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Benchmarking in Ambulatory Surgery
OCTOBER 2002, VOL 76, NO 4 copp
Benchmarking in Ambulatory Surgerv J
he health care system in the United States continues to consume more of the gross national product.’ This poses a problem for health care organizations, which are pressured constantly to decrease spending. In an effort to find the most efficient, high quality, low expenditure processes, health care organizations are borrowing techniques from the business world. One quality improvement technique that has been employed is benchmarking. Benchmarking originated in nonhealth care industries and has been defined as “the process of regularly comparing oneself to others performing similar activities so as to continuously improve.”* Benchmarking was recognized and first practiced at the Xerox Corp, Rochester, NY, less than 20 years ago.’ Since then, the concept has spread rapidly throughout business organizations because “it ~ 0 r k s . l Benchmarking ’~ is both general and flexible, so it is adaptable to numerous situations. Xerox defines benchmarking as “finding and implementing the best practi~e.”~ Benchmarking requires that existing processes in an organization be analyzed and understood before they are compared with processes outside the organization.6 According to some authors, when
applying the principles of benchmarking to the health care industry, the following - elements are key. Focus on core products, services, or processes. It is important to focus on processes that will have a large impact on the organization so cost savings from the new process will outweigh costs incurred from creating the benchmark. Adopt the attitude of a learner. Learning from others is basic to the benchmarking process. The capacity for learning can accelerate or retard benchmarking effectiveness. Adapt best practices to fit an organization. Part of every benchmarking project must be determining how to apply what has been discovered. Using quality improvement teams within the organization offers the potential for breakthrough improvements. It is a way to learn and practice the discipline and achieve uniform results. Improve patient care practices. The hndamental purpose for health care benchmarking is improving patient care practices. Focus on producing healthier communities. Health care organizations should benchmark the process of delivering care to make ueoule healthier.’ These five principles can be combined to create a definition for health care benchmarking as
A B S T R A C T The health care industry is relatively new to benchmarking. More clinical benchmarking Is needed because little is known about which practices and processes lead to which outcomes. Benchmarking is a valuable quality improvementtool that can be used to improve practices and performances when instituted properly. This article describes the benchmarking process, its usefulness, and how ambulatory surgery centers can improve performance by using benchmarking. AORN J 7 6 (Oct 2002) 643-647. N A N C Y A. COPP, R N 643 AORN JOURNAL
a continual and collaborative discipline, which involves measuring and comparing results of key processes with the best perjormers and adapting the best practices to achieve bizabhrough process improvements in support of healthier communities.8 Understanding benchmarking
OCTOBER 2002, VOL 76, NO 4 copp
AU available personnel would monitor procedures
and respond immediately to help with turnover.
in this way implies that collaboration, not competition, is a more effective way to improve practices and outcomes on behalf of those served. The use of benchmarking in this manner serves the common good of the health care industry and local communities and helps individual health care organizations thrive. BENCHMARKINGIN H W T H CARE
Benchmarking has been used by organizations to make improvements in many processes, including those concerning worker’s compensation, fulltime equivalent costs, acuity staffing ratios, billing, payroll, purchasing and delivery of clinical supplies, average surgery cost, average length of stay, and medical records. Administrative processes generally are less complex and traditionally have been more attractive candidates for Clinical benchmarking projects must be controlled carefully, using matched subjects to achieve credible results. The effect that benchmarking has had on nursing and the health care industry is similar to those of any quality improvement technique. As new techniques and processes are identified, nursing practice and the health care industry improve. BENCHMARKING PHASES
The benchmarking process comprises 11 steps that are divided into four phases (Table 1). The steps begin with identifying the area for improvement and end with monitoring whether the desired improvement was achieved. The first of the four phases is the planning phase. Benchmarking requires an investment of time and resources, so it needs to yield a return. Select a subject to benchmark. To select indicators to meas-
