MARCH 1992, VOL 55, NO 3
-
AORN JOURNAL
Combating Crime in Outpatient Surgery Centers MONITORING BEHAVIORS AND PRACTICES Leigh G. Anderson, KN
M
anagers of outpatient surgicenters devote a major portion of every working day to ensuring the profitability of their facilities. To achieve this end, they attend management enhancement seminars, read volumes of state and federal regulations, and agonize over the state of their agencies’ affairs. They do not understand that a few we 11-chosen manage in e n t activities can improve their profit margin. Experts in the field of management today believe that internal theft is the single largest profit drain on business.’ They suggest that additional sources of loss include consumers and suppliers. Criminal acts from inside and outside an outpatient surgicenter can affect its profitability, and management needs to learn to prevent these losses. Honest individuals are those who clearly know the difference between right and wrong and who act accordingly. Their behavior is governed by society’s religious beliefs, traditions, codes of conduct, and civil law. In contrast, dishonest individuals are those who choose to disregard society’s moral and ethical standards. Their criminal acts are the result of willful violations of civil law. Often, their behavior is progressively criminal. Crime, as experienced by the surgicenter, can range from minor dishonest employee behavior to planned, complex, criminal acts by those within the organization or by people outside the organization. This article discusses dishonest employee behavior and identifies some additional sources of sophisticated criminal activity.
Shoplifting
S
hoplifting, or casual loss, frequently is seen in work environments where relaxed management style is coupled with indifferent employees. Stationery, office supplies, bulk medications, and uniforms are common examples of items that are shoplifted. These low-cost, all-purpose items are stolen without much forethought. A recent US Chamber of Commerce study suggests that up to 75% of all employees steal at least once, and half of those who steal once will steal a second time.2 Dishonest employees often fail to identify their
Leigh G. Anderson, RN, MA, is an owner and the administrator of The Centre f o r Plastic Surgery, Sun Bernadino, Culg and a management consultant for plastic surgery outpatient centers. She earned her bachelor of science degree in nursing f ro m Loma Linda (Calif) University and her master of arts degree in management,from Redlands (Calif) University. 801
MARCH 1992, VOL 55, NO 3
AORN JOURNAL
If the employee does not make restitution, the manager should take the grievance to small claims court. behavior as unlawful. Management can address casual loss in several ways. Have employees read and sign a written policy regarding the unauthorized and negligent use of supplies. Hold each employee responsible for the proper use of his or her supplies. Use inventory control sheets. Review usage patterns regularly. Report operational expenses at staff meetings. Remove the opportunity to steal by having everything in its place. Store high-risk, costly inventory in a locked room or cabinet. Design work areas thoughtfully and provide good lighting. Position mirrors judiciously. Be visible to your employees. If a manager suspects that an employee is stealing supplies, he or she should establish proof of wrongful action and document it, confront the employee in private, and require restitution. If the employee does not make restitution, the manager should take the grievance to small claims court. He or she must not let the issue go unresolved. Lack of responsiveness by managers may be interpreted by staff members as a license to abuse supplies, which can lead to repeated theft.
Telephone Abuse
T
he nineties are being called the “electronic communication age” by many. Today’s managers rely heavily on spaceage telephone systems for effective management of people and services. Telephone lines are used for written and verbal communication. When these lines are tied up by employees who 802
are engaged in personal activities, surgicenter productivity is reduced, patient care is neglected, and communication with individuals outside the surgicenter is compromised. These losses, combined with the cost of unauthorized toll calls, can make telephone abuse costly. Managers may find it useful to require all employees to read and sign a written telephoneusage policy. They also should review monthly telephone statements. If the bill is low, managers should check for work left undone (eg, increased accounts receivable, neglected postoperative patient telephone calls). If the bill increases dramatically, managers should check for unauthorized calls and determine if outside calls are being billed to surgicenter. They should report any changes in the monthly bill at the next staff meeting. If there is a problem with telephone abuse, managers can identify the telephone abuser, require restitution, initiate the use of a telephone log, place an electronic lock on the telephone, and, if necessary, install a pay telephone. Telephone abuse can have drastic financial consequences and is another example of how criminal behavior can erode a profit margin.
Waste
M
onitoring material waste and the inappropriate use of supplies often is neglected by managers. Employee carelessness when using supplies can cause supply costs to escalate into a major operational expense. This is a subtle form of theft. Managers must take responsibility for educating and monitoring staff members regularly so that supplies are used correctly and efficiently. When monitoring waste, managers should
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MARCH 1992,VOL 55, NO 3
expect employees to use supplies for their intended purposes, encourage employees to work carefully and accurately, and teach employees how to use supplies correctly. Managers should have examples of paperwork and surgical procedures handy for this purpose. When managers report and discuss operational costs with employees, the importance of proper material usage should be emphasized. Through proper example by the manager, employees learn that waste is not acceptable.
Personal Loss
M
anagers are encouraged to provide a place where employees can safely store their personal belongings during work hours. Ideally, each employee should have a locker with a lock, preferrably provided by the surgicenter. Managers should have a duplicate key or a copy of the combination for each locker to prevent frustration and wasted time if an employee misplaces his or her key or forgets the locker combination. If it is not possible for each employee to have a locker there should be a storage area, away from patient contact areas, that is protected and secured with a lock. Occasionally, disgruntled employees hold their employers responsible for loss of personal items in the workplace. By providing a place for employees to store their personal items, the responsibility for personal items belongs to employees. Another benefit of having an assigned place for personal belongings is that work areas are neat and free from distractions, which creates an environment that favors productivity.
Reimbursement, Benefits
T
here probably is no area in personnel management that presents a greater challenge to management than reimbursement and employee benefits. One researcher estimates that American businesses lose more than $100 billion annually because of employee time theft.3 Time theft occurs in the forms of 804
long lunches, late arrivals, early departures, fake sick days, extended breaks, and employees’ tending to personal business on company time. Some managers feel that an adversarial relationship exists between employees and themselves in this area. It is not uncommon for employees to feel it is their right to be indulgent in these areas. They consider the extra time a well deserved “perk.” On the other hand, managers may see employees as inexhaustible resource pools from which to squeeze every ounce of possible service. Both views are selfindulgent and dishonest. Managers should provide the following guidelines for reimbursement and employee benefits. Have a job description for every employment position. Clearly state reimbursement and benefit policies. Require all employees to read and sign all policies. Update all policies regularly. Conform to state and federal employment regulations. Keep accurate employee reimbursement records. Be fair with employees. Conflict resolution in this area can be costly if employees seek help from the labor relations board or the judicial system.
Substance Abuse
A
ccording to the US Drug Enforcement Administration, substance abuse by employees costs US employers more than $60 billion a year.4 This huge loss is attributed to increased employee absenteeism, decreased productivity, employee theft, and jobrelated accidents. Alcohol is identified as the drug most abused by Americans, followed by marijuana and cocaine. Federal experts estimate that between 10% and 23% of all American workers use dangerous drugs while on the job.5 Conservative estimates suggest that up to 10% of RNs and LPNs are chemically dependent.6 Another researcher reported that many drug
AORN JOURNAL
abusers trace their initial chemical use to a need to unwind, relax, and sleep.7 In view of this observation, managers are encouraged to monitor the stress levels of employees and to be alert for signs of drug usage as a means of dealing with stress. Managers are advised to review and update their hiring protocols, be aware of employers’ legal rights to test and search for drugs, educate employees about alternatives to drug abuse, and provide a drug recovery program for employees.
Computer Fraud
T
oday it is virtually impossible to function in the business world without knowledge of, and assistance from, computers. As with all good things, abuse and misuse exist. Investigators of computer abuse believe that employee crimes involving loss of sensitive information, illegal copying of software, and theft of assets cost US businesses more than $10 billion a year.8 Managers often neglect to monitor computer activities properly because they lack adequate computer skills themselves. They frequently choose to delegate this important task to “disinterested” experts. When managers do not fully understand the vulnerability of their systems and the importance of controls, low levels of computer security likely will exist in their surgicenters. Computer fraud is committed by people, not computers. Computers can do only what they are instructed to do. As a result, controls need to be in place so that any deviation from established procedures will be detected promptly. Three major areas that should be monitored are personnel, software, and availability or access. Managers are advised to have a policy that describes the roles and responsibilities of all personnel involved with computer programs, screen all data entry personnel, rotate data entry personnel’s tasks, monitor all program changes by a control
group, 806
MARCH 1992, VOL 55, NO 3
back up all data entered, limit computer program access to authorized personnel, use passwords, require a log of all computer activities, and have a documented computer emergency plan. A few final words of caution: All computerized accounting records must be verified by hard copy. The use of computer programs to write business checks should be evaluated carefully. Managers should consider bonding all computer personnel. Bonding is considered an additional means for deterring criminal behavior and, on occasion, may help recover stolen funds.
Embezzlement
E
mbezzlement is defined in Webster’s Twentieth Century Dictionary as, “fraudulent appropriation of property by a person to whom it has been entrusted.” The key word is “entrusted.” This is what makes embezzlement different from ordinary theft or larceny. The embezzler is often someone a manager trusts. According to one researcher, half of those caught embezzling are caught accidentally. Of embezzlers caught, tips help authorities catch one-third, and audits catch the rest.9 Embezzlers usually think they are smarter than their managers. As stated in the definition, the embezzler is a trusted employee who takes advantage of his or her manager’s confidence. Several common schemes used by embezzlers follow: Simple embezzlement. When an employee pockets cash without making any record of the transaction. Lapping. Withholding a portion of funds from one account, thus creating a temporary shortfall. The withheld funds are pocketed. The shortfall is covered by funds taken from a second account. This is progressive embezzlement and requires a second set of books.
Check-kiting.When an individual takes
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MARCH 1992,VOL 55, NO 3 -
advantage of the time period, or “float time,” that elapses between the deposit of a check and the collection of funds. By keeping checks in motion, an embezzler can conceal the difference between the actual amount of funds available and the amount being spent or transferred. Payroll fraud. When the embezzler adds the name of a relative or some fictitious individual to the payroll. On payday, the embezzler pockets the extra check. Dummy accounts, When accounts are set up so that fictitious purchases and mythical transactions can be charged against the surgicenter. Kickbacks. When items are purchased at inflated prices, and the difference is pocketed by the embezzler. Managers can help prevent embezzlement by keeping cash transactions to a minimum, conducting all cash transaction between patients and employees in public places, not keeping cash in the surgicenter overnight, watching for evidence that an employee is keeping records or a second set of “books,” rotating accounting tasks, not having the same person open the mail and credit patient accounts with payments, rotating vacation schedules and insisting that all employees take vacation time every year, auditing transactions in checking accounts regularly and keeping accounting tasks well segregated, requiring that the chief financial officer be responsible for hiring, and using outside auditors on a regular schedule, requiring multiple signatures for ordering and purchasing expensive items and disbursing large sums of money, having two employees verify all deposits, and using a courier, not an employee, to deliver large sums of cash to the bank. Managers must be alert for clues that signal irregularities in the handling of surgicenter funds. There is no substitute for monitoring.
An Outside Job
N
‘ot all criminal activity is performed by someone in the organization. Precautions have to be taken to protect employees and their facilities from criminally minded people outside the organization. Attention to outside security is important. Employees must not be at risk when getting in or out of their cars in the parking lot; common areas, such as elevators and halls, should be monitored; and appropriate measures to protect employees inside the surgicenter during business hours should be taken. Criminal acts can be committed by a variety of individuals who pass through the surgicenter. Managers usually give little thought to monitoring patient activity. To prevent problems caused by dishonest patients, employees should accompany patients to their destinations and leave examining room doors slightly ajar. After providing patient care, employees shoulnot leave soiled supplies and instruments where patients can see them and might be tempted to steal them. Repair people and detail representatives also are frequently permitted access to many areas within the surgicenter. Employees should accompany them to their work areas and stay close by until their tasks are completed. Housekeeping personnel are the least supervised group of people who enter the surgicenter. They usually are in the surgicenter when all other personnel are gone. Charts, ledgers, cupboards, and supplies are available to them for exploration. At the day’s end, employees should put things away, and managers should lock up important areas.
Bud Checks, Credit Curds
M
ore surgicenters are requesting that patients not pay with cash. Their reasons are quite simple; cash takes time to count, errors can be made in counting it, and cash increases the risk of robbery. Cashless surgicenters risk receiving bad checks and bad credit cards. The simplest safe807
MARCH 1992, VOL 55, NO 3 -
guard is to run all checks and credit cards through a verification service at the time of payment. When accepting checks for payment, employees should look at the following: Bank. Is it local? Date. Is it incorrectly dated or more than 30 days old? Amount. Does the numerical amount match the written amount? Payee. Is the check made out correctly? Signature. Does the signature compare accurately with the signature on the identification provided? Types of identification. Driver’s licenses and military or government identification are acceptable; credit cards are unacceptable. Low sequence number. Lower sequence number checks are more likely to be returned than those with higher sequence numbers. Several additional actions can be taken by the individual who accepts the check. When a check is offered for payment, the employee can look up the patient’s name in the local telephone book to confirm that the information on the check is correct. Employees should watch for suspicious behavior, and they should never accept a check from an individual who appears to be drunk. If the surgicenter accepts credit cards, those who accept payments should check the expiration date on the card, examine the card for signs of alteration, compare the printed name on the card with the signature on the card, check the signature on the voucher with the signature on the card, and call for authorization. Payment for services by insurance is another way dishonest practices occur. Unscrupulous patients may take advantage of insurance carriers and abuse the intended coverage. These individuals count on the inefficiency of the insurance industry for successful deception. Insurance clerks are responsible for obtaining a signed statement from all insurance patients that assigns insurance benefits to the surgeon or surgicenter. Insurance clerks are cautioned not to provide billing information
AORN JOURNAL
that will help patients commit illegal practices.
