Administration of perioperative patient care services

Chapter 6


Administration of perioperative patient care services



Chapter objectives


After studying this chapter, the learner will be able to:


• Define the role of the perioperative management team.


• Describe the relationship between the perioperative environment and other patient care departments.


• Define the role of intradepartmental surgical services committees.


• Facilitate mediation in conflict resolution.



Key terms and definitions



Administrator 


Person who directs or manages departmental affairs; may be a nurse or physician.


Capital budget 


Monies for larger purchases that have lasting use implications for a time-defined period. Some items depreciate over time and need replacement as technologies change.


Committee 


A group within the organization that is assembled to perform a specific task.


Evidence-based practice 


A procedure or activity that is validated with scientific proof in a clinical setting.


Inservice education 


Departmental programs designed to introduce or demonstrate equipment, techniques, or procedures used in perioperative patient care.


Learning organization 


The functional group that includes all personnel involved with the facility. The organization needs to be able to learn from experience and the environment if it is to survive and grow. Stagnation and inflexibility are costly and a main cause of failure and financial loss.


Manager 


Person who plans and executes directives passed down from administration.


Materials 


Supplies, such as reusable or disposable goods, ordered and maintained in stock for departmental use in patient care.


Operational budget 


Monies appropriated for the costs of day-to-day business.


Sacred cow 


A practice that continues despite lack of scientific evidence or validation with evidence-based practice.


Systems thinking 


A process by which the learning organization collectively examines practices and processes during the analysis of root causes. This mechanism examines long-term activity, not just one single change. It is a circular process of business and people skills.



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Establishing administrative roles


The perioperative patient care team surrounds the patient throughout the perioperative experience. This direct perioperative patient care team functions within the physical confines of the OR, which is one part of the physical facilities that make up the total perioperative environment. Other areas in the perioperative environment include preadmission testing (PAT), the ambulatory services unit (ASU), and the postanesthesia care unit (PACU). Similarly, the perioperative patient care team makes up only one part of the human activity directed toward the care of the surgical patient.


Many other people function in an indirect relationship with the patient and contribute vital supporting services toward the common goal of ensuring a safe, comfortable, and effective perioperative environment. The relationship and duties of perioperative staff members vary according to the size and extent of the physical facilities and the number of personnel employed. No person’s job is insignificant. Each staff member has important functions to perform, and each is responsible for assuming a part of the total workload.


The purpose of this chapter is to acquaint the perioperative staff with the role of the management team and the nature of the job they have to perform. This is not a “how-to” chapter on management, but a descriptive collection of structural and elemental components of the underpinnings of a surgical services department. This chapter could serve to create ideas or a conceptual framework for a new manager in the OR.


Many article reviews and up-to-date notices for managers can be found at AORN Management Connections at www.aorn.org/News/Managers. This leadership-based managerial online newsletter on the AORN website (www.aorn.org) keeps the manager informed of many new developments in the perioperative arena.



Magnet recognition


Leading the way to magnet status


The Magnet Recognition Program was founded in 1993 by the American Nurses Credentialing Center (ANCC) as a way to improve health care management, staffing, and outcomes. Magnet recognition is the highest acknowledgment on a national level of ongoing nursing care excellence. Detailed information and a visual diagram are available at www.nursecredentialing.org/magnet.aspx.


Activities in a Magnet hospital are highly visible to the public and point to 14 forces that form the core values of this distinguished title (Box 6-1). The five primary hallmarks of Magnet status include the following:



BOX 6-1   Fourteen Dimensions of Magnet Recognition Status (Known as “Forces of Magnetism”)





1. Transformational leadership: Demonstrated vision, influence, clinical knowledge, and expertise in professional nursing practice.


2. Structural empowerment: Mission, values, and vision are manifest in outcomes through professional partnerships and collaborations with the staff.


3. Exemplary professional practice: Application of the nursing process and the emergence of new knowledge are reflected with the response from patients, families, the team, and the community at large. This is a circular process.


4. New knowledge: Innovation and improvement: Continual implementation of improved methods helps to refine the system through evidence-based practice. Individualized care uses a blend of new and old techniques.


5. Empirical quality outcomes: The end result of care is compared with benchmarks established along the way. Making a difference is emphasized through innovation and creativity. Standards still remain, but flexibility is key to gaining new learning directed at improved outcomes.



Eligibility for magnet status


A formal application is preceded by an analysis of current workplace status. The nursing division must be part of a larger health care organization. A manual is available from the ANCC website (www.nursecredentialing.org/magnet.aspx) to assist in determination of eligibility. The process includes a written documentation phase and a site visit by the Magnet recognition appraisal committee. The site visit is funded totally by the applicant organization. The Commission on Magnet Recognition renders a decision concerning status within 4 to 6 weeks of the site visit and a review of all application documentation. Magnet recognition is effective for 4 years, during which time spot inspections may be made to assess for variances.


Some prerequisites to application include but are not limited to the following requirements:



1. Data collection concerning quality and outcomes must become part of a national database for benchmarking nurse-sensitive quality indicators at the patient care division level.


2. Educational preparation of nursing administration:



3. ANCC’s Scope and Standards for Nurse Administrators must be in effect for adequate measuring and surveying by Magnet site visitors.


4. The organization must be in full compliance with all local, state, and federal laws and regulations.


5. Compliance with National Safety Patient Goals from The Joint Commission (TJC) is required.


6. Policies and procedures must be in place to permit nurses to voice concerns concerning practice environment without retribution.


7. In the previous 3 years, no complaints of unfair labor practices can have been filed by nurses or be pending before the National Labor Relations Board or other federal or state court.




Benefits of magnet status


Nursing care is more clearly defined, which offers the opportunity for professional growth and enrichment and thereby supports recruitment and retention of staff.2,5,7 Nursing turnover is minimized. Nursing administrators remain with the organization, which in turn provides a stable managerial environment. Magnet status can be highly publicized and prized by the marketing department of the facility. Reimbursement sources recognize the credential and use the facility as a referred recommendation to insured groups. The public views the credential as a reassuring atmosphere of safe efficient care.



Management of surgical services


Perioperative administrative personnel


Personnel should know the direction of the entire organizational effort as a prerequisite for successful functioning. Administrative personnel interpret hospital and departmental philosophy, objectives, policies, and procedures to the perioperative staff.3,9 These terms are defined as follows:



1. Philosophy: Statement of beliefs regarding patient care and the nature of perioperative nursing that clarifies the overall responsibilities to be fulfilled.


2. Objectives: Statements of specific goals and purposes to be accomplished during the course of action and definitions of criteria for acceptable performance.


3. Policies: Specific authoritative statements of governing principles or actions, within the context of the philosophy and objectives, that assist in decision making by providing guidelines for action to be taken or, in some situations, for what is not to be done.



4. Procedures: Statements of task-oriented and skill-oriented actions to be taken in the implementation of policies.



Perioperative nurse manager


In most accredited facilities, a registered nurse (RN) is responsible for administration and supervision of all perioperative patient care services. The perioperative environment is a business unit and high-cost center of the hospital. It should be managed as a business to manage costs and maintain effectiveness; therefore the title and functions of the perioperative nurse manager reflect the extent and complexity of the administrative responsibilities (i.e., director, administrator, or vice president).


In larger hospitals, the perioperative nurse manager may hold some variation of the title of director of perioperative services or assistant vice president. Because of the magnitude of the administrative duties, actual supervision of personnel may be delegated to a line manager or charge nurse. In smaller hospitals in which administrative responsibilities focus mostly on one department, the perioperative nurse manager directly supervises personnel. In other situations, one nurse may manage more than one clinical service, such as the OR, PACU, ASU, special procedures room, or central processing department. The term manager is used throughout this text to designate the perioperative nurse who is responsible for coordinating patient care and related support services of the department.


