- Email: [email protected]
Building a Better Preoperative Assessment Clinic
Building a Better Preoperative Assessment Clinic Lanette Siragusa, MN, RN, Lorena Thiessen, BN, RN, Dean Grabowski, BN, RN, R. Shawn Young, MD In every surgical patient’s journey, a well-run preoperative assessment clinic (PAC) is an essential first step in ensuring excellence in quality and patient safety. In 2007, the PAC at Victoria General Hospital, a busy community hospital, averaging more than 7,000 surgical procedures per year, struggled to support the volume of surgical patients. Processes were ill defined, staffing levels were suboptimal, and the physical space was inadequate. This hospital is one of seven acute care hospitals that provide surgical services within the city, under the umbrella of a regional health authority, and is the largest of 11 regional health authorities within the province. With support of the PAC team and administration, a commitment was made to embark on improvements with limited financial resources and space available. After implementing the proposed changes and evaluating the data, the evidence indicates that several small changes can make significant overall improvements in providing superior patient care, more efficient processes, and healthier work environments. Keywords: preoperative assessment, preoperative assessment clinic, best practice. Ó 2011 by American Society of PeriAnesthesia Nurses
PREOPERATIVE ASSESSMENT CLINICS (PACs) facilitate health care practitioners to enhance the delivery of safe care. They provide the opportunity to evaluate a surgical patient’s preoperative risk, optimize health, and plan for perioperative management while ensuring the patient’s individual physical, emotional, social, and cultural needs are met before surgery.1-3 From an administrative perspective, assessment and education of patients Lanette Siragusa, MN, RN, is Director of Programs and Patient Services-Surgery, Anesthesia and Women’s Health; Lorena Thiessen, BN, RN, is a Perioperative Nurse Clinician; Dean Grabowski, BN, RN, is a Perioperative Nurse Clinician; and R. Shawn Young, MD, is a Site Medical Director of Anesthesia, Victoria General Hospital, Winnipeg, Manitoba, Canada. Conflicts of interest: None to report. Address correspondence to Lanette Siragusa, MN, RN, Victoria General Hospital, 2340 Pembina Highway, Winnipeg, Manitoba R3T 2E8, Canada; e-mail address: LanetteSiragusa@ gmail.com or [email protected]. Ó 2011 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 doi:10.1016/j.jopan.2011.05.008
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preoperatively has the potential to increase efficiency of operating room resources in terms of time management, human resource planning, and fiscal accountability.4-7 From a quality perspective, thorough preoperative assessments allow for identification of comorbidities, American Society of Anesthesiologists classification of risk, and optimization of health status, thereby leading to fewer patient cancellations on the day of surgery because of unforeseen unresolved medical issues that can add risk to even the most minor of procedures.8,9 Also the quality of PACs can be assessed through examining logistic performance, quality of medical evaluation, patient satisfaction, and patient flow, as it relates to efficient organization and the need for preoperative testing.10 From a patient’s perspective of health care, quality is not only determined by the outcome of treatment but also by the extent to which patients are supported.11 Preoperative anesthetic assessments provide the opportunity for patients to gain
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knowledge, develop trusting relationships with health care providers, decrease anxieties, and improve satisfaction.11,12 Researchers have demonstrated that patient-focused nursing care is often one of the key components to high-quality preoperative care related to communication of knowledge, empathy, and the ability to decrease patient anxiety.13-16
Purpose Before the implementation of change, the PAC lacked a dedicated space, consistency of staff, and well-defined processes related to screening and patient flow. Two small rooms were dedicated for preoperative assessment. One room was used on a daily basis by one of several general duty nurses for preoperative patient teaching. The second room was shared among a team of anesthesia providers to conduct necessary assessments 2 or 3 days per week. Screening of preoperative charts was assigned to the on-call anesthesia provider who determined which patients required a PAC visit before surgery. The PAC patient-waiting area was shared with the busy crowded day surgery unit, as was the nursing staff. Without having a dedicated clerk, duties for the PAC were shared among the day surgery clerks, slating clerks, and admitting clerks. There was no designated space large enough to house the PAC patients’ charts, so charts were stored in three different offices out of necessity, often becoming misplaced or misfiled. Previous anesthesiology shortages and no consistently assigned nurse to the PAC contributed to ill-defined processes that relied on individuals’ preferred practices rather than consistency. It is important to note that despite obvious flaws in this system, patient care was always of utmost importance to the team, and they worked diligently to do the best job possible within this often-chaotic environment.
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patients who are at an increased risk of a perioperative thromboembolic event, perioperative aspirin management, required laboratory investigations), (3) group consensus and continuity of staffing, (4) relocation to a functional physical environment to improve efficiencies within the surgical program, and (5) resources and development of partnerships with the community of health care providers to coordinate services across the continuum of care.
Methods Growing the Team The first order of business was to staff the PAC appropriately. Originally, three full-time permanent staff were hired to enable consistency among the team. A perioperative nurse clinician (nurse IV) was hired to screen all surgical patients’ charts preoperatively and conduct preoperative evaluation for low to moderate risk surgical patients. Qualifications require that the perioperative nurse clinician (nurse IV) must have a baccalaureate degree and critical care certification combined with relevant experience. One full-time general duty registered nurse (II) was deemed responsible for patient education. Both of these nursing classifications are governed by the same professional body. One clerk was assigned to manage the incoming paperwork, office flow, and patient visits. It was quickly determined that an additional clerk was necessary to manage the intake of all preoperative paperwork; thus another clerk was hired shortly after opening the clinic. High-risk anesthesia–led PACs occur 2-3 days per week now on a consistent basis. Also, the anesthesia providers make themselves available to the perioperative nurse clinician to review charts and consult whenever necessary. Volunteers also are valued members of this team, helping wherever they can within the clinic, greeting, and escorting patients throughout the facility as required.
Design Improving Processes With the above challenges presented, steps were taken to begin building a better PAC. High priority was placed on (1) adequate staff baselines reflective of the volumes of surgical patients, (2) development of improved well-defined processes based on best practice guidelines (eg, obstructive sleep apnea, bridging protocol to identify and manage
The LEAN, Six Sigma, and Toyota approach in reducing waste and eliciting best practice through a focus on effective and efficient operations makes sense theoretically. However, the reality of arriving at consensus of opinions and attitudes among health care professionals can prove to be more
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challenging.17,18 We did not have the time, financial resources, or human resources required to orchestrate a traditional LEAN approach to change. However, the opportunity and team’s strong drive and desire propelled the instigation of improvements. The homogeneity of this small clinic allowed us to prioritize standardized processes based on patient need. Traditionally, a surgeon’s office would send patient documentation by a variety of methods (fax, courier, or hand delivered) to the slating department before surgery. There was no enforced time expectation of when this information should arrive, and as a result, patient documentation might arrive months in advance or the day before surgery. It was common for information to be missing (ie, an incomplete history and physical, absent laboratory work, or patient questionnaire). Thus, a ‘‘2-week rule’’ was implemented as the minimum time before surgery that patient documentation must be received. All patient information was redirected from the slating (scheduling) department to the PAC, and no procedure would be slated until all necessary patient information was received and assessed by the perioperative nurse clinician. This was a significant change in the work culture. Instead of relying on a task-focused environment, where the slating clerks’ primary goal was to schedule a procedure, all patient documentation is now received in the PAC for assessment. This was a shift to safer patient-focused care (Fig 1). Surgeons’ offices are now required to ensure that all patient documentation is clearly identified and to provide a complete list of patients assigned to the designated surgical slate. A logbook was created by the PAC clerk to keep track of paperwork that has been submitted, noting incomplete or omitted information, correlated by the proposed date of surgery. A newly established filing system keeps all patient charts in chronological order by date of surgery. Charts, which were once all kept in manila folders, are now color coded based on surgical specialty for easy identification. A perioperative pathway checklist (Fig 2) was created as an organizational tool to track the flow of the patient’s chart and related activities (ie, incomplete documentation,
patient PAC visit booked, awaiting laboratory work). This standardization tool has proven to be a key element for quality control. Patient charts are kept in PAC until 2 days before surgery at which time they are delivered to the preoperative unit in preparation for the patients’ arrival. Friday is designated as a ‘‘catch up’’ office day when charting, phone calls, and urgent visits can be scheduled if necessary. Group Consensus Because discrepancies occurred due to individual differences in anesthesia providers’ practices, new forms were created to ensure standardization of the screening process. Consensus among anesthesia providers was achieved to determine which patients require a PAC visit, considering the invasiveness and complexity of the surgical procedure planned and patients’ comorbidities. Incorporating evidence-based guidelines, the PAC anesthesia providers also arrived at a consensus of acceptable directives for patients to take or hold preoperative medications and alternative therapies. Patients now take home a copy of their individualized medication instructions, while the original is left on the patient chart for reference purposes. An anticoagulation bridging protocol was established for surgical patients at varying risk for thromboembolism and managed through the PAC. Establishing a Suitable Physical Space It was through years of sustained persistence and the unwavering vision of a better way to manage the PAC, which perpetuated the long-awaited physical move to a new and improved space. This move allowed for double the number of clinic rooms (four), a designated PAC patient-waiting area, office space for clerical staff, and a staff area where the PAC team could have their breaks, team meetings, and education sessions. Staff were encouraged to participate in the creation of the space that would ultimately belong to them. They picked out their own paint colors, collaborated among each other to determine their new designated office spaces, hung their own framed photographic artwork, and rearranged office furniture to best suit their needs. The result was a warm, inviting environment for this fastpaced clinic.
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Preoperative Assessment Clinic Patient Pathway Surgeon responsible to submit all required preoperative patient documentation two weeks prior to surgical date, Relevant bloodwork, EKGs and CXRs are required prior to slating. Surgeon directs the patient on continuation or cessation of vitamins, herbs, oral contraceptives and Hormone Replacement Therapy.
Perioperative Nurse Clinican (PNC) assesses charts (preferably with lab results) to determine need for PAC appointment. Medications not addressed by the surgeon will be evaluated. Incomplete charts will not be assessed
PAC appointment required
PAC Clerk phones patient to notify of upcoming appointment. High Risk: Anesthesiologist or Low- Moderate Risk: PNC Preoperative Patient Teaching: Registered Nurse
Additional reports will be requested by the PNC & clerk as necessary. Medications not addressed by the surgeon will be addressed by a member of the PAC Team & communicated to patient.
Patient will be assessed in PAC. Labs, tests & medications will be addressed.
Labs, tests or reports requested from PAC appointment will be reviewed. PNC to follow up with patient if results received after PAC appt. Consultation with anesthesiologist as required.
Notify PAC Manager
PAC appointment NOT required
Surgeon submits all bloodwork, reports and tests prior to surgical date.
Directions for medications not addressed by the surgeon will be communicated to the patient by Registered Nurse.
Patient arrives to hospital on the day of surgery having taken the correct medications. All required labs, tests, reports and consults complete, reviewed and on the patient’s chart.
Figure 1. PAC Patient Pathway. Reprinted with permission by Victoria General Hospital. This figure is available in color online at www.jopan.org.
Building Partnerships Although the core group of staff consisted of anesthesia providers, perioperative nurse clinicians, general duty registered nurses, and clerical staff, the underlying premise of the team was that it had to be interdisciplinary in nature. Thus, striving to build partnerships throughout the facility and community was, and remains, a primary goal for best patient care.
On moving to the new physical space, communication was distributed in writing and verbally to all surgeons and their office staff indicating the PAC’s new contacts and their roles, new processes, and a now mandatory ‘‘2-week rule.’’ We also invited surgeons’ office staff to the site to establish positive relationships, clarify the new processes, explain the rationale behind PAC’s required needs, and provide a tour of the site’s surgical areas so that there was a visual
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Name:_______________________________________
OR Date:________________________
PART ONE:
Date Change:_____________________
Please check off once complete. Booking Request
Consent
Questionnaire
History & Physical
CONSULTATION ONLY
Incomplete: Office Faxed _____________________________________
Date Complete: ______________________ SURGEON: _________________________________ PART TWO:
SDA
Assessed for PAC Please date when completed (mm/dd).
Meds
Noted in BOOK Periop Blood Conservation
___________________ Booking card copy provided to slating OR time booked by slating and confirmation sent to surgeon (by slating) _____________________ Booking card received from SLATING with “SLATED” stamped Date & Time of PAC Appointment: ___________________________ Date & Time of Assessment Appt: ____________________________
Date & Time Pt informed of Appt:______________________________Initals:__________
PART THREE: PAC Appointment attended
Rebooked:__________________________
Assessment Appointment attended
Rebooked:__________________________
Labs Complete and on chart
Waiting for:_________________________
Comments:______________________________________________________________ _______________________________________________________________________ Cancelled by patient/office Chart to Preop Area
Postponed Medical Concerns/pending consult Date:____________________________
Figure 2. Preoperative Pathway Checklist. Reprinted with permission by Victoria General Hospital.
appreciation of the environment. These meetings were very well received and proved to be beneficial on many levels. The new PAC is now conveniently located next to an outpatient cardiology clinic. This is potentially beneficial in the event that a surgical patient requires a cardiology consult preoperatively. An in-
formal partnership exists whereby the cardiology clinic provides rapid access cardiology appointments for PAC patients if urgently necessary. This provides anesthesia providers with important information for safe patient management and prevents delays in surgical procedures. Results are also communicated to primary care physicians for continuity of care.