ure, determine which are the most important. For example, the choice might include turnover time, physician preference cards, or patient satisfaction surveys. One useful test is to ask whether the data collected can be used to solve a problem or achieve a specific result. If the answer is no, then the data need not be collected. The second phase is the analysis phase. To actually collect the data, the benchmarking team will need a methodology to fit its particular needs. Much of the necessary data already may be available in a useable format generated from medical records. If so, the quality improvement team may discover differences when comparing data. These differences can project future performance. The integration phase is the third phase. The team communicates results of the findings to staff members, determines what changes could and should be made, and establishes functional goals. The final phase is the action phase. Develop the necessary plans for improvement. Implement and monitor the results, and identify an appropriate time frame. BENCHMARKING IN AMBULATORY SURGERY
The most obvious implication of benchmarking for nurses who work in ambulatory surgery centers is that it can be used to identify superior avenues of serving the needs of surgical patients and, thus, increase their satisfaction with care received. For benchmarking to be successful, both nurses and managers must be dedicated to their goal. Benchmarking creates learning and team-oriented environments, which are associated with satisfied employees. If employees are satisfied, there is less employee turnover, which provides additional savings for the ambulatory surgery center. Employees are more likely to be attentive to surgical patient needs in a center where they are motivated and satisfied with their positions. This translates into improved patient care and improved patient satisfaction. Benchmarking can facilitate communication and much needed cooperation among health care centers.’” Collaborative benchmarking efforts are economical for all parties involved in the process and allow more organizations to take advantage of the result produced or process identified by the benchmarking process. One researcher, however, cautions, “health care leaders will have to invest in information systems and the creation of customer and knowledge bases to enable effective benchmarking.””
644 AORN JOURNAL
OCTOBER 2002, VOL 76, NO 4 ' copp
Table 1 BENCHMARKING MODEL'
Phase I-olannlna Select a subject to benchmark. Identify the best team. Determine the data collection method.
Phase Il-unalysis Collect data. Analyze collected data to identify competitive gaps. Project future performance.
Phase illintegration Communicate results of the analysis. Establish functional goals.
Phase IV-action Develop action plans. Implement plans and monitor results. Recalibrate benchmark. NOTE 1. R C Camp, A G Tweet, "Benchmarking applied to health care," Joint Commission Journal on Qualify Improvement 20 (May 1994) 229-238; S Len2 et 01, "Benchmarking: Finding ways to improve," Joint Commission Journal on Qualify Improvement 20 (May 1994) 250-259.
Benchmarking also affects organizational structure. For benchmarking to be effective, dedicated personnel need to monitor the ongoing benchmarking process continuously." Positions dedicated to this process may have to be created within the organization or coupled with the organization's quality improvement plan. Conversely, some organizations may choose to use a consultant to facilitate and drive the pro~ess.'~ ONE FACIUN'S EXAMPLE
At the Lawrence Surgery Center, Lawrence, Kan, an example of an established benchmark for turnover time is 15 minutes or less. AORN defines turnover time as the time from when one patient leaves the OR suite until the next patient enter^.'^ For example, if a procedure ends (ie, last suture inserted) at 10 AM, the patient actually leaves the OR at 10:15 AM, and the next patient enters the OR at 10:30 AM, the turnover time per AORN's defini-
tion would be 15 minutes. Currently, room turnover times at the Lawrence Surgery Center average 14.8 minutes, which is close to the benchmark. Obviously the less time it takes to turn a room over, the more OR suite time is available, which translates into a potential for increased revenue. This provided the impetus for the project to establish this particular benchmark. Using the benchmarking model, the subject selected. was turnover time. The unwritten but universally accepted industry standard for turnover time is 15 minutes. This provided the best practice measure. Data on turnover times for procedures performed during a one-month time period were collected from computerized perioperative records. Times then were analyzed using an average derived from the AORN definition of turnover time. The information received was communicated to all perioperative staff members during a staff meeting. The turnover time was found to be 14.8 minutes, so the goal was to maintain the 15-minute benchmark. Team members decided that the plan to facilitate turnover time would continue to include all personnel not involved in another procedure at the time one procedure concluded. All available personnel would monitor the status of procedures and respond immediately to help with turnover as patients left the OR. This process alleviates waiting for help to respond to a call and essentially allows a circulating nurse to report and leave one patient in the postanesthesia care unit and immediately report to the preoperative area to assess the next patient and bring him or her into the OR suite. Team members will monitor this plan monthly. The benchmark was found to be a reasonable time frame without compromising patient care. CONCLUSION