Management
A
final source of criminal activity is managers or members of the medical staff. It is assumed that these individuals have the best interest of the surgicenter at heart; unfortunately, this is not always the case. They can and do commit all of the same criminal acts as other employees. Falsifying surgicenter records is one of the most serious criminal acts they can commit. Fraud in this area often is promoted by unrealistic profit and budget pressures nurtured by high personal incentives to maintain the surgicenter’s financial performance. The Treadway Commission describes fraudulent financial reporting as, “intentional conduct that results in misleading financial statements.”1° This conduct includes deliberately destroying records, falsifying transactions, and misapplying accounting principles. Federal, state, and private insurance agencies, not to mention the US Internal Revenue Service, respond harshly to individuals and organizations who make fraudulent claims.
Conclusion
M
‘anagers today are faced with the unfortunate reality that crime lurks in .and around every comer of the workplace. Sometimes subtly, but more often boldly, criminal elements attack the profit margins of businesses. This problem may reflect a general decline in the moral and ethical values held by society as a whole; however, through thoughtful and skillful implementation of precautions, surgicenter managers can better deal with the problems associated with crime in the workplace and can assure the ongoing profitability of their facilities. 0 Notes 1 . S C Kilgo, “A theft control approach,” Security Management 33 (April 1989) 81-82. 2. W A McGurn, “Spotting the thieves who
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work among us,” Wall Street Journal (March 7,
1988). 3. J D Walls, “When theft is an inside job,” Security Management 33 (April 1989) 69-72. 4. J Castro, “Battling the enemy within,” Time
(March 17 1986) 53. 5. Ibid. 6. M Buxton et al, “Treatment of the chemically dependent health professional,” in The Addictions: Multidisciplinary Perspectives and Treatments, ed H B Milkman, H J Shaffer (Lexington, Mass: Lexington Books, 1985) 131-143. 7. K H Selbach, “Chemical dependency in nurs-
MARCH 1992, VOL 55, NO 3
ing: Identifying and helping the troubled nurse,” AORN Journal 52 (September 1990) 531-542. 8. R P Hull, L E Serio, Jr, “What Managers should know about computer security,” Business 37 (October/November/December1987) 3-8. 9. P Pae, “To catch an embezzler, best be nimble, be quick,” Wall Street Journal (August 3, 1989). 10. National Commission on Fraudulent Financial Reporting, Report of the National Commission on Fraudulent Financial Reporting exposure draft (Washington, DC: National Commission on Fraudulent Financial Reporting, 1987) 2.
Breast Cancer Survival Not Age-Related According to a group of researchers at the 1991 Clinical Congress of the American College of Surgeons, young women with breast cancer do not have a poorer prognosis than older women with the disease. The findings were based on a study that encompassed 40 years of experience in the treatment of young women with breast cancer at Memorial Sloan-Kettering Cancer Center, New York City. The survival rate of women under 30 years of age who were treated for primary operable breast cancer has increased steadily, according to an October 24, 1991, press release from the American College of Surgeons. The 10-year survival rate rose from 48% in 1949-1959 to 74% in 1980-1989. The improvement in survival rate occurred at the same time that patients with primary operable breast cancer were being treated with less extensive surgical procedures (ie, modified radical mastectomy versus radical mastectomy), according to the release. Because the breasts of young women are more difficult to examine mammographically and clinically, breast cancer in these patients is harder to detect at an early stage. Young breasts have a dense glandular nature, and there is lower contrast between glandular and fatty tissue. This makes mammography less accurate than with postmenopausal women, 810
according to the release. Data from the study demonstrate that the prognosis is the same for younger women as it is for older women when correlated to the stage of the disease at the time it is diagnosed and treated.
Sperm May Carry Cocaine to Fetus Cocaine use by males has been linked to developmental abnormalities in offspring. A study reported in the Oct 9, 1991, issue of the Journal of the American Medical Association shows that sperm may act as a vector to transport cocaine to the ovum. The study was conducted at the Washington University School of Medicine, St Louis. The researchers incubated prepared sperm with cocaine solutions for varying lengths of time at various temperatures. The concentrations of cocaine used in the study commonly would be found in drug addicts, according to the report. The study demonstrated that the cocaine could bind to the sperm; binding was optimal after 20 minutes of incubation at 23 “C (73.4 O F ) . This could explain the abnormal development of offspring of cocaine-exposed males.. Researchers found that the cocaine had no effect on the sperm’s motility or viability.