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For surgical patients experiencing moderate to severe anemia or at risk for transfusion, referrals are submitted to the perioperative blood conservation unit. This is an optimization resource at a neighboring hospital within the region. These patients have a hematologist, and/or nurse review their blood work and offer treatment (oral or parenteral iron) and provide recommendations to best manage their hematological needs. The pharmacy department also has been instrumental in elevating the quality of care delivered in the PAC. Recently, the pharmacy manager collaborated with the perioperative nurse clinician and site medical director for anesthesiology in creating a new protocol for thromboprophylaxis determined by patient risk and based on best practice guidelines.19 This protocol, now implemented in the PAC, has been circulated to other programs, sites, and regions to promote preoperative enhancement of postoperative outcomes. Overall, the process changes that have occurred in the PAC have been successful. Processes have been disseminated throughout the regional surgery program in the effort to share our success with other facilities and improve patients’ access to surgical care. The director of surgery was invited to participate at another site’s LEAN initiative to improve its PAC; other sites regularly send representatives to tour our PAC and ask questions of the staff; regional requests to outline our specific processes, access forms, and understand the manner in which consequences occur for violators of the ‘‘2-week rule’’ have been willingly provided. Reinforcing the Boundaries The historical goal in PAC had been to ensure that all preoperative patient documentation (patient questionnaire, history and physical, and booking request) arrived 2 weeks before the scheduled surgery to ensure that enough time was allocated to screen the patients’ information. Incomplete information was problematic, as it prevented timely screening of patient charts to determine whether a PAC visit was necessary for further assessment, education, laboratory, or diagnostic testing. Before the PAC move, this ‘‘2-week rule’’ was not followed by all surgeons, and there were no con-
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sistent consequences in place to deter this lackadaisical practice. In the past, late charts were never refused because they were late, but this practice led to scrambling to accommodate essential preoperative patient appointments, excessive overtime, and burnout of staff. If one of these last-minute patients were assessed in clinic as unsafe to proceed with surgery, the insufficient time necessary to substitute another patient onto the slate further led to poor use of surgical resources. A decision was made by the surgical leadership team that the ‘‘2-week rule’’ was essential in ensuring safe patient care and responsible use of the system’s resources. A commitment was made that if a surgeon did not comply with the 2-week rule for planned elective surgical procedures, a penalty of one lost surgical slate the following month would occur. The monitoring of this fell to the director of surgery, and the communication of the surgeon’s lost slate was given in writing by the site medical director of surgery, supported by the site medical director of anesthesia. Occasionally, exceptions to the ‘‘2-week’’ rule are made to accommodate special circumstances, such as urgent cancer cases or backfilling of time for cases that were canceled by PAC. It was important to ensure that in enforcing this decision, no blame be allowed to fall on the PAC staff. Clerks and nurses needed to maintain healthy working relationships with surgeons and their office staff. It had to be clearly evident that the penalty of a surgeons’ lost slate was decided on and enforced by the surgical leadership team, not the staff. Also, consistency in enforcement was essential to ensure that there was no reversion to past patterns. This proved to be highly effective. In the past two years, only one surgeon (of 42 who practice at the site), has received a letter to address late paperwork resulting in a loss of scheduled operating room time.
Findings Staffing and process changes began in 2008, followed by the physical move to the new PAC space in March 2009. A 3-year analysis was conducted comparing surgery procedures and PAC volumes from 2007 to 2010. It was hypothesized that the number of patients canceled on the day of surgery
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The data demonstrated that the average volume of elective surgical procedures performed at the site increased by 4% (n 5 319) overall within the 3-year period (Fig 3). Within the PAC, preoperative nursing assessment/teaching visits increased comparatively by 3% (n 5 18), whereas preoperative anesthesia assessment visits increased by 51% (n 5 1,439) over the same time frame (Fig 4). This dramatic increase is likely because of multiple coinciding factors. With the increase in physical space, improved process changes, developed screening guidelines, achieved consensus among anesthesia providers, and consistency in screening by the perioperative nurse clinician, there was a natural and expected increase in PAC patient volumes. However, the degree of increase was likely because of some influences beyond the site’s control.
8000
# o f P ro c e d u r e s
7900 7800 7700 7600 7500 7400 7300 7200 7100
2007-8
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Figure 3. Number of procedures. This figure is available in color online at www.jopan.org.
2500 2000 1500 1000 500 0
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Figure 4. Number of PAC appointments by year. PAC, preoperative assessment clinic. This figure is available in color online at www.jopan.org.
to body mass index .40.). Also, in 2008 and 2009, the region mandated that 20 extra slates be added to the traditional summer slowdown period. Thus, more elective patients required screening through PAC. Furthermore, to meet the safety needs of our unique patient population, a six-bed postoperative obstructive sleep apnea–monitored room on the inpatient surgery unit was constructed. It is plausible that more surgeons have become aware of these changes and, while being reassured by our commitment to high quality, specialized obstructive sleep apneic and preoperative care have also inadvertently brought more high-risk elective patients, contributing to increased PAC volumes. Through electronic data collection and verification through manual chart audits, the cancellation rate 2007-2008 2008-2009 2009-2010 Number of Procedures Cancelled
At the same time the internal PAC changes were occurring at the site, the regional surgery program embarked on consolidation of surgical services— eliminating 22 orthopedic slates from the site and replacing them with ear, nose, and throat (ENT) procedures. With approximately two to three orthopedic procedures now replaced by six to eight ENT procedures within the same allocated time per slate, this specialty change spawned an increase in elective surgical volumes. Simultaneously, the region developed new obstructive sleep apnea guidelines that required all patients with a body mass index .35 to have a PAC visit. (This indication has since been relaxed
3000 # of PAC appointments
because of preexisting documented medical reasons would be dramatically decreased because of the additional resources and the ability to optimize patients before their procedure.
20 18 16 14 12 10 8 6 4 2 0
Figure 5. Cancellations on the day of surgery because of medical reasons. This figure is available in color online at www.jopan.org.
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on the day of surgery because of medical reasons overall remained relatively stable when comparing 2007, 2008, and 2009 data. In both 2008 and 2009, 0.4% of all operative procedures were canceled specifically because of medical reasons. However, if these medical reasons are broken down between preexisting medical conditions that can be managed through PAC, and unforeseen medical procedures beyond one’s control, an interesting trend is observed (Fig 5). Cancellations because of unforeseen medical reasons include unanticipated acute illness (ie, respiratory tract infections, flu), failing to follow medical directions, previous undisclosed medical problems, and other (examples in these circumstances included undiagnosed pregnancy, infected animal bite). These are random factors that timely documentation and PAC assessments may not be able to anticipate, control, or optimize. Thus, the statistics demonstrate equal variability. However, further review of the data shows a fascinating trend when comparing the number of cases canceled on the day of surgery for documented preexisting health conditions (Figs 6 and 7). In this analysis, 2007-2008 showed that 56% of surgeries cancelled for medical reasons were based on documented preexisting medical conditions and 41% of these potentially could have been prevented with proper assessment and management through the PAC. In 2008-2009, 24% of surgeries cancelled for medical reasons were based on documented preexisting medical conditions, 6% of these possibly could have been avoided with a PAC visit. In 2009-2010, 31% of surgeries cancelled for medical reasons were based on documented preexisting medical conditions, 9% could 60 50 40 % 30 20
10 0 2007-8
2008-9
2009-10
Year
Figure 6. Percentage of cancelled procedures on the day of surgery because of documented medical condition. This figure is available in color online at www.jopan.org.
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14 12 10 8 6 4 2 0
2007-8
2008-9
2009-10
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Figure 7. Number of patients cancelled, which may have been prevented with PAC appointments. This figure is available in color online at www.jopan.org.
have been avoided with a PAC visit. These numbers demonstrate that as our PAC processes changed, our ability to reduce the number of patients cancelled on the day of surgery improved.
Discussion Although the percentage of overall patient cancellation rates for medical reasons did not change dramatically throughout the 3-year analysis, cancellations specifically because of preexisting documented medical conditions did decrease significantly from 2007-2008 to 2008-2009 and 2009-2010. Likely, this would not have been the case should the previous space limitations, suboptimal staffing baselines, and unrefined processes have remained constant. Cancellations on the day of surgery for medical reasons (not preexisting, not documented) are often found to be because of reasons beyond the PAC’s control, such as flu or fever. Although overall cancellation rates remain unchanged, the processes, quality, access, and timeliness of preoperative assessments have improved as evidenced by the 52% increase in PAC assessments. It is important to note that circumstances occurred throughout this analyzed time frame that changed the population of patients seen through the surgical program, including an increase in elective surgical cases and decrease in emergency surgeries secondary to regional consolidation and the implementation of an obstructive sleep apnea guideline. Given the fragile state of the PAC previously, these changes could have been hugely problematic. However, improved processes and timely assessments have enabled the PAC to not only improve the preoperative care provided but also successfully embrace regional changes. By improving the
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PAC processes, and therefore the ability to assess those patients at risk, there is an increased feeling of assurance that the majority of patients presenting on the day of their surgery have had their health optimized to the best of the team’s ability. In addition to improved patient care, staff morale in the PAC has improved because of the enhanced environment and improved organizational changes. Overtime hours have decreased, sick time has improved, patient charts no longer get misfiled or lost, frustration because of late arrival of paperwork and incomplete laboratory work still exists, but with valid reasons for delays, this problem is significantly minimized. Also, consistently staffing with the same individuals has demonstrated a level of expertise not previously seen when different nurses rotated through the PAC and several segregated clerks shared duties.
Lessons Learned It takes teamwork to make change happen. There were many individuals who toiled toward creating this improved clinic: facilities management, capital planning, the regional surgery program, nursing and clerical staff, physicians, and senior administrators were all essential. Our talented PAC manager demonstrated the true meaning of vision, creativeness, and perseverance. Ultimately, it was the combined commitment from the above people that allowed our processes to positively change how we do our business. Sometimes the change process can be painful. Enforcing the 2-week rule was extremely difficult at the beginning, causing anger among surgeons, frustration for their office staff, and for a time, unused surgical slates that took added effort for our slating clerks to backfill. With the strong support of both the site medical directors of surgery and anesthesia and understanding that short-term pain would result in long-term gain, we persevered and have now seen marked improvement in the ‘‘2-week rule.’’ Never lose sight of the vision. There were times before the PAC move when staff were at their breaking points: overburdened, under resourced, disorganized, and frustrated. It was sometimes difficult on a daily basis to stay positive and believe that the
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change, which took years of planning and negotiating, would finally arrive. Even when it did, there was not instant perfection: some of the processes needed to evolve and be redefined, roles needed to be clarified, and relationships were strained. The leaders of the PAC were essential in guiding the team toward success: diligently working through the processes and communication issues, brainstorming together to challenge the status quo, and modeling the way toward a positive end. Always strive for excellence. Although we have experienced a dramatic improvement in our PAC processes and staff now express more happiness than frustration, we continue to relentlessly explore ways to improve. Currently, we are looking at ways to condense some of the paperwork so that it is not as onerous, but still pertinent. We are exploring ways to improve communication and education for preoperative patients through Internet access and DVD demonstrations. The beginning of telehealth conferences will enable outof-town patients to no longer travel far distances to get access to PAC services. We are constantly reevaluating criteria as to which patients require PAC visits, what they specifically need from the visit, and how we can provide the best possible service to meet individual, family, and group needs within our preoperative setting. We are working toward establishing further protocols to better prioritize patients’ physical risk versus complexity and invasiveness of the surgical procedure. The province and regional surgery team have worked with the site to establish an electronic process of booking surgical cases and created a specialized grid outlining required laboratory work before surgery based on procedures and patient risk. Increased electronic communication between offices, hospital sites, and departments within the regional setting and facility will continue to improve processes. Again, these efforts have required extensive collaboration between multiple stakeholders and are indeed a testament to the combined desire to improve processes, patient access to care, and partnerships among health care professionals. Further assessment of our perioperative processes will be enhanced through patient satisfaction questionnaires, ongoing evaluation of cancellation rates, unforeseen admissions, and
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length of stay statistics. Also, continually pushing the boundaries to challenge traditional processes, responsibly balancing the resources and technology available to provide improved clinical care, and exploring new ways of practice in our ever-changing environment will continue to benefit surgical patients and the hospital staff who serve them.
Conclusion Following this great transition, the biggest hurdles related to the physical PAC move, staffing, and
process changes are, for the most part, behind us. There are areas that we will continue to strive toward improving, related to evaluating the education and assessment needs of our patient population and responsibly enhancing the work environment for staff. Established and more efficient processes will need to be revisited and solidified to prevent reversion back to past practices. In summary, the collaborative efforts among our dedicated team have demonstrated that the goal of providing best patient care safely and efficiently is a challenging but achievable endeavor within our PAC. It is a goal we will constantly strive toward.
References 1. Merchant R, Bosenberg C, Brown K, et al. Guidelines to the practice of anesthesia: Revised edition 2011. Can J Anaesth. 2010;58:74-107. 2. Lingnau W, Strohmenger HU. Responsibility of the anaesthesiologist in the preoperative risk evaluation. Anaesthesist. 2002;51:704-715. 3. Muravachick S. Preoperative assessment of the elderly patient. Anesthesiol Clin North America. 2001;8:71-89. 4. Ferschl MB, Tung A, Sweitzer B, Huo D, Glick DB. Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology. 2005;103:855-859. 5. Boothe P, Finegan BA. Changing the admission process for elective surgery: An economic analysis. Can J Anaesth. 1995; 42:391-394. 6. Conway JB, Goldberg J, Chung F. Preadmission anaesthesia consultation clinic. Can J Anaesth. 1992;39:1051-1057. 7. Livingstone J, Harvey M, Kitchen N, Shah N, Westell C. Role of pre-admission clinics in a general surgical unit: A six month audit. Ann R Coll Surg Engl. 1993;75:211-212. 8. Schmiesing CA, Brodsky JB. The preoperative anesthesia evaluation. Thorac Surg Clin. 2005;15:305-315. 9. Singh G, Agha R, Roberts D. Cancellations in day-case ENT surgery. Ambul Surg. 2005;12:57-60. 10. Edward GM, Razzaq S, deRoode A, et al. Patient flow in the preoperative assessment clinic. Eur J Anaesthesiol. 2008; 25:280-286. 11. Caljouw MAA, van Beuzekom M, Boer F. Patient’s satisfaction with perioperative care: Development, validation, and
application of a questionnaire. Br J Anaesth. 2008;100: 637-644. 642. 12. Matthey P, Finucan BT, Finegan BA. The attitude of the general public towards preoperative assessment and risks associated with general anesthesia. Can J Anaesth. 2001;48: 333-339. 13. Fraczyk L, Godfrey H. Perceived levels of satisfaction with the preoperative assessment service experienced by patients undergoing general anaesthesia in a day surgery setting. J Clin Nurs. 2010;19:2849-2859. 14. Harnett MJP, Correll DJ, Hurwitz S, Bader AM, Hepner DL. Improving efficiency and patient satisfaction in a tertiary, teaching hospital preoperative clinic. Anesthesiology. 2009;112: 66-72. 15. Gilmartin J. Day surgery: Patients’ perceptions of a nurseled preadmission clinic. J Clin Nurs. 2004;13:243-250. 16. Casey D, Ormrod G. The effectiveness of nurse-led surgical pre-assessments clinics. Prof Nurse. 2003;18:685-687. 17. Merrill DG, Laur JJ. Management by outcomes: Efficiency and operational success in the ambulatory surgery centre. Anesthesiol Clin. 2010;28:329-351. 18. Mahid SS, Polk HC, Lewis JN, Turina M. Opportunities for improved performance in surgical specialty practice. Ann Surg. 2008;247:380-388. 19. Weitz JI, Hirsh J, Samama MM. New antithrombotic drugs: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines. Ed 8. Chest. 2008;133: 234-256.
PREOPERATIVE ASSESSMENT CLINICS (PACs) facilitate health care practitioners to enhance the delivery of safe care. They provide the opportunity to evaluate a surgical patient’s preoperative risk, optimize health, and plan for perioperative management while ensuring the patient’s individual physical, emotional, social, and cultural needs are met before surgery.1-3 From an administrative perspective, assessment and education of patients Lanette Siragusa, MN, RN, is Director of Programs and Patient Services-Surgery, Anesthesia and Women’s Health; Lorena Thiessen, BN, RN, is a Perioperative Nurse Clinician; Dean Grabowski, BN, RN, is a Perioperative Nurse Clinician; and R. Shawn Young, MD, is a Site Medical Director of Anesthesia, Victoria General Hospital, Winnipeg, Manitoba, Canada. Conflicts of interest: None to report. Address correspondence to Lanette Siragusa, MN, RN, Victoria General Hospital, 2340 Pembina Highway, Winnipeg, Manitoba R3T 2E8, Canada; e-mail address: LanetteSiragusa@ gmail.com or [email protected]. Ó 2011 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 doi:10.1016/j.jopan.2011.05.008
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preoperatively has the potential to increase efficiency of operating room resources in terms of time management, human resource planning, and fiscal accountability.4-7 From a quality perspective, thorough preoperative assessments allow for identification of comorbidities, American Society of Anesthesiologists classification of risk, and optimization of health status, thereby leading to fewer patient cancellations on the day of surgery because of unforeseen unresolved medical issues that can add risk to even the most minor of procedures.8,9 Also the quality of PACs can be assessed through examining logistic performance, quality of medical evaluation, patient satisfaction, and patient flow, as it relates to efficient organization and the need for preoperative testing.10 From a patient’s perspective of health care, quality is not only determined by the outcome of treatment but also by the extent to which patients are supported.11 Preoperative anesthetic assessments provide the opportunity for patients to gain
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knowledge, develop trusting relationships with health care providers, decrease anxieties, and improve satisfaction.11,12 Researchers have demonstrated that patient-focused nursing care is often one of the key components to high-quality preoperative care related to communication of knowledge, empathy, and the ability to decrease patient anxiety.13-16
Purpose Before the implementation of change, the PAC lacked a dedicated space, consistency of staff, and well-defined processes related to screening and patient flow. Two small rooms were dedicated for preoperative assessment. One room was used on a daily basis by one of several general duty nurses for preoperative patient teaching. The second room was shared among a team of anesthesia providers to conduct necessary assessments 2 or 3 days per week. Screening of preoperative charts was assigned to the on-call anesthesia provider who determined which patients required a PAC visit before surgery. The PAC patient-waiting area was shared with the busy crowded day surgery unit, as was the nursing staff. Without having a dedicated clerk, duties for the PAC were shared among the day surgery clerks, slating clerks, and admitting clerks. There was no designated space large enough to house the PAC patients’ charts, so charts were stored in three different offices out of necessity, often becoming misplaced or misfiled. Previous anesthesiology shortages and no consistently assigned nurse to the PAC contributed to ill-defined processes that relied on individuals’ preferred practices rather than consistency. It is important to note that despite obvious flaws in this system, patient care was always of utmost importance to the team, and they worked diligently to do the best job possible within this often-chaotic environment.
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patients who are at an increased risk of a perioperative thromboembolic event, perioperative aspirin management, required laboratory investigations), (3) group consensus and continuity of staffing, (4) relocation to a functional physical environment to improve efficiencies within the surgical program, and (5) resources and development of partnerships with the community of health care providers to coordinate services across the continuum of care.
Methods Growing the Team The first order of business was to staff the PAC appropriately. Originally, three full-time permanent staff were hired to enable consistency among the team. A perioperative nurse clinician (nurse IV) was hired to screen all surgical patients’ charts preoperatively and conduct preoperative evaluation for low to moderate risk surgical patients. Qualifications require that the perioperative nurse clinician (nurse IV) must have a baccalaureate degree and critical care certification combined with relevant experience. One full-time general duty registered nurse (II) was deemed responsible for patient education. Both of these nursing classifications are governed by the same professional body. One clerk was assigned to manage the incoming paperwork, office flow, and patient visits. It was quickly determined that an additional clerk was necessary to manage the intake of all preoperative paperwork; thus another clerk was hired shortly after opening the clinic. High-risk anesthesia–led PACs occur 2-3 days per week now on a consistent basis. Also, the anesthesia providers make themselves available to the perioperative nurse clinician to review charts and consult whenever necessary. Volunteers also are valued members of this team, helping wherever they can within the clinic, greeting, and escorting patients throughout the facility as required.
Design Improving Processes With the above challenges presented, steps were taken to begin building a better PAC. High priority was placed on (1) adequate staff baselines reflective of the volumes of surgical patients, (2) development of improved well-defined processes based on best practice guidelines (eg, obstructive sleep apnea, bridging protocol to identify and manage
The LEAN, Six Sigma, and Toyota approach in reducing waste and eliciting best practice through a focus on effective and efficient operations makes sense theoretically. However, the reality of arriving at consensus of opinions and attitudes among health care professionals can prove to be more
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challenging.17,18 We did not have the time, financial resources, or human resources required to orchestrate a traditional LEAN approach to change. However, the opportunity and team’s strong drive and desire propelled the instigation of improvements. The homogeneity of this small clinic allowed us to prioritize standardized processes based on patient need. Traditionally, a surgeon’s office would send patient documentation by a variety of methods (fax, courier, or hand delivered) to the slating department before surgery. There was no enforced time expectation of when this information should arrive, and as a result, patient documentation might arrive months in advance or the day before surgery. It was common for information to be missing (ie, an incomplete history and physical, absent laboratory work, or patient questionnaire). Thus, a ‘‘2-week rule’’ was implemented as the minimum time before surgery that patient documentation must be received. All patient information was redirected from the slating (scheduling) department to the PAC, and no procedure would be slated until all necessary patient information was received and assessed by the perioperative nurse clinician. This was a significant change in the work culture. Instead of relying on a task-focused environment, where the slating clerks’ primary goal was to schedule a procedure, all patient documentation is now received in the PAC for assessment. This was a shift to safer patient-focused care (Fig 1). Surgeons’ offices are now required to ensure that all patient documentation is clearly identified and to provide a complete list of patients assigned to the designated surgical slate. A logbook was created by the PAC clerk to keep track of paperwork that has been submitted, noting incomplete or omitted information, correlated by the proposed date of surgery. A newly established filing system keeps all patient charts in chronological order by date of surgery. Charts, which were once all kept in manila folders, are now color coded based on surgical specialty for easy identification. A perioperative pathway checklist (Fig 2) was created as an organizational tool to track the flow of the patient’s chart and related activities (ie, incomplete documentation,
patient PAC visit booked, awaiting laboratory work). This standardization tool has proven to be a key element for quality control. Patient charts are kept in PAC until 2 days before surgery at which time they are delivered to the preoperative unit in preparation for the patients’ arrival. Friday is designated as a ‘‘catch up’’ office day when charting, phone calls, and urgent visits can be scheduled if necessary. Group Consensus Because discrepancies occurred due to individual differences in anesthesia providers’ practices, new forms were created to ensure standardization of the screening process. Consensus among anesthesia providers was achieved to determine which patients require a PAC visit, considering the invasiveness and complexity of the surgical procedure planned and patients’ comorbidities. Incorporating evidence-based guidelines, the PAC anesthesia providers also arrived at a consensus of acceptable directives for patients to take or hold preoperative medications and alternative therapies. Patients now take home a copy of their individualized medication instructions, while the original is left on the patient chart for reference purposes. An anticoagulation bridging protocol was established for surgical patients at varying risk for thromboembolism and managed through the PAC. Establishing a Suitable Physical Space It was through years of sustained persistence and the unwavering vision of a better way to manage the PAC, which perpetuated the long-awaited physical move to a new and improved space. This move allowed for double the number of clinic rooms (four), a designated PAC patient-waiting area, office space for clerical staff, and a staff area where the PAC team could have their breaks, team meetings, and education sessions. Staff were encouraged to participate in the creation of the space that would ultimately belong to them. They picked out their own paint colors, collaborated among each other to determine their new designated office spaces, hung their own framed photographic artwork, and rearranged office furniture to best suit their needs. The result was a warm, inviting environment for this fastpaced clinic.
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Preoperative Assessment Clinic Patient Pathway Surgeon responsible to submit all required preoperative patient documentation two weeks prior to surgical date, Relevant bloodwork, EKGs and CXRs are required prior to slating. Surgeon directs the patient on continuation or cessation of vitamins, herbs, oral contraceptives and Hormone Replacement Therapy.
Perioperative Nurse Clinican (PNC) assesses charts (preferably with lab results) to determine need for PAC appointment. Medications not addressed by the surgeon will be evaluated. Incomplete charts will not be assessed
PAC appointment required
PAC Clerk phones patient to notify of upcoming appointment. High Risk: Anesthesiologist or Low- Moderate Risk: PNC Preoperative Patient Teaching: Registered Nurse
Additional reports will be requested by the PNC & clerk as necessary. Medications not addressed by the surgeon will be addressed by a member of the PAC Team & communicated to patient.
Patient will be assessed in PAC. Labs, tests & medications will be addressed.
Labs, tests or reports requested from PAC appointment will be reviewed. PNC to follow up with patient if results received after PAC appt. Consultation with anesthesiologist as required.
Notify PAC Manager
PAC appointment NOT required
Surgeon submits all bloodwork, reports and tests prior to surgical date.
Directions for medications not addressed by the surgeon will be communicated to the patient by Registered Nurse.
Patient arrives to hospital on the day of surgery having taken the correct medications. All required labs, tests, reports and consults complete, reviewed and on the patient’s chart.
Figure 1. PAC Patient Pathway. Reprinted with permission by Victoria General Hospital. This figure is available in color online at www.jopan.org.
Building Partnerships Although the core group of staff consisted of anesthesia providers, perioperative nurse clinicians, general duty registered nurses, and clerical staff, the underlying premise of the team was that it had to be interdisciplinary in nature. Thus, striving to build partnerships throughout the facility and community was, and remains, a primary goal for best patient care.
On moving to the new physical space, communication was distributed in writing and verbally to all surgeons and their office staff indicating the PAC’s new contacts and their roles, new processes, and a now mandatory ‘‘2-week rule.’’ We also invited surgeons’ office staff to the site to establish positive relationships, clarify the new processes, explain the rationale behind PAC’s required needs, and provide a tour of the site’s surgical areas so that there was a visual
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Name:_______________________________________
OR Date:________________________
PART ONE:
Date Change:_____________________
Please check off once complete. Booking Request
Consent
Questionnaire
History & Physical
CONSULTATION ONLY
Incomplete: Office Faxed _____________________________________
Date Complete: ______________________ SURGEON: _________________________________ PART TWO:
SDA
Assessed for PAC Please date when completed (mm/dd).
Meds
Noted in BOOK Periop Blood Conservation
___________________ Booking card copy provided to slating OR time booked by slating and confirmation sent to surgeon (by slating) _____________________ Booking card received from SLATING with “SLATED” stamped Date & Time of PAC Appointment: ___________________________ Date & Time of Assessment Appt: ____________________________
Date & Time Pt informed of Appt:______________________________Initals:__________
PART THREE: PAC Appointment attended
Rebooked:__________________________
Assessment Appointment attended
Rebooked:__________________________
Labs Complete and on chart
Waiting for:_________________________
Comments:______________________________________________________________ _______________________________________________________________________ Cancelled by patient/office Chart to Preop Area
Postponed Medical Concerns/pending consult Date:____________________________
Figure 2. Preoperative Pathway Checklist. Reprinted with permission by Victoria General Hospital.
appreciation of the environment. These meetings were very well received and proved to be beneficial on many levels. The new PAC is now conveniently located next to an outpatient cardiology clinic. This is potentially beneficial in the event that a surgical patient requires a cardiology consult preoperatively. An in-
formal partnership exists whereby the cardiology clinic provides rapid access cardiology appointments for PAC patients if urgently necessary. This provides anesthesia providers with important information for safe patient management and prevents delays in surgical procedures. Results are also communicated to primary care physicians for continuity of care.
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For surgical patients experiencing moderate to severe anemia or at risk for transfusion, referrals are submitted to the perioperative blood conservation unit. This is an optimization resource at a neighboring hospital within the region. These patients have a hematologist, and/or nurse review their blood work and offer treatment (oral or parenteral iron) and provide recommendations to best manage their hematological needs. The pharmacy department also has been instrumental in elevating the quality of care delivered in the PAC. Recently, the pharmacy manager collaborated with the perioperative nurse clinician and site medical director for anesthesiology in creating a new protocol for thromboprophylaxis determined by patient risk and based on best practice guidelines.19 This protocol, now implemented in the PAC, has been circulated to other programs, sites, and regions to promote preoperative enhancement of postoperative outcomes. Overall, the process changes that have occurred in the PAC have been successful. Processes have been disseminated throughout the regional surgery program in the effort to share our success with other facilities and improve patients’ access to surgical care. The director of surgery was invited to participate at another site’s LEAN initiative to improve its PAC; other sites regularly send representatives to tour our PAC and ask questions of the staff; regional requests to outline our specific processes, access forms, and understand the manner in which consequences occur for violators of the ‘‘2-week rule’’ have been willingly provided. Reinforcing the Boundaries The historical goal in PAC had been to ensure that all preoperative patient documentation (patient questionnaire, history and physical, and booking request) arrived 2 weeks before the scheduled surgery to ensure that enough time was allocated to screen the patients’ information. Incomplete information was problematic, as it prevented timely screening of patient charts to determine whether a PAC visit was necessary for further assessment, education, laboratory, or diagnostic testing. Before the PAC move, this ‘‘2-week rule’’ was not followed by all surgeons, and there were no con-
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sistent consequences in place to deter this lackadaisical practice. In the past, late charts were never refused because they were late, but this practice led to scrambling to accommodate essential preoperative patient appointments, excessive overtime, and burnout of staff. If one of these last-minute patients were assessed in clinic as unsafe to proceed with surgery, the insufficient time necessary to substitute another patient onto the slate further led to poor use of surgical resources. A decision was made by the surgical leadership team that the ‘‘2-week rule’’ was essential in ensuring safe patient care and responsible use of the system’s resources. A commitment was made that if a surgeon did not comply with the 2-week rule for planned elective surgical procedures, a penalty of one lost surgical slate the following month would occur. The monitoring of this fell to the director of surgery, and the communication of the surgeon’s lost slate was given in writing by the site medical director of surgery, supported by the site medical director of anesthesia. Occasionally, exceptions to the ‘‘2-week’’ rule are made to accommodate special circumstances, such as urgent cancer cases or backfilling of time for cases that were canceled by PAC. It was important to ensure that in enforcing this decision, no blame be allowed to fall on the PAC staff. Clerks and nurses needed to maintain healthy working relationships with surgeons and their office staff. It had to be clearly evident that the penalty of a surgeons’ lost slate was decided on and enforced by the surgical leadership team, not the staff. Also, consistency in enforcement was essential to ensure that there was no reversion to past patterns. This proved to be highly effective. In the past two years, only one surgeon (of 42 who practice at the site), has received a letter to address late paperwork resulting in a loss of scheduled operating room time.
Findings Staffing and process changes began in 2008, followed by the physical move to the new PAC space in March 2009. A 3-year analysis was conducted comparing surgery procedures and PAC volumes from 2007 to 2010. It was hypothesized that the number of patients canceled on the day of surgery
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The data demonstrated that the average volume of elective surgical procedures performed at the site increased by 4% (n 5 319) overall within the 3-year period (Fig 3). Within the PAC, preoperative nursing assessment/teaching visits increased comparatively by 3% (n 5 18), whereas preoperative anesthesia assessment visits increased by 51% (n 5 1,439) over the same time frame (Fig 4). This dramatic increase is likely because of multiple coinciding factors. With the increase in physical space, improved process changes, developed screening guidelines, achieved consensus among anesthesia providers, and consistency in screening by the perioperative nurse clinician, there was a natural and expected increase in PAC patient volumes. However, the degree of increase was likely because of some influences beyond the site’s control.
8000
# o f P ro c e d u r e s
7900 7800 7700 7600 7500 7400 7300 7200 7100
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Figure 3. Number of procedures. This figure is available in color online at www.jopan.org.
2500 2000 1500 1000 500 0
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Figure 4. Number of PAC appointments by year. PAC, preoperative assessment clinic. This figure is available in color online at www.jopan.org.
to body mass index .40.). Also, in 2008 and 2009, the region mandated that 20 extra slates be added to the traditional summer slowdown period. Thus, more elective patients required screening through PAC. Furthermore, to meet the safety needs of our unique patient population, a six-bed postoperative obstructive sleep apnea–monitored room on the inpatient surgery unit was constructed. It is plausible that more surgeons have become aware of these changes and, while being reassured by our commitment to high quality, specialized obstructive sleep apneic and preoperative care have also inadvertently brought more high-risk elective patients, contributing to increased PAC volumes. Through electronic data collection and verification through manual chart audits, the cancellation rate 2007-2008 2008-2009 2009-2010 Number of Procedures Cancelled
At the same time the internal PAC changes were occurring at the site, the regional surgery program embarked on consolidation of surgical services— eliminating 22 orthopedic slates from the site and replacing them with ear, nose, and throat (ENT) procedures. With approximately two to three orthopedic procedures now replaced by six to eight ENT procedures within the same allocated time per slate, this specialty change spawned an increase in elective surgical volumes. Simultaneously, the region developed new obstructive sleep apnea guidelines that required all patients with a body mass index .35 to have a PAC visit. (This indication has since been relaxed
3000 # of PAC appointments
because of preexisting documented medical reasons would be dramatically decreased because of the additional resources and the ability to optimize patients before their procedure.
20 18 16 14 12 10 8 6 4 2 0
Figure 5. Cancellations on the day of surgery because of medical reasons. This figure is available in color online at www.jopan.org.
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on the day of surgery because of medical reasons overall remained relatively stable when comparing 2007, 2008, and 2009 data. In both 2008 and 2009, 0.4% of all operative procedures were canceled specifically because of medical reasons. However, if these medical reasons are broken down between preexisting medical conditions that can be managed through PAC, and unforeseen medical procedures beyond one’s control, an interesting trend is observed (Fig 5). Cancellations because of unforeseen medical reasons include unanticipated acute illness (ie, respiratory tract infections, flu), failing to follow medical directions, previous undisclosed medical problems, and other (examples in these circumstances included undiagnosed pregnancy, infected animal bite). These are random factors that timely documentation and PAC assessments may not be able to anticipate, control, or optimize. Thus, the statistics demonstrate equal variability. However, further review of the data shows a fascinating trend when comparing the number of cases canceled on the day of surgery for documented preexisting health conditions (Figs 6 and 7). In this analysis, 2007-2008 showed that 56% of surgeries cancelled for medical reasons were based on documented preexisting medical conditions and 41% of these potentially could have been prevented with proper assessment and management through the PAC. In 2008-2009, 24% of surgeries cancelled for medical reasons were based on documented preexisting medical conditions, 6% of these possibly could have been avoided with a PAC visit. In 2009-2010, 31% of surgeries cancelled for medical reasons were based on documented preexisting medical conditions, 9% could 60 50 40 % 30 20
10 0 2007-8
2008-9
2009-10
Year
Figure 6. Percentage of cancelled procedures on the day of surgery because of documented medical condition. This figure is available in color online at www.jopan.org.
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14 12 10 8 6 4 2 0
2007-8
2008-9
2009-10
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Figure 7. Number of patients cancelled, which may have been prevented with PAC appointments. This figure is available in color online at www.jopan.org.
have been avoided with a PAC visit. These numbers demonstrate that as our PAC processes changed, our ability to reduce the number of patients cancelled on the day of surgery improved.
Discussion Although the percentage of overall patient cancellation rates for medical reasons did not change dramatically throughout the 3-year analysis, cancellations specifically because of preexisting documented medical conditions did decrease significantly from 2007-2008 to 2008-2009 and 2009-2010. Likely, this would not have been the case should the previous space limitations, suboptimal staffing baselines, and unrefined processes have remained constant. Cancellations on the day of surgery for medical reasons (not preexisting, not documented) are often found to be because of reasons beyond the PAC’s control, such as flu or fever. Although overall cancellation rates remain unchanged, the processes, quality, access, and timeliness of preoperative assessments have improved as evidenced by the 52% increase in PAC assessments. It is important to note that circumstances occurred throughout this analyzed time frame that changed the population of patients seen through the surgical program, including an increase in elective surgical cases and decrease in emergency surgeries secondary to regional consolidation and the implementation of an obstructive sleep apnea guideline. Given the fragile state of the PAC previously, these changes could have been hugely problematic. However, improved processes and timely assessments have enabled the PAC to not only improve the preoperative care provided but also successfully embrace regional changes. By improving the
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PAC processes, and therefore the ability to assess those patients at risk, there is an increased feeling of assurance that the majority of patients presenting on the day of their surgery have had their health optimized to the best of the team’s ability. In addition to improved patient care, staff morale in the PAC has improved because of the enhanced environment and improved organizational changes. Overtime hours have decreased, sick time has improved, patient charts no longer get misfiled or lost, frustration because of late arrival of paperwork and incomplete laboratory work still exists, but with valid reasons for delays, this problem is significantly minimized. Also, consistently staffing with the same individuals has demonstrated a level of expertise not previously seen when different nurses rotated through the PAC and several segregated clerks shared duties.
Lessons Learned It takes teamwork to make change happen. There were many individuals who toiled toward creating this improved clinic: facilities management, capital planning, the regional surgery program, nursing and clerical staff, physicians, and senior administrators were all essential. Our talented PAC manager demonstrated the true meaning of vision, creativeness, and perseverance. Ultimately, it was the combined commitment from the above people that allowed our processes to positively change how we do our business. Sometimes the change process can be painful. Enforcing the 2-week rule was extremely difficult at the beginning, causing anger among surgeons, frustration for their office staff, and for a time, unused surgical slates that took added effort for our slating clerks to backfill. With the strong support of both the site medical directors of surgery and anesthesia and understanding that short-term pain would result in long-term gain, we persevered and have now seen marked improvement in the ‘‘2-week rule.’’ Never lose sight of the vision. There were times before the PAC move when staff were at their breaking points: overburdened, under resourced, disorganized, and frustrated. It was sometimes difficult on a daily basis to stay positive and believe that the
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change, which took years of planning and negotiating, would finally arrive. Even when it did, there was not instant perfection: some of the processes needed to evolve and be redefined, roles needed to be clarified, and relationships were strained. The leaders of the PAC were essential in guiding the team toward success: diligently working through the processes and communication issues, brainstorming together to challenge the status quo, and modeling the way toward a positive end. Always strive for excellence. Although we have experienced a dramatic improvement in our PAC processes and staff now express more happiness than frustration, we continue to relentlessly explore ways to improve. Currently, we are looking at ways to condense some of the paperwork so that it is not as onerous, but still pertinent. We are exploring ways to improve communication and education for preoperative patients through Internet access and DVD demonstrations. The beginning of telehealth conferences will enable outof-town patients to no longer travel far distances to get access to PAC services. We are constantly reevaluating criteria as to which patients require PAC visits, what they specifically need from the visit, and how we can provide the best possible service to meet individual, family, and group needs within our preoperative setting. We are working toward establishing further protocols to better prioritize patients’ physical risk versus complexity and invasiveness of the surgical procedure. The province and regional surgery team have worked with the site to establish an electronic process of booking surgical cases and created a specialized grid outlining required laboratory work before surgery based on procedures and patient risk. Increased electronic communication between offices, hospital sites, and departments within the regional setting and facility will continue to improve processes. Again, these efforts have required extensive collaboration between multiple stakeholders and are indeed a testament to the combined desire to improve processes, patient access to care, and partnerships among health care professionals. Further assessment of our perioperative processes will be enhanced through patient satisfaction questionnaires, ongoing evaluation of cancellation rates, unforeseen admissions, and
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length of stay statistics. Also, continually pushing the boundaries to challenge traditional processes, responsibly balancing the resources and technology available to provide improved clinical care, and exploring new ways of practice in our ever-changing environment will continue to benefit surgical patients and the hospital staff who serve them.
Conclusion Following this great transition, the biggest hurdles related to the physical PAC move, staffing, and
process changes are, for the most part, behind us. There are areas that we will continue to strive toward improving, related to evaluating the education and assessment needs of our patient population and responsibly enhancing the work environment for staff. Established and more efficient processes will need to be revisited and solidified to prevent reversion back to past practices. In summary, the collaborative efforts among our dedicated team have demonstrated that the goal of providing best patient care safely and efficiently is a challenging but achievable endeavor within our PAC. It is a goal we will constantly strive toward.
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application of a questionnaire. Br J Anaesth. 2008;100: 637-644. 642. 12. Matthey P, Finucan BT, Finegan BA. The attitude of the general public towards preoperative assessment and risks associated with general anesthesia. Can J Anaesth. 2001;48: 333-339. 13. Fraczyk L, Godfrey H. Perceived levels of satisfaction with the preoperative assessment service experienced by patients undergoing general anaesthesia in a day surgery setting. J Clin Nurs. 2010;19:2849-2859. 14. Harnett MJP, Correll DJ, Hurwitz S, Bader AM, Hepner DL. Improving efficiency and patient satisfaction in a tertiary, teaching hospital preoperative clinic. Anesthesiology. 2009;112: 66-72. 15. Gilmartin J. Day surgery: Patients’ perceptions of a nurseled preadmission clinic. J Clin Nurs. 2004;13:243-250. 16. Casey D, Ormrod G. The effectiveness of nurse-led surgical pre-assessments clinics. Prof Nurse. 2003;18:685-687. 17. Merrill DG, Laur JJ. Management by outcomes: Efficiency and operational success in the ambulatory surgery centre. Anesthesiol Clin. 2010;28:329-351. 18. Mahid SS, Polk HC, Lewis JN, Turina M. Opportunities for improved performance in surgical specialty practice. Ann Surg. 2008;247:380-388. 19. Weitz JI, Hirsh J, Samama MM. New antithrombotic drugs: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines. Ed 8. Chest. 2008;133: 234-256.