The benchmarking process, although new to the health care industry, is not new to nursing. It closely resembles the assess, plan, implement, and evaluate steps of the nursing process. As such, it is a familiar transition for nurses. After they establish an effective routine, it easily becomes part of the patient care process Health care benchmarking is a continual and collaborative discipline that involves measuring and comparing the results of key processes. Adapting best practices to achieve improvements will result in healthier communities. Benchmarking is a valuable quality improvement tool that can produce exponential improvement in many practices
646 AORN JOURNAL
OCTOBER 2002, VOL 76, NO 4 copp
and performances when instituted properly. Further research is needed to help improve and define the benchmarking procedure.-A ’ NOTES 1 . A B Campbell, “Benchmarking: A performance intervention tool,” Joint Commission Journal on Qualify Improvement 20 (May 1994) 225-228. 2. S Lenz et al, “Benchmarking: Finding ways to improve,” Joint Commission Journal on Qualify Improvement 20 (May 1994) 250-259. 3. R C Camp, A G Tweet,
“Benchmarking applied to health care,” Joint Commission Journal on Qualify Improvement 20 (May 1994) 229-238.
Nancy A. Copp*iuv,BSN, CNOR, is an orthopedic sta# nurse at the Lawrence Suxery Center;Lawrence, Kan.
4. Zbid. 5 . Ibid. 6. T McKeon, “Benchmarks and performance indicators: Two tools
for evaluating organizational results and continuous quality improvement efforts,” Journal of Nursing Care Qualify I0 (April 1996) 12-17. 7. D Mosel, B Gift, “Collaborative benchmarking in health care,” Joint Commission Journal on Quality Improvement 20 (May 1994) 239-249. 8. Ibid. 9. Campbell, “Benchmarking: A
performance intervention tool,” 225228. 10. Mosel, Gift, “Collaborative benchmarking in health care,” 24 1. 11. Ibid. 12. Campbell, “B&hmarking: A performance intervention tool,” 225228. 13. Ibid. 14, “AACD glossary of times
used for scheduling and monitoring of diagnostic and therapeutic procedures,” in Standards; Recommended Practices, and Guidelines (Denver: AORN, Inc, 2002) 81-87.
Pain is Undertreated in African Americans The National Medical Association (NMA) has concluded that inadequate pain management is a serious national public health problem that affects millions of African Americans and other underserved minority populations, according to an Aug 6 , 2002, news release from the association. In response, the association convened a consensus panel to discuss the challenges related to pain management in African Americans and other minorities. According to the NMA, M c a n Americans who experience excruciating pain as the result of life-threatening illness or major surgery are denied effective pain medication due to factors that center on race. The association will release its final report on pain management in March 2003. The following preliminary findings, however, have been released. Pain causes more disability than cancer and heart disease combined. Racial and ethnic minorities are at higher risk for receiving ineffective treatment for chronic and severe pain. Some physicians are fearfUl of prescribing certain medications because of drug abuse concerns relating to minority populations. Racial profiling is more prominent in urban-area pharmacies. These pharmacies may refke to
stock certain opioids for reasons such as low demand, potential for fraud, fear of being robbed, or a belief that certain prescriptions are diverted for illegal use. In response to these findings, the NMA has issued the following recommendations. Encourage physicians who prescribe strong pain medication to contact the pharmacist directly. Provide physicians with guidelines on using tamper-resistant prescription pads. Integrate a pain management curricula in medical and related health education programs at the undergraduate, postgraduate, and continuing education levels. Develop public health education programs that increase understanding of pain management and address prevention of medication abuse and illegal drug trafficking. Increase focus on data collection as a means to better identify the reasons for racial disparities in pain management. National Medical Association (NMA) Panel Says Untreated Pain is a Public Health Crisis for Minorities (news rdease, Honolulu: National Medical Association, Aug 6, 2002) h f t p : / W .pmewwire.com (accessed 7 Aug 2002).
647 AORN JOURNAL
Benchmarking in Ambulatory Surgerv J
he health care system in the United States continues to consume more of the gross national product.’ This poses a problem for health care organizations, which are pressured constantly to decrease spending. In an effort to find the most efficient, high quality, low expenditure processes, health care organizations are borrowing techniques from the business world. One quality improvement technique that has been employed is benchmarking. Benchmarking originated in nonhealth care industries and has been defined as “the process of regularly comparing oneself to others performing similar activities so as to continuously improve.”* Benchmarking was recognized and first practiced at the Xerox Corp, Rochester, NY, less than 20 years ago.’ Since then, the concept has spread rapidly throughout business organizations because “it ~ 0 r k s . l Benchmarking ’~ is both general and flexible, so it is adaptable to numerous situations. Xerox defines benchmarking as “finding and implementing the best practi~e.”~ Benchmarking requires that existing processes in an organization be analyzed and understood before they are compared with processes outside the organization.6 According to some authors, when
applying the principles of benchmarking to the health care industry, the following - elements are key. Focus on core products, services, or processes. It is important to focus on processes that will have a large impact on the organization so cost savings from the new process will outweigh costs incurred from creating the benchmark. Adopt the attitude of a learner. Learning from others is basic to the benchmarking process. The capacity for learning can accelerate or retard benchmarking effectiveness. Adapt best practices to fit an organization. Part of every benchmarking project must be determining how to apply what has been discovered. Using quality improvement teams within the organization offers the potential for breakthrough improvements. It is a way to learn and practice the discipline and achieve uniform results. Improve patient care practices. The hndamental purpose for health care benchmarking is improving patient care practices. Focus on producing healthier communities. Health care organizations should benchmark the process of delivering care to make ueoule healthier.’ These five principles can be combined to create a definition for health care benchmarking as
A B S T R A C T The health care industry is relatively new to benchmarking. More clinical benchmarking Is needed because little is known about which practices and processes lead to which outcomes. Benchmarking is a valuable quality improvementtool that can be used to improve practices and performances when instituted properly. This article describes the benchmarking process, its usefulness, and how ambulatory surgery centers can improve performance by using benchmarking. AORN J 7 6 (Oct 2002) 643-647. N A N C Y A. COPP, R N 643 AORN JOURNAL
a continual and collaborative discipline, which involves measuring and comparing results of key processes with the best perjormers and adapting the best practices to achieve bizabhrough process improvements in support of healthier communities.8 Understanding benchmarking
OCTOBER 2002, VOL 76, NO 4 copp
AU available personnel would monitor procedures
and respond immediately to help with turnover.
in this way implies that collaboration, not competition, is a more effective way to improve practices and outcomes on behalf of those served. The use of benchmarking in this manner serves the common good of the health care industry and local communities and helps individual health care organizations thrive. BENCHMARKINGIN H W T H CARE
Benchmarking has been used by organizations to make improvements in many processes, including those concerning worker’s compensation, fulltime equivalent costs, acuity staffing ratios, billing, payroll, purchasing and delivery of clinical supplies, average surgery cost, average length of stay, and medical records. Administrative processes generally are less complex and traditionally have been more attractive candidates for Clinical benchmarking projects must be controlled carefully, using matched subjects to achieve credible results. The effect that benchmarking has had on nursing and the health care industry is similar to those of any quality improvement technique. As new techniques and processes are identified, nursing practice and the health care industry improve. BENCHMARKING PHASES
The benchmarking process comprises 11 steps that are divided into four phases (Table 1). The steps begin with identifying the area for improvement and end with monitoring whether the desired improvement was achieved. The first of the four phases is the planning phase. Benchmarking requires an investment of time and resources, so it needs to yield a return. Select a subject to benchmark. To select indicators to meas-
