cited surgeon resistance as the reason standardization may never happen in their hospitals. Respondents also were asked to rate the resistance level among surgeons on a scale of one to 10, with 10 being the highest resistance level. The average response was seven. A score of four was the lowest score given, and 29% said 10. Orthopedics was the service with the most surgeon resistance.

Consignment of products is another way to reduce OR costs. Consignment allows hospitals to spend money on only what they use. It places much of the risk on the vendor, who must ensure that the product is desirable to the patient and surgeon. Not all vendors are willing to sell on consignment, however. They often request to be paid up front and pass the risk to the hospital.

Vendors sometimes are unwilling to sell on consignment unless a hospital can guarantee them a minimum use level. It is critical for the vendor, the surgeon, and the purchaser to be actively involved in the purchase agreement. Survey respondents were asked to provide their current level of consignment vendor use. Answers varied widely with an average of 7% and a general range of 3% to 10%. Outliers had percentages in the 80% to 90% range.

Another cost reduction method cited frequently in the literature is instituting clinical pathways. (3) Clinical pathways identify a specific procedure and organize it in terms of sequence and timing of major care activities and interventions from the entire multidisciplinary team. When asked whether they had attempted to institute clinical pathways for individual procedures and to list those that have had the greatest positive effect on the department, 60% of respondents said they had instituted clinical pathways, and 58% said total joint replacement had the greatest departmental effect. Vaginal delivery received the second largest response, followed by cesarean section, coronary artery bypass grafting, and laparoscopic cholecystectomy.

Health Care Industry

Sacred cows revisited

AORN Journal, Dec, 2004 by Michael P. Ryon

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