The perioperative nurse manager should have strong knowledge of nursing theory and practice, specialized knowledge of OR technique and management, and knowledge of business and financial management. The manager should possess leadership skills to supervise and direct patient care within the perioperative environment according to established principles and professional standards. The main function of the manager is to provide leadership that promotes a cooperative team effort. Leaders need additional business skills and knowledge, which concern functions of management that include planning, organizing, staffing, directing, and controlling, plus the processes of problem solving, decision making, coordinating, and communicating.



People skills and communications.

The perioperative manager works to build a successful team. Communications are fostered through the philosophy extended by those in leadership. Many tools are used by perioperative personnel to communicate information; some of the standardized mechanisms for relaying information and enhancing team performance are expressed in the following:



1. TeamSTEPPS was developed for the Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality. It includes core values of teamwork such as leadership, situation monitoring, mutual support, and communication. The outcomes affect performance, knowledge, and attitudes. Detailed information can be found at http://teamstepps.ahrq.gov/.


2. Leadership organizes and articulates clear goals. Decisions are made with input from team members, who feel empowered enough to speak when information needs to be imparted to the group. Team relations are supported, and conflicts are resolved. Events are planned, problems are solved, and performance is improved by evaluating processes.


3. Situation monitoring (STEP: Status of patient, Team members, Environment, and Progress toward goal) is an ongoing process of constant vigilance for progress or regress of goal attainment.


4. Mutual support is actively given and received by all team members. Feedback is timely, considerate, and respectful. Information exchanged is specific and directed toward improvement of team performance. Concerns should be voiced and should elicit a response to be certain of successful communication.1 If a situation is an essential safety breach, any team member may “stop the line,” meaning that the activity or procedure immediately halts without fear of repercussions. The goal is still met without compromising relationships.


5. Communication ranges from basic information to critical dialogue. One structured communication technique uses SBAR (Situation: What is going on with the patient? Background: What is the clinical context or history related to the patient? Assessment: What is the presumed problem? Recommendation and request: What can we or I do immediately to correct the situation?)


“Call out” and “check back” are feedback methods to validate the correctness of the received message (e.g., surgeon asks for 10 mL of lidocaine plain and the scrub person states “10 mL lidocaine plain” as the syringe is passed to the surgeon’s hand). The surgeon should acknowledge the correctness of the exchange. “Hand-off” or patient transfer of care report is included in this activity. Transitions of care include shift change, breaks, addition of team members to the field, and change of surgeons or anesthesia providers.




Managerial responsibilities


The manager is responsible for the allocation and completion of work but does not do it all or make all of the decisions. Qualified personnel are employed, and they are delegated increasing responsibility as they develop competence in their work. An organizational attitude develops that can function well in the manager’s absence.


The manager implements and enforces hospital and departmental policies and procedures. He or she also analyzes and evaluates continuously all patient care services rendered and, through participation in research, seeks to improve the quality of patient care given. The manager retains accountability for all related activities in the perioperative environment.9 The scope of this accountability includes the following:



• Provision of competent staff and supportive services that are adequately prepared to achieve quality patient care objectives.


• Delegation of responsibilities to professional nurses and assignment of duties to other patient care personnel.


• Responsibility for evaluation of the performance of all departmental personnel and for assessment and continuous improvement of the quality of care and services.


• Provision of educational opportunities to increase knowledge and skills of all personnel.


• Coordination of administrative duties to ensure proper functioning of staff.


• Provision and fiscal control of materials, supplies, and equipment.


• Coordination of activities between the perioperative environment and other departments.


• Creation of an atmosphere that fosters teamwork and provides job satisfaction for all staff members.


• Identification of problems and resolution of those problems in a decisive timely manner.


• Initiation of data collection and analyses to develop effective systems and to monitor efficiency and productivity.




Head nurse or charge nurse


The head nurse or charge nurse functions in a line management position as a liaison between staff members and administrative personnel. In some hospitals, the title of head nurse is given to the person whose position is comparable with that of a coordinator. In other, usually smaller, hospitals, the perioperative nurse manager functions more or less in the capacity of a head nurse; so, for simplicity, the term head nurse is used to refer to this role.