ure, determine which are the most important. For example, the choice might include turnover time, physician preference cards, or patient satisfaction surveys. One useful test is to ask whether the data collected can be used to solve a problem or achieve a specific result. If the answer is no, then the data need not be collected. The second phase is the analysis phase. To actually collect the data, the benchmarking team will need a methodology to fit its particular needs. Much of the necessary data already may be available in a useable format generated from medical records. If so, the quality improvement team may discover differences when comparing data. These differences can project future performance. The integration phase is the third phase. The team communicates results of the findings to staff members, determines what changes could and should be made, and establishes functional goals. The final phase is the action phase. Develop the necessary plans for improvement. Implement and monitor the results, and identify an appropriate time frame. BENCHMARKING IN AMBULATORY SURGERY
The most obvious implication of benchmarking for nurses who work in ambulatory surgery centers is that it can be used to identify superior avenues of serving the needs of surgical patients and, thus, increase their satisfaction with care received. For benchmarking to be successful, both nurses and managers must be dedicated to their goal. Benchmarking creates learning and team-oriented environments, which are associated with satisfied employees. If employees are satisfied, there is less employee turnover, which provides additional savings for the ambulatory surgery center. Employees are more likely to be attentive to surgical patient needs in a center where they are motivated and satisfied with their positions. This translates into improved patient care and improved patient satisfaction. Benchmarking can facilitate communication and much needed cooperation among health care centers.’” Collaborative benchmarking efforts are economical for all parties involved in the process and allow more organizations to take advantage of the result produced or process identified by the benchmarking process. One researcher, however, cautions, “health care leaders will have to invest in information systems and the creation of customer and knowledge bases to enable effective benchmarking.””
644 AORN JOURNAL
OCTOBER 2002, VOL 76, NO 4 ' copp
Table 1 BENCHMARKING MODEL'
Phase I-olannlna Select a subject to benchmark. Identify the best team. Determine the data collection method.
Phase Il-unalysis Collect data. Analyze collected data to identify competitive gaps. Project future performance.
Phase illintegration Communicate results of the analysis. Establish functional goals.
Phase IV-action Develop action plans. Implement plans and monitor results. Recalibrate benchmark. NOTE 1. R C Camp, A G Tweet, "Benchmarking applied to health care," Joint Commission Journal on Qualify Improvement 20 (May 1994) 229-238; S Len2 et 01, "Benchmarking: Finding ways to improve," Joint Commission Journal on Qualify Improvement 20 (May 1994) 250-259.
Benchmarking also affects organizational structure. For benchmarking to be effective, dedicated personnel need to monitor the ongoing benchmarking process continuously." Positions dedicated to this process may have to be created within the organization or coupled with the organization's quality improvement plan. Conversely, some organizations may choose to use a consultant to facilitate and drive the pro~ess.'~ ONE FACIUN'S EXAMPLE
At the Lawrence Surgery Center, Lawrence, Kan, an example of an established benchmark for turnover time is 15 minutes or less. AORN defines turnover time as the time from when one patient leaves the OR suite until the next patient enter^.'^ For example, if a procedure ends (ie, last suture inserted) at 10 AM, the patient actually leaves the OR at 10:15 AM, and the next patient enters the OR at 10:30 AM, the turnover time per AORN's defini-
tion would be 15 minutes. Currently, room turnover times at the Lawrence Surgery Center average 14.8 minutes, which is close to the benchmark. Obviously the less time it takes to turn a room over, the more OR suite time is available, which translates into a potential for increased revenue. This provided the impetus for the project to establish this particular benchmark. Using the benchmarking model, the subject selected. was turnover time. The unwritten but universally accepted industry standard for turnover time is 15 minutes. This provided the best practice measure. Data on turnover times for procedures performed during a one-month time period were collected from computerized perioperative records. Times then were analyzed using an average derived from the AORN definition of turnover time. The information received was communicated to all perioperative staff members during a staff meeting. The turnover time was found to be 14.8 minutes, so the goal was to maintain the 15-minute benchmark. Team members decided that the plan to facilitate turnover time would continue to include all personnel not involved in another procedure at the time one procedure concluded. All available personnel would monitor the status of procedures and respond immediately to help with turnover as patients left the OR. This process alleviates waiting for help to respond to a call and essentially allows a circulating nurse to report and leave one patient in the postanesthesia care unit and immediately report to the preoperative area to assess the next patient and bring him or her into the OR suite. Team members will monitor this plan monthly. The benchmark was found to be a reasonable time frame without compromising patient care. CONCLUSION
The benchmarking process, although new to the health care industry, is not new to nursing. It closely resembles the assess, plan, implement, and evaluate steps of the nursing process. As such, it is a familiar transition for nurses. After they establish an effective routine, it easily becomes part of the patient care process Health care benchmarking is a continual and collaborative discipline that involves measuring and comparing the results of key processes. Adapting best practices to achieve improvements will result in healthier communities. Benchmarking is a valuable quality improvement tool that can produce exponential improvement in many practices
646 AORN JOURNAL
OCTOBER 2002, VOL 76, NO 4 copp
and performances when instituted properly. Further research is needed to help improve and define the benchmarking procedure.-A ’ NOTES 1 . A B Campbell, “Benchmarking: A performance intervention tool,” Joint Commission Journal on Qualify Improvement 20 (May 1994) 225-228. 2. S Lenz et al, “Benchmarking: Finding ways to improve,” Joint Commission Journal on Qualify Improvement 20 (May 1994) 250-259. 3. R C Camp, A G Tweet,
“Benchmarking applied to health care,” Joint Commission Journal on Qualify Improvement 20 (May 1994) 229-238.
Nancy A. Copp*iuv,BSN, CNOR, is an orthopedic sta# nurse at the Lawrence Suxery Center;Lawrence, Kan.
4. Zbid. 5 . Ibid. 6. T McKeon, “Benchmarks and performance indicators: Two tools
for evaluating organizational results and continuous quality improvement efforts,” Journal of Nursing Care Qualify I0 (April 1996) 12-17. 7. D Mosel, B Gift, “Collaborative benchmarking in health care,” Joint Commission Journal on Quality Improvement 20 (May 1994) 239-249. 8. Ibid. 9. Campbell, “Benchmarking: A
performance intervention tool,” 225228. 10. Mosel, Gift, “Collaborative benchmarking in health care,” 24 1. 11. Ibid. 12. Campbell, “B&hmarking: A performance intervention tool,” 225228. 13. Ibid. 14, “AACD glossary of times
used for scheduling and monitoring of diagnostic and therapeutic procedures,” in Standards; Recommended Practices, and Guidelines (Denver: AORN, Inc, 2002) 81-87.
Pain is Undertreated in African Americans The National Medical Association (NMA) has concluded that inadequate pain management is a serious national public health problem that affects millions of African Americans and other underserved minority populations, according to an Aug 6 , 2002, news release from the association. In response, the association convened a consensus panel to discuss the challenges related to pain management in African Americans and other minorities. According to the NMA, M c a n Americans who experience excruciating pain as the result of life-threatening illness or major surgery are denied effective pain medication due to factors that center on race. The association will release its final report on pain management in March 2003. The following preliminary findings, however, have been released. Pain causes more disability than cancer and heart disease combined. Racial and ethnic minorities are at higher risk for receiving ineffective treatment for chronic and severe pain. Some physicians are fearfUl of prescribing certain medications because of drug abuse concerns relating to minority populations. Racial profiling is more prominent in urban-area pharmacies. These pharmacies may refke to
stock certain opioids for reasons such as low demand, potential for fraud, fear of being robbed, or a belief that certain prescriptions are diverted for illegal use. In response to these findings, the NMA has issued the following recommendations. Encourage physicians who prescribe strong pain medication to contact the pharmacist directly. Provide physicians with guidelines on using tamper-resistant prescription pads. Integrate a pain management curricula in medical and related health education programs at the undergraduate, postgraduate, and continuing education levels. Develop public health education programs that increase understanding of pain management and address prevention of medication abuse and illegal drug trafficking. Increase focus on data collection as a means to better identify the reasons for racial disparities in pain management. National Medical Association (NMA) Panel Says Untreated Pain is a Public Health Crisis for Minorities (news rdease, Honolulu: National Medical Association, Aug 6, 2002) h f t p : / W .pmewwire.com (accessed 7 Aug 2002).
647 AORN JOURNAL