-
AORN JOURNAL
Combating Crime in Outpatient Surgery Centers MONITORING BEHAVIORS AND PRACTICES Leigh G. Anderson, KN
M
anagers of outpatient surgicenters devote a major portion of every working day to ensuring the profitability of their facilities. To achieve this end, they attend management enhancement seminars, read volumes of state and federal regulations, and agonize over the state of their agencies’ affairs. They do not understand that a few we 11-chosen manage in e n t activities can improve their profit margin. Experts in the field of management today believe that internal theft is the single largest profit drain on business.’ They suggest that additional sources of loss include consumers and suppliers. Criminal acts from inside and outside an outpatient surgicenter can affect its profitability, and management needs to learn to prevent these losses. Honest individuals are those who clearly know the difference between right and wrong and who act accordingly. Their behavior is governed by society’s religious beliefs, traditions, codes of conduct, and civil law. In contrast, dishonest individuals are those who choose to disregard society’s moral and ethical standards. Their criminal acts are the result of willful violations of civil law. Often, their behavior is progressively criminal. Crime, as experienced by the surgicenter, can range from minor dishonest employee behavior to planned, complex, criminal acts by those within the organization or by people outside the organization. This article discusses dishonest employee behavior and identifies some additional sources of sophisticated criminal activity.
Shoplifting
S
hoplifting, or casual loss, frequently is seen in work environments where relaxed management style is coupled with indifferent employees. Stationery, office supplies, bulk medications, and uniforms are common examples of items that are shoplifted. These low-cost, all-purpose items are stolen without much forethought. A recent US Chamber of Commerce study suggests that up to 75% of all employees steal at least once, and half of those who steal once will steal a second time.2 Dishonest employees often fail to identify their
Leigh G. Anderson, RN, MA, is an owner and the administrator of The Centre f o r Plastic Surgery, Sun Bernadino, Culg and a management consultant for plastic surgery outpatient centers. She earned her bachelor of science degree in nursing f ro m Loma Linda (Calif) University and her master of arts degree in management,from Redlands (Calif) University. 801
MARCH 1992, VOL 55, NO 3
AORN JOURNAL
If the employee does not make restitution, the manager should take the grievance to small claims court. behavior as unlawful. Management can address casual loss in several ways. Have employees read and sign a written policy regarding the unauthorized and negligent use of supplies. Hold each employee responsible for the proper use of his or her supplies. Use inventory control sheets. Review usage patterns regularly. Report operational expenses at staff meetings. Remove the opportunity to steal by having everything in its place. Store high-risk, costly inventory in a locked room or cabinet. Design work areas thoughtfully and provide good lighting. Position mirrors judiciously. Be visible to your employees. If a manager suspects that an employee is stealing supplies, he or she should establish proof of wrongful action and document it, confront the employee in private, and require restitution. If the employee does not make restitution, the manager should take the grievance to small claims court. He or she must not let the issue go unresolved. Lack of responsiveness by managers may be interpreted by staff members as a license to abuse supplies, which can lead to repeated theft.
Telephone Abuse
T
he nineties are being called the “electronic communication age” by many. Today’s managers rely heavily on spaceage telephone systems for effective management of people and services. Telephone lines are used for written and verbal communication. When these lines are tied up by employees who 802
are engaged in personal activities, surgicenter productivity is reduced, patient care is neglected, and communication with individuals outside the surgicenter is compromised. These losses, combined with the cost of unauthorized toll calls, can make telephone abuse costly. Managers may find it useful to require all employees to read and sign a written telephoneusage policy. They also should review monthly telephone statements. If the bill is low, managers should check for work left undone (eg, increased accounts receivable, neglected postoperative patient telephone calls). If the bill increases dramatically, managers should check for unauthorized calls and determine if outside calls are being billed to surgicenter. They should report any changes in the monthly bill at the next staff meeting. If there is a problem with telephone abuse, managers can identify the telephone abuser, require restitution, initiate the use of a telephone log, place an electronic lock on the telephone, and, if necessary, install a pay telephone. Telephone abuse can have drastic financial consequences and is another example of how criminal behavior can erode a profit margin.
Waste
M
onitoring material waste and the inappropriate use of supplies often is neglected by managers. Employee carelessness when using supplies can cause supply costs to escalate into a major operational expense. This is a subtle form of theft. Managers must take responsibility for educating and monitoring staff members regularly so that supplies are used correctly and efficiently. When monitoring waste, managers should
AORN JOURNAL
MARCH 1992,VOL 55, NO 3
expect employees to use supplies for their intended purposes, encourage employees to work carefully and accurately, and teach employees how to use supplies correctly. Managers should have examples of paperwork and surgical procedures handy for this purpose. When managers report and discuss operational costs with employees, the importance of proper material usage should be emphasized. Through proper example by the manager, employees learn that waste is not acceptable.
Personal Loss
M
anagers are encouraged to provide a place where employees can safely store their personal belongings during work hours. Ideally, each employee should have a locker with a lock, preferrably provided by the surgicenter. Managers should have a duplicate key or a copy of the combination for each locker to prevent frustration and wasted time if an employee misplaces his or her key or forgets the locker combination. If it is not possible for each employee to have a locker there should be a storage area, away from patient contact areas, that is protected and secured with a lock. Occasionally, disgruntled employees hold their employers responsible for loss of personal items in the workplace. By providing a place for employees to store their personal items, the responsibility for personal items belongs to employees. Another benefit of having an assigned place for personal belongings is that work areas are neat and free from distractions, which creates an environment that favors productivity.
Reimbursement, Benefits
T
here probably is no area in personnel management that presents a greater challenge to management than reimbursement and employee benefits. One researcher estimates that American businesses lose more than $100 billion annually because of employee time theft.3 Time theft occurs in the forms of 804
long lunches, late arrivals, early departures, fake sick days, extended breaks, and employees’ tending to personal business on company time. Some managers feel that an adversarial relationship exists between employees and themselves in this area. It is not uncommon for employees to feel it is their right to be indulgent in these areas. They consider the extra time a well deserved “perk.” On the other hand, managers may see employees as inexhaustible resource pools from which to squeeze every ounce of possible service. Both views are selfindulgent and dishonest. Managers should provide the following guidelines for reimbursement and employee benefits. Have a job description for every employment position. Clearly state reimbursement and benefit policies. Require all employees to read and sign all policies. Update all policies regularly. Conform to state and federal employment regulations. Keep accurate employee reimbursement records. Be fair with employees. Conflict resolution in this area can be costly if employees seek help from the labor relations board or the judicial system.
Substance Abuse
A
ccording to the US Drug Enforcement Administration, substance abuse by employees costs US employers more than $60 billion a year.4 This huge loss is attributed to increased employee absenteeism, decreased productivity, employee theft, and jobrelated accidents. Alcohol is identified as the drug most abused by Americans, followed by marijuana and cocaine. Federal experts estimate that between 10% and 23% of all American workers use dangerous drugs while on the job.5 Conservative estimates suggest that up to 10% of RNs and LPNs are chemically dependent.6 Another researcher reported that many drug
AORN JOURNAL
abusers trace their initial chemical use to a need to unwind, relax, and sleep.7 In view of this observation, managers are encouraged to monitor the stress levels of employees and to be alert for signs of drug usage as a means of dealing with stress. Managers are advised to review and update their hiring protocols, be aware of employers’ legal rights to test and search for drugs, educate employees about alternatives to drug abuse, and provide a drug recovery program for employees.
Computer Fraud
T
oday it is virtually impossible to function in the business world without knowledge of, and assistance from, computers. As with all good things, abuse and misuse exist. Investigators of computer abuse believe that employee crimes involving loss of sensitive information, illegal copying of software, and theft of assets cost US businesses more than $10 billion a year.8 Managers often neglect to monitor computer activities properly because they lack adequate computer skills themselves. They frequently choose to delegate this important task to “disinterested” experts. When managers do not fully understand the vulnerability of their systems and the importance of controls, low levels of computer security likely will exist in their surgicenters. Computer fraud is committed by people, not computers. Computers can do only what they are instructed to do. As a result, controls need to be in place so that any deviation from established procedures will be detected promptly. Three major areas that should be monitored are personnel, software, and availability or access. Managers are advised to have a policy that describes the roles and responsibilities of all personnel involved with computer programs, screen all data entry personnel, rotate data entry personnel’s tasks, monitor all program changes by a control
group, 806
MARCH 1992, VOL 55, NO 3
back up all data entered, limit computer program access to authorized personnel, use passwords, require a log of all computer activities, and have a documented computer emergency plan. A few final words of caution: All computerized accounting records must be verified by hard copy. The use of computer programs to write business checks should be evaluated carefully. Managers should consider bonding all computer personnel. Bonding is considered an additional means for deterring criminal behavior and, on occasion, may help recover stolen funds.