In large hospitals with many surgical specialty services, a head nurse may be responsible for the administration and direct supervision of patient care in a particular specialty service, such as ophthalmology, neurosurgery, cardiovascular surgery, or urology. With this structure, several head nurses are in the department. These head nurses should have the technical proficiency necessary for the specialty service for which they are responsible and should have sufficient managerial ability to plan for and administer effectively the patient care activities.


The duties of the head nurse include, but are not limited to, the following:



Functions vary in different hospitals, but the position of head nurse, with its direct and continuous responsibility for both patients and staff, is an important one.



Perioperative business manager


Some hospitals employ a perioperative business manager, who sometimes has the title of unit manager. This person may report to the perioperative manager or directly to the hospital administrator. Lines of authority and responsibility between the business manager and the perioperative nurse manager should be clearly defined regardless of the organizational structure. The business manager directs the management of daily operational and indirect patient care functions in the perioperative environment.


Nonnursing administrative duties should include maintenance of a clean, orderly, safe environment within the department for patients and personnel. This entails more than removing visible dust and dirt.


A safe environment is one that is free of contamination, electrical and fire hazards, and negligence. Formulation of procedures is necessary. Personnel should be trained. However, inspection and follow-up are equally important. The business manager coordinates these efforts with the supporting service departments: housekeeping, maintenance, laundry, and materials management.


A business manager may prepare and administer the department budget. This duty may include maintaining inventories and evaluating supplies and equipment. If the hospital does not employ a business manager, the nurse manager or coordinator assumes responsibility for these duties.



Advanced practice nurse or clinical nurse specialist


Within any organization, a formal structure of authority and responsibility exists. However, the evolution of technology and the acute illnesses of patients have changed the focus of functions for many nurses within the hospital organization. With experience, the advanced practice nurse (APN) can manage patient care and direct the activities of others. This practitioner may hold the title of perioperative nurse clinician, clinical nurse specialist (CNS), or APN. Although the term practitioner is used to describe any or all of these advanced roles, differentiation is made within the profession on the basis of formal academic education that includes master’s degree preparation and specialty certification.


The CNS is similar to other perioperative APNs in an advanced role and is a graduate of a master’s degree program in nursing (master of science in nursing [MSN]), with a clinical specialty. APNs and CNSs serve as role models for and consultants to the professional nursing staff and as teachers of patients and other personnel. The CNS conducts research to validate nursing interventions. These skills can be used effectively for advanced practice in the perioperative environment.


Many APNs are registered nurse first assistants (RNFAs), and those who have attained certification in this role are titled certified registered nurse first assistants (CRNFAs). APNs in this role are not required to concurrently maintain a certified perioperative nurse (CNOR) status because of other advanced certifications.


The APN is capable of exercising a high degree of discriminative judgment in planning, executing, and evaluating nursing care based on the assessed needs of patients with one or more common clinical manifestations. A practitioner may develop the plan of care for a group of orthopedic patients, for example. This plan is coordinated for each patient with the surgeon, other professional nurses, and allied health care personnel who assist in the performance of functions related to the plan.


Clinical nursing interventions are not necessarily performed by the practitioner. The APN decides which nursing interventions can be performed by others and which he or she personally should do. These decisions are based on personal interaction with each patient and knowledge of the clinical condition. The practitioner exercises a degree of autonomy and independence within the clinical setting. Some state boards of nursing have permitted select APNs to have minimal prescriptive powers.


Because a practitioner has advanced academic preparation in theoretic knowledge and clinical experience in a particular clinical patient care setting and is an expert in nursing situations in that setting, qualified clinical coordinators may function as practitioners. In this role, they assist in planning the total care for each surgical patient, in coordinating nursing and supportive services, and in participating in the orientation, development, and evaluation of caregivers assigned to direct patient care functions in the perioperative environment.


The APNs who assess individual patient needs through personal patient interviews and physical examinations and who plan for individualized care in the perioperative environment truly function as perioperative nurse practitioners. They make decisions relative to direct and indirect patient care in the perioperative environment, with use of specialized judgments and skills. Problem solving and decision making are the heart of professional management and professional leadership.


The practitioner may work solely or primarily with the surgeons in a specific surgical specialty. Some APNs work as independent contractors with a surgical group as a qualifier for APN certification. This concept of nursing specialization coincides with the specialization of surgeons. With practice and formal or informal study, nurses develop expertise in planning and implementing care for patients with similar surgical problems. Skills and knowledge become highly specialized. Surgeons in that particular specialty rely on these nurses to supervise the care of their patients and to direct less experienced personnel on the perioperative team.



Perioperative education coordinator


Planned educational experiences are provided in the job setting to help staff members perform competently and knowledgeably. Most hospitals have a staff development department committee to plan, coordinate, and conduct educational and training programs.


An orientation program is planned for each new employee. All new personnel should become familiar with the philosophy, objectives, policies, and procedures of the hospital and patient care services. This general orientation program assists the new employee to adjust to the organization and environment. It is coordinated with an orientation to the duties in the unit to which the employee is assigned.


The inservice coordinator may be a member of the staff development department, the administrative staff, or both. This person is responsible for planning, scheduling, and coordinating the orientation of new staff, including a review of policies and procedures, performance description, and standards specific to the perioperative environment. On the basis of an assessment of individual skills, the new employee is given guidance and supervision for a period of weeks to months until basic competencies are adequate for independent functioning. Head nurses, preceptors, and other experienced staff members assist with the orientation of new personnel.


Inservice education programs should be planned to keep the perioperative staff up-to-date on new techniques, equipment, and patient care practices. Programs that focus on fire prevention, electrical hazards, security measures, and resuscitation training are important to ensure personnel and patient safety. Professional and technical programs designed to develop specialized job knowledge, skills, and attitudes that affect patient care are planned and presented. The inservice coordinator is responsible for assessing the educational needs of staff members collectively and individually and then for planning, scheduling, coordinating, and evaluating inservice programs. This individual may also conduct some sessions.


Staff development programs conducted on a continual basis enhance performance by maintaining job knowledge and clinical competence. Inservice programs may be supplemented by other appropriate continuing education programs held outside the health care facility or presented by qualified people who represent industry.



Preceptor.

The orientation process is facilitated by a one-to-one relationship between the new employee and an experienced staff member. The preceptor teaches, counsels, advises, and encourages the orientee until he or she can function independently. The preceptor is accountable for assessing the orientee’s abilities, assigning activities accordingly, and assisting in carrying out duties safely. Learning needs can be assessed through interview, observation, and a skills checklist.


To ensure consistency in teaching, the preceptor coordinates development of appropriate and measurable behavioral objectives for the orientee with the inservice coordinator, the management staff, or both. The preceptor should evaluate performance and offer constructive feedback to build the orientee’s self-confidence. To be effective, the preceptor should have an interest in teaching and should have acquired the necessary skills and experience with adult learners.



Interdepartmental relationships


The perioperative environment is one of many departments within the total hospital organization. For continuity in patient care, many departments coordinate their efforts through the administration of the formal organizational structure of the hospital.


Every hospital has a governing body that appoints a chief executive officer (CEO), usually with the title of hospital administrator, to provide appropriate physical resources and personnel to meet the needs of patients. Administrative lines of authority, responsibility, and accountability are defined to establish the working relationships among departments and personnel (Fig. 6-1).


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FIG. 6-1 Management structure. Administrative lines of authority, responsibility, and accountability are defined to establish working relationships among departments and personnel.

A nurse executive, sometimes referred to as the vice president of patient care services or director of nursing services, reports to the hospital administrator. The perioperative nurse manager reports to the nurse executive if perioperative services are a division under management of the nursing service. In some facilities, perioperative services are an independent unit not managed by the nursing service. The perioperative nurse manager then reports directly to the CEO, an assistant administrator, or the chief of one of the medical services. Through either channel of administration, many activities in the perioperative environment are coordinated with other patient care units and departments within the facility.



Patient care departments


Patient care division


Patients come to the OR directly from a short-stay or in-house patient care unit, an outpatient ambulatory care area, or the emergency department (ED). Channels of communication should be kept open among perioperative personnel and patient care personnel in other units. Coordination of preoperative preparation and transportation of patients prevents downtime in the perioperative environment. Many facilities use a comprehensive checklist system to ensure adequate preparation of surgical patients in a timely manner. This document accompanies the patient throughout the intraoperative and postoperative care period for continuity. An RN or licensed practical/vocational nurse (LPN/LVN) signs or initials each item accomplished. By the time the patient leaves for the patient care unit, all the preparations have been completed.



Emergency department/trauma center


Victims of trauma and acutely ill patients often are seen initially in the hospital ED. Cardiopulmonary resuscitative and other equipment are available for initiation of prompt triage and treatment. Minor injuries usually can be treated in the ED. Some patients must be scheduled for an emergency surgical procedure, however. These patients may arrive in the OR before the results of all diagnostic tests are confirmed; therefore, communication among the OR, ED, laboratory, and radiology personnel is vital to the success of surgical intervention. OR personnel should be advised of the nature of the injury or illness to prepare all needed equipment and obtain supplies for the emergency surgical procedure.


Designated regional trauma centers should have teams of surgeons, anesthesia providers, and perioperative personnel who are immediately available in the hospital 24 hours a day. A trauma nurse coordinator is administratively responsible for all personnel and activities to ensure comprehensive trauma care.



Intensive care unit


Because surgery has become more specialized and complex, specialized patient care facilities where concentrated treatment can bring the patient to a satisfactory recovery have become a necessity. This care is provided in an intensive care unit (ICU), which is open 24 hours a day, 7 days a week. It is staffed by highly trained and specialized RNs. Critically ill patients who need constant care for several days are admitted directly from the OR, PACU, ED, or other patient care unit. Each bedside is equipped with therapeutic and monitoring equipment.


Depending on the size of the facility and its specialty services, more than one specially designed and equipped surgical intensive care unit (SICU) may be provided. One ICU may admit only cardiovascular surgical patients (coronary care unit [CCU]), another may admit only pediatric patients (pediatric intensive care unit [PICU]), and another may admit only neurologic patients (neurologic intensive care unit [NICU]). In addition to SICUs, most hospitals also have a unit for nonsurgical (medical) patients (medical intensive care unit [MICU]). The increased efficiency that these units afford serves the best interests of both the facility and the patient. They create the most effective use of personnel and equipment and lower morbidity and mortality rates.


Movements of patients to and from the SICUs should be closely coordinated with the anesthesia provider, the perioperative nurse, and the PACU personnel. If the surgeon or anesthesia provider anticipates that a patient will need intensive care postoperatively, an SICU bed is reserved at the same time the patient is scheduled for the surgical procedure. The appropriate SICU should be notified promptly when the surgeon determines an unanticipated need for a bed. Sometimes the patient must wait in the OR or PACU for an available bed, and sometimes elective surgical procedures are postponed because sufficient SICU beds or staff are not available.



Obstetric services


The obstetric unit is divided into three separate areas: labor and delivery (L&D), postpartum care, and newborn nursery. Most L&D units are equipped and staffed for delivery by cesarean section (C-section). However, in other hospitals, patients scheduled for either elective or emergency C-section are brought to the OR. In addition to supplies needed for the surgical procedure, adequate resuscitative equipment must be available for the newborn. Some facilities require the OR personnel to be on call for all C-sections in both the OR and the L&D unit.


The L&D units that staff for C-sections provide their own circulating and scrub nurses. These nurses are eligible for CNOR status. Many departments are staffed with their own RNFAs specific to the role of assisting on C-sections. Certified nurse midwives (CNMs) serve in the first assistant capacity after appropriate training but are not considered RNFAs unless they have completed a Competency & Credentialing Institute (CCI)–accepted RNFA program.

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  4. Urologic surgery

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Apr 6, 2017 | Posted by in GENERAL SURGERY | Comments Off on Administration of perioperative patient care services

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