Practice Management/Role o f t h e Me di c a l D i re c t o r Douglas G. Merrill,
MD, MBA
KEYWORDS Administration Practice management Medical director Business Ambulatory surgery center Anesthesiology Outcomes Quality KEY POINTS The history of the ambulatory surgery center begins with Ralph Waters’ inspiration to create a different kind of facility that catered to the needs of patients and the surgeon in a manner that the hospital could not. Today’s medical director should actively manage the systems, policies, and providers using quantifiable outcomes of care and systems as well as planned process-improvement events. This work will ensure the medical director’s ability to lead the center to excellence in care delivery, safety, and, by extension, the metrics of successful accreditation and finances.
INTRODUCTION
A medical director in an ambulatory surgery setting should be focused on the development and improvement of systems that support excellence in clinical and nonclinical outcomes. The effort requires individual patient’s clinical and social assessment on a daily basis, personnel management, accreditation and compliance oversight, contracting, and strategic business planning. The role calls for the development of expertise in a wide variety of skills. Ideally, the medical director is on site most of the time to enforce policy but, more importantly, to provide coherence of attitude regarding service excellence and a full understanding of the challenges faced by the facility. Thus, an anesthesiologist, rather than a surgeon, is more often chosen for this role.
Anesthesiology, Center for Perioperative Services, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth, 1 Medical Center Drive, Lebanon, NH 03756, USA E-mail address: [email protected] Anesthesiology Clin 32 (2014) 529–540 http://dx.doi.org/10.1016/j.anclin.2014.02.021 anesthesiology.theclinics.com 1932-2275/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
530
Merrill
Fig. 1. Ralph Waters. (Image courtesy of the Wood Library-Museum of Anesthesiology, Park Ridge, IL.)
HISTORY AND DEVELOPMENT OF THE AMBULATORY SURGERY MEDICAL DIRECTOR
The first outpatient surgery center was developed by Dr Ralph Waters in Sioux City, Iowa in the years after World War I (Figs. 1 and 2). In creating the Downtown Anesthesia Clinic, Waters moved procedures out of the hospital with a primary aim: .to give satisfaction to operator and patient and charge a fee that will pay expenses and a good profit.considerably less than for similar work in the hospital because less time and trouble is involved1. He intended that this remarkable innovation target both patient and surgeon satisfaction. In his published account in an article in 1919, he noted the following wry customer service observations that remain accurate today:
Fig. 2. Site of the Sioux City, Iowa downtown anesthesia clinic. Arrow shows the location of Dr Waters first “downtown anesthesia clinic”. (From Waters RM. The down-town anesthesia clinic. Am J Surg 1919;33(7):71–73(S).)
Practice Management/Role of the Medical Director
We aim to keep an abundant supply of N2O-O2 and use it freely. Many patients and some doctors object to the fees, but they come back and their friends come back. Satisfactory anesthesia and too large fees work out better than bargain sale fees and unsatisfactory anesthesia.People forget the fee but they never forget the hurt, nor fail to tell their friends about it.1 In that short description, Waters distilled the essence of the modern ambulatory surgery industry and the role of the medical director in particular: provision of excellent customer service and outcomes and increased convenience for surgeons and patients, thereby ensuring a sustaining financial profit. MANAGEMENT BY OUTCOMES AND PROCESS IMPROVEMENT
A modern, powerful means of maintaining the high quality and excellent service needed for an ambulatory surgery center is the ability to measure clinical and process outcomes. Outcome measurement may identify variation that is better than average, identifying practices that should be emulated, or worse than average, identifying opportunities for the guided revision of variable practice. A long-term program of assessment of a few clinical and process outcomes in all patients can either validate or identify the needed revision of care pathways and/or systems that might benefit from the implementation of process-improvement projects. Process improvement is best managed by the participation of all stakeholders so that the changes invoked are recognized as valid by all. Although relatively new to health care, the importance of providing outcome data to employees in an effort to support process improvement is well accepted in manufacturing2: .(employees) experience a surprising mismatch between expected and actual results of action and respond to that mismatch through a process of thought and further action that leads them to modify their images of organization or their understandings of organizational phenomena and to restructure their activities so as to bring outcomes and expectations into line1. The measurement and communication of outcomes to caregivers to direct process improvement has been shown to be of value in several health care settings.3 One
Fig. 3. RPIW basics. DMAIC, Define, Measure, Analyze, Improve, Control; PDSA, Plan, Do, Study, Act. (Courtesy of Daniel L. Herrick, BS, CPHQ, The Center for Perioperative Services and The Value Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH; with permission.)