Embezzlement
E
mbezzlement is defined in Webster’s Twentieth Century Dictionary as, “fraudulent appropriation of property by a person to whom it has been entrusted.” The key word is “entrusted.” This is what makes embezzlement different from ordinary theft or larceny. The embezzler is often someone a manager trusts. According to one researcher, half of those caught embezzling are caught accidentally. Of embezzlers caught, tips help authorities catch one-third, and audits catch the rest.9 Embezzlers usually think they are smarter than their managers. As stated in the definition, the embezzler is a trusted employee who takes advantage of his or her manager’s confidence. Several common schemes used by embezzlers follow: Simple embezzlement. When an employee pockets cash without making any record of the transaction. Lapping. Withholding a portion of funds from one account, thus creating a temporary shortfall. The withheld funds are pocketed. The shortfall is covered by funds taken from a second account. This is progressive embezzlement and requires a second set of books.
Check-kiting.When an individual takes
AORN JOURNAL
MARCH 1992,VOL 55, NO 3 -
advantage of the time period, or “float time,” that elapses between the deposit of a check and the collection of funds. By keeping checks in motion, an embezzler can conceal the difference between the actual amount of funds available and the amount being spent or transferred. Payroll fraud. When the embezzler adds the name of a relative or some fictitious individual to the payroll. On payday, the embezzler pockets the extra check. Dummy accounts, When accounts are set up so that fictitious purchases and mythical transactions can be charged against the surgicenter. Kickbacks. When items are purchased at inflated prices, and the difference is pocketed by the embezzler. Managers can help prevent embezzlement by keeping cash transactions to a minimum, conducting all cash transaction between patients and employees in public places, not keeping cash in the surgicenter overnight, watching for evidence that an employee is keeping records or a second set of “books,” rotating accounting tasks, not having the same person open the mail and credit patient accounts with payments, rotating vacation schedules and insisting that all employees take vacation time every year, auditing transactions in checking accounts regularly and keeping accounting tasks well segregated, requiring that the chief financial officer be responsible for hiring, and using outside auditors on a regular schedule, requiring multiple signatures for ordering and purchasing expensive items and disbursing large sums of money, having two employees verify all deposits, and using a courier, not an employee, to deliver large sums of cash to the bank. Managers must be alert for clues that signal irregularities in the handling of surgicenter funds. There is no substitute for monitoring.
An Outside Job
N
‘ot all criminal activity is performed by someone in the organization. Precautions have to be taken to protect employees and their facilities from criminally minded people outside the organization. Attention to outside security is important. Employees must not be at risk when getting in or out of their cars in the parking lot; common areas, such as elevators and halls, should be monitored; and appropriate measures to protect employees inside the surgicenter during business hours should be taken. Criminal acts can be committed by a variety of individuals who pass through the surgicenter. Managers usually give little thought to monitoring patient activity. To prevent problems caused by dishonest patients, employees should accompany patients to their destinations and leave examining room doors slightly ajar. After providing patient care, employees shoulnot leave soiled supplies and instruments where patients can see them and might be tempted to steal them. Repair people and detail representatives also are frequently permitted access to many areas within the surgicenter. Employees should accompany them to their work areas and stay close by until their tasks are completed. Housekeeping personnel are the least supervised group of people who enter the surgicenter. They usually are in the surgicenter when all other personnel are gone. Charts, ledgers, cupboards, and supplies are available to them for exploration. At the day’s end, employees should put things away, and managers should lock up important areas.
Bud Checks, Credit Curds
M
ore surgicenters are requesting that patients not pay with cash. Their reasons are quite simple; cash takes time to count, errors can be made in counting it, and cash increases the risk of robbery. Cashless surgicenters risk receiving bad checks and bad credit cards. The simplest safe807
MARCH 1992, VOL 55, NO 3 -
guard is to run all checks and credit cards through a verification service at the time of payment. When accepting checks for payment, employees should look at the following: Bank. Is it local? Date. Is it incorrectly dated or more than 30 days old? Amount. Does the numerical amount match the written amount? Payee. Is the check made out correctly? Signature. Does the signature compare accurately with the signature on the identification provided? Types of identification. Driver’s licenses and military or government identification are acceptable; credit cards are unacceptable. Low sequence number. Lower sequence number checks are more likely to be returned than those with higher sequence numbers. Several additional actions can be taken by the individual who accepts the check. When a check is offered for payment, the employee can look up the patient’s name in the local telephone book to confirm that the information on the check is correct. Employees should watch for suspicious behavior, and they should never accept a check from an individual who appears to be drunk. If the surgicenter accepts credit cards, those who accept payments should check the expiration date on the card, examine the card for signs of alteration, compare the printed name on the card with the signature on the card, check the signature on the voucher with the signature on the card, and call for authorization. Payment for services by insurance is another way dishonest practices occur. Unscrupulous patients may take advantage of insurance carriers and abuse the intended coverage. These individuals count on the inefficiency of the insurance industry for successful deception. Insurance clerks are responsible for obtaining a signed statement from all insurance patients that assigns insurance benefits to the surgeon or surgicenter. Insurance clerks are cautioned not to provide billing information
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that will help patients commit illegal practices.
Management
A
final source of criminal activity is managers or members of the medical staff. It is assumed that these individuals have the best interest of the surgicenter at heart; unfortunately, this is not always the case. They can and do commit all of the same criminal acts as other employees. Falsifying surgicenter records is one of the most serious criminal acts they can commit. Fraud in this area often is promoted by unrealistic profit and budget pressures nurtured by high personal incentives to maintain the surgicenter’s financial performance. The Treadway Commission describes fraudulent financial reporting as, “intentional conduct that results in misleading financial statements.”1° This conduct includes deliberately destroying records, falsifying transactions, and misapplying accounting principles. Federal, state, and private insurance agencies, not to mention the US Internal Revenue Service, respond harshly to individuals and organizations who make fraudulent claims.
Conclusion
M
‘anagers today are faced with the unfortunate reality that crime lurks in .and around every comer of the workplace. Sometimes subtly, but more often boldly, criminal elements attack the profit margins of businesses. This problem may reflect a general decline in the moral and ethical values held by society as a whole; however, through thoughtful and skillful implementation of precautions, surgicenter managers can better deal with the problems associated with crime in the workplace and can assure the ongoing profitability of their facilities. 0 Notes 1 . S C Kilgo, “A theft control approach,” Security Management 33 (April 1989) 81-82. 2. W A McGurn, “Spotting the thieves who
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work among us,” Wall Street Journal (March 7,
1988). 3. J D Walls, “When theft is an inside job,” Security Management 33 (April 1989) 69-72. 4. J Castro, “Battling the enemy within,” Time
(March 17 1986) 53. 5. Ibid. 6. M Buxton et al, “Treatment of the chemically dependent health professional,” in The Addictions: Multidisciplinary Perspectives and Treatments, ed H B Milkman, H J Shaffer (Lexington, Mass: Lexington Books, 1985) 131-143. 7. K H Selbach, “Chemical dependency in nurs-
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ing: Identifying and helping the troubled nurse,” AORN Journal 52 (September 1990) 531-542. 8. R P Hull, L E Serio, Jr, “What Managers should know about computer security,” Business 37 (October/November/December1987) 3-8. 9. P Pae, “To catch an embezzler, best be nimble, be quick,” Wall Street Journal (August 3, 1989). 10. National Commission on Fraudulent Financial Reporting, Report of the National Commission on Fraudulent Financial Reporting exposure draft (Washington, DC: National Commission on Fraudulent Financial Reporting, 1987) 2.
Breast Cancer Survival Not Age-Related According to a group of researchers at the 1991 Clinical Congress of the American College of Surgeons, young women with breast cancer do not have a poorer prognosis than older women with the disease. The findings were based on a study that encompassed 40 years of experience in the treatment of young women with breast cancer at Memorial Sloan-Kettering Cancer Center, New York City. The survival rate of women under 30 years of age who were treated for primary operable breast cancer has increased steadily, according to an October 24, 1991, press release from the American College of Surgeons. The 10-year survival rate rose from 48% in 1949-1959 to 74% in 1980-1989. The improvement in survival rate occurred at the same time that patients with primary operable breast cancer were being treated with less extensive surgical procedures (ie, modified radical mastectomy versus radical mastectomy), according to the release. Because the breasts of young women are more difficult to examine mammographically and clinically, breast cancer in these patients is harder to detect at an early stage. Young breasts have a dense glandular nature, and there is lower contrast between glandular and fatty tissue. This makes mammography less accurate than with postmenopausal women, 810
according to the release. Data from the study demonstrate that the prognosis is the same for younger women as it is for older women when correlated to the stage of the disease at the time it is diagnosed and treated.
Sperm May Carry Cocaine to Fetus Cocaine use by males has been linked to developmental abnormalities in offspring. A study reported in the Oct 9, 1991, issue of the Journal of the American Medical Association shows that sperm may act as a vector to transport cocaine to the ovum. The study was conducted at the Washington University School of Medicine, St Louis. The researchers incubated prepared sperm with cocaine solutions for varying lengths of time at various temperatures. The concentrations of cocaine used in the study commonly would be found in drug addicts, according to the report. The study demonstrated that the cocaine could bind to the sperm; binding was optimal after 20 minutes of incubation at 23 “C (73.4 O F ) . This could explain the abnormal development of offspring of cocaine-exposed males.. Researchers found that the cocaine had no effect on the sperm’s motility or viability.