531
532
Merrill
Fig. 4. The role of Plan, Do, Study, Act (PDSA) in an RPIW. (Courtesy of Daniel L. Herrick, BS, CPHQ, The Center for Perioperative Services and The Value Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH; with permission.)
approach, Lean Management, pioneered by the Toyota automobile company, was used to transform the Virginia Mason Medical Center and Clinics.4 A short primer follows on the use of Rapid Process Improvement Workshop (RPIW), a helpful methodology drawn from Lean, in which a small group representing all interested parties meets in an intensive manner (2–5 days) to completely revise a process based on data analysis (Figs. 3–6).
Fig. 5. The role of Define, Measure, Analyze, Improve, Control (DMAIC) in an RPIW process. KPI, key process improvements. (Courtesy of Daniel L. Herrick, BS, CPHQ, The Center for Perioperative Services and The Value Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH; with permission.)
Practice Management/Role of the Medical Director
Fig. 6. The typical RPIW cycle. KPI, key process improvements. (Courtesy of Daniel L. Herrick, BS, CPHQ, The Center for Perioperative Services and The Value Institute, DartmouthHitchcock Medical Center, Lebanon, NH; with permission.)
Using this technique and targeted outcome measurements, any process or care pathway can be evaluated and revised, resulting in a standard process that will reduce variation-induced error or diminished patient care quality. An example of an action item list from an RPIW that successfully streamlined and reduced error in the author’s institution’s operating room setup process is shown in Table 1. The use of outcome measurement to support process improvement can be used to improve quality one provider at a time or to transform the culture of an entire facility (Table 2).5 For instance, when using one or a group of surgeons as risk adjustors, one can compare the outcomes for a set of anesthesia providers looking only at those cases that shared a similar surgeon or surgeons, thus, minimizing confounding variables. Looking at those providers who have surgeons F and G in common, we see that anesthesia provider 4 tends toward longer turnovers than provider 8. If this trend were to hold over several quarters, it would provide an objective basis for a conversation with provider 4 to discuss differences in process between them. Number 8’s lower
533
534
Merrill
Table 1 Example of RPIW action item list PDSAs Action Items
Team
Rollout
First
Second
Third
Pilot
Final 6/17
1
End-of-day OR calling for final cleaning
Danni
Susan
—
—
—
5/3
6/3–6/14
2
End-of-day OR completion checklist
Danni
Susan
—
—
5/2
5/3
6/10–6/21
6/24
3
Standard room equipment templates, basic equipment counts and locations
Linda
Greg
—
—
5/2
5/3
6/10–6/21
6/24
4
Processing of anesthesia blades, dirty room to CSR to clean core
Greg
Glenda
—
5/1
5/2
5/3
6/10–6/21
6/24
5
Change in dinner break times for evening staff, new times from 16:15–16:45
Susan
—
—
5/1
5/2
5/3
6/3–6/14
6/17
6
Nonfolding of trash bags and linen, work order for improvements to shelving in OR core
Joyce
Merit
—
5/1
5/2
5/3
Work order entered 5/31
—
7
Housekeeping and PST staffing schedule adjustments, based on filling existing open positions
Matt
Glenda
Colleen
—
—
5/3
Pending staff hiring
—
8
Linen to be delivered, no longer retrieved by OR staff
Glenda
Matt
—
—
—
—
Future work
TBD
9
Standardize OR table and mattresses and identify surgeon preference options, specialty beds excluded
Mike
Michaela
—
—
—
—
Future work
TBD
10
Schedule all eye cases in same room (room 21 if possible or colocate with supplies)
Joyce
Merit
—
—
—
—
Future work
TBD
11
Dedicated cystoscopy room setup
Joyce
Merit
—
—
—
—
Future work
TBD
12
Check preference cards daily for accuracy and update, leverage current superusers
Danni
Linda
—
—
—
—
Future work
TBD
Abbreviations: CSR, central sterile reprocessing; OR, operating room; PDSA, Plan, Do, Study, Act; PST, patient support technician; TBD, to be determined.
Table 2 Outcome measurement
Practice Management/Role of the Medical Director
Abbreviation: ASC, ambulatory surgery center; N, nausea; PACU, postanesthesia care unit; PD, post-discharge; TO, turnover; V, vomiting.
535
536
Merrill
Fig. 7. Monitored Anesthesia Care (MAC) patient disposition and staffing algorithm. PACU, postanesthesia care unit; SDP, same day program.
postoperative nausea and vomiting (PONV) rate would also bear further observation, searching for emulative methods, particularly with regard to the kinds of cases performed by surgeon G. CARE PATHWAY DEVELOPMENT: REDUCING ERROR AND IMPROVING QUALITY BY REDUCING VARIATION
The use of standard care pathways has been decried as cookbook medicine, which subverts the value of clinical autonomy and judgment. In reality, care pathways are the cornerstone of evidence-based medicine, drawing on the literature, expert opinion, and, most notably, the outcomes of local practice.6 The use of standard algorithms allows the reduction of variation responsible for error.7 Care pathway creation has reduced waste and cost, thereby improving margins in operating rooms.8 In outpatient anesthesia, we take care of a narrow profile of procedures and patients and should take advantage of this because a narrow cohort of patients can be expected to respond relatively cohesively to similar therapies. Algorithms based on the literature and checked over time by local outcome assessment can be expected to produce improved outcomes and reduce error. The use of safety events to drive algorithm creation can be an extremely successful means of improving safety for patients and a sense of teamwork for caregivers.9 One example of a recovery room algorithm to manage patients who have had monitored anesthesia care is shown in Fig. 7, whereas an algorithm for adult PONV prevention appears in Fig. 8. An algorithm for anesthesia and surgical team interactions and procedures associated with breast reductions and liposuction that was created in response to a patient safety event (severe hypovolemia, unrecognized) is available in Appendix 1. One value of sustained outcome measurement is to support the ongoing improvement of quality and safety required by facility accreditors, which is the responsibility of the medical director. A significant aspect of this work is the development of evidencebased policies. SUMMARY
The history of the ambulatory surgery center begins with Ralph Waters’ inspiration to create a different kind of facility that catered to the needs of patients and the surgeon in a manner that the hospital could not. His emphasis on quality of care and service excellence should be echoed in the modern medical director’s role. Today’s medical
Fig. 8. Adult PONV prevention algorithm.
Practice Management/Role of the Medical Director
537
538
Merrill
director should actively manage the systems, policies, and providers using quantifiable outcomes of care and systems as well as planned process-improvement events. This work will ensure the medical director’s ability to lead the center to excellence in care delivery, safety, and, by extension, the metrics of successful accreditation and finances. REFERENCES
1. Waters RM. The down-town anesthesia clinic. Am J Surg 1919;33(7):71–73(S). 2. Argyris C, Schon D. Organisational learning: a theory of action perspective. New York: Addison-Wesley; 1978. 3. Available at: http://www.vnews.com/home/6122247-95/surgeons-take-criticallook-at-their-process. Accessed March 17, 2014. 4. Kenney C. Transforming health care: Virginia Mason Medical Center’s pursuit of the perfect patient experience. New York: Productivity Press; 2011. 5. Gorenflo G. Achieving a culture of quality improvement. J Public Health Manag Pract 2010;16(1):83–4. 6. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71–2. 7. Redberg RF. Getting to best care at lower cost. JAMA Intern Med 2013;173(2): 91–2. 8. Cima RR, Brown MJ, Hebl JR, et al. Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg 2011;213:83–92. 9. McDonald TB, Helmchen LA, Smith KM, et al. Responding to patient safety incidents: the “seven pillars”. Qual Saf Health Care 2010;19(6):e11. APPENDIX 1: EXAMPLE OF A MULTIDISCIPLINARY ALGORITHM OF CARE RESULTING FROM A SAFETY EVENT Surgical Team
Preoperative Surgeon orders preoperative hemoglobin (Hb) On arrival in the preoperative area, a point-of-care Hb (outpatient surgery center) or blood draw Hb test (same day program) should be performed as a baseline. If anemia is present (Hb
MD, MBA
KEYWORDS Administration Practice management Medical director Business Ambulatory surgery center Anesthesiology Outcomes Quality KEY POINTS The history of the ambulatory surgery center begins with Ralph Waters’ inspiration to create a different kind of facility that catered to the needs of patients and the surgeon in a manner that the hospital could not. Today’s medical director should actively manage the systems, policies, and providers using quantifiable outcomes of care and systems as well as planned process-improvement events. This work will ensure the medical director’s ability to lead the center to excellence in care delivery, safety, and, by extension, the metrics of successful accreditation and finances.
INTRODUCTION
A medical director in an ambulatory surgery setting should be focused on the development and improvement of systems that support excellence in clinical and nonclinical outcomes. The effort requires individual patient’s clinical and social assessment on a daily basis, personnel management, accreditation and compliance oversight, contracting, and strategic business planning. The role calls for the development of expertise in a wide variety of skills. Ideally, the medical director is on site most of the time to enforce policy but, more importantly, to provide coherence of attitude regarding service excellence and a full understanding of the challenges faced by the facility. Thus, an anesthesiologist, rather than a surgeon, is more often chosen for this role.
Anesthesiology, Center for Perioperative Services, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine, Dartmouth, 1 Medical Center Drive, Lebanon, NH 03756, USA E-mail address: [email protected] Anesthesiology Clin 32 (2014) 529–540 http://dx.doi.org/10.1016/j.anclin.2014.02.021 anesthesiology.theclinics.com 1932-2275/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
530
Merrill
Fig. 1. Ralph Waters. (Image courtesy of the Wood Library-Museum of Anesthesiology, Park Ridge, IL.)
HISTORY AND DEVELOPMENT OF THE AMBULATORY SURGERY MEDICAL DIRECTOR
The first outpatient surgery center was developed by Dr Ralph Waters in Sioux City, Iowa in the years after World War I (Figs. 1 and 2). In creating the Downtown Anesthesia Clinic, Waters moved procedures out of the hospital with a primary aim: .to give satisfaction to operator and patient and charge a fee that will pay expenses and a good profit.considerably less than for similar work in the hospital because less time and trouble is involved1. He intended that this remarkable innovation target both patient and surgeon satisfaction. In his published account in an article in 1919, he noted the following wry customer service observations that remain accurate today:
Fig. 2. Site of the Sioux City, Iowa downtown anesthesia clinic. Arrow shows the location of Dr Waters first “downtown anesthesia clinic”. (From Waters RM. The down-town anesthesia clinic. Am J Surg 1919;33(7):71–73(S).)
Practice Management/Role of the Medical Director
We aim to keep an abundant supply of N2O-O2 and use it freely. Many patients and some doctors object to the fees, but they come back and their friends come back. Satisfactory anesthesia and too large fees work out better than bargain sale fees and unsatisfactory anesthesia.People forget the fee but they never forget the hurt, nor fail to tell their friends about it.1 In that short description, Waters distilled the essence of the modern ambulatory surgery industry and the role of the medical director in particular: provision of excellent customer service and outcomes and increased convenience for surgeons and patients, thereby ensuring a sustaining financial profit. MANAGEMENT BY OUTCOMES AND PROCESS IMPROVEMENT
A modern, powerful means of maintaining the high quality and excellent service needed for an ambulatory surgery center is the ability to measure clinical and process outcomes. Outcome measurement may identify variation that is better than average, identifying practices that should be emulated, or worse than average, identifying opportunities for the guided revision of variable practice. A long-term program of assessment of a few clinical and process outcomes in all patients can either validate or identify the needed revision of care pathways and/or systems that might benefit from the implementation of process-improvement projects. Process improvement is best managed by the participation of all stakeholders so that the changes invoked are recognized as valid by all. Although relatively new to health care, the importance of providing outcome data to employees in an effort to support process improvement is well accepted in manufacturing2: .(employees) experience a surprising mismatch between expected and actual results of action and respond to that mismatch through a process of thought and further action that leads them to modify their images of organization or their understandings of organizational phenomena and to restructure their activities so as to bring outcomes and expectations into line1. The measurement and communication of outcomes to caregivers to direct process improvement has been shown to be of value in several health care settings.3 One
Fig. 3. RPIW basics. DMAIC, Define, Measure, Analyze, Improve, Control; PDSA, Plan, Do, Study, Act. (Courtesy of Daniel L. Herrick, BS, CPHQ, The Center for Perioperative Services and The Value Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH; with permission.)
531
532
Merrill
Fig. 4. The role of Plan, Do, Study, Act (PDSA) in an RPIW. (Courtesy of Daniel L. Herrick, BS, CPHQ, The Center for Perioperative Services and The Value Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH; with permission.)
approach, Lean Management, pioneered by the Toyota automobile company, was used to transform the Virginia Mason Medical Center and Clinics.4 A short primer follows on the use of Rapid Process Improvement Workshop (RPIW), a helpful methodology drawn from Lean, in which a small group representing all interested parties meets in an intensive manner (2–5 days) to completely revise a process based on data analysis (Figs. 3–6).
Fig. 5. The role of Define, Measure, Analyze, Improve, Control (DMAIC) in an RPIW process. KPI, key process improvements. (Courtesy of Daniel L. Herrick, BS, CPHQ, The Center for Perioperative Services and The Value Institute, Dartmouth-Hitchcock Medical Center, Lebanon, NH; with permission.)
Practice Management/Role of the Medical Director
Fig. 6. The typical RPIW cycle. KPI, key process improvements. (Courtesy of Daniel L. Herrick, BS, CPHQ, The Center for Perioperative Services and The Value Institute, DartmouthHitchcock Medical Center, Lebanon, NH; with permission.)
Using this technique and targeted outcome measurements, any process or care pathway can be evaluated and revised, resulting in a standard process that will reduce variation-induced error or diminished patient care quality. An example of an action item list from an RPIW that successfully streamlined and reduced error in the author’s institution’s operating room setup process is shown in Table 1. The use of outcome measurement to support process improvement can be used to improve quality one provider at a time or to transform the culture of an entire facility (Table 2).5 For instance, when using one or a group of surgeons as risk adjustors, one can compare the outcomes for a set of anesthesia providers looking only at those cases that shared a similar surgeon or surgeons, thus, minimizing confounding variables. Looking at those providers who have surgeons F and G in common, we see that anesthesia provider 4 tends toward longer turnovers than provider 8. If this trend were to hold over several quarters, it would provide an objective basis for a conversation with provider 4 to discuss differences in process between them. Number 8’s lower
533
534
Merrill
Table 1 Example of RPIW action item list PDSAs Action Items
Team
Rollout
First
Second
Third
Pilot
Final 6/17
1
End-of-day OR calling for final cleaning
Danni
Susan
—
—
—
5/3
6/3–6/14
2
End-of-day OR completion checklist
Danni
Susan
—
—
5/2
5/3
6/10–6/21
6/24
3
Standard room equipment templates, basic equipment counts and locations
Linda
Greg
—
—
5/2
5/3
6/10–6/21
6/24
4
Processing of anesthesia blades, dirty room to CSR to clean core
Greg
Glenda
—
5/1
5/2
5/3
6/10–6/21
6/24
5
Change in dinner break times for evening staff, new times from 16:15–16:45
Susan
—
—
5/1
5/2
5/3
6/3–6/14
6/17
6
Nonfolding of trash bags and linen, work order for improvements to shelving in OR core
Joyce
Merit
—
5/1
5/2
5/3
Work order entered 5/31
—
7
Housekeeping and PST staffing schedule adjustments, based on filling existing open positions
Matt
Glenda
Colleen
—
—
5/3
Pending staff hiring
—
8
Linen to be delivered, no longer retrieved by OR staff
Glenda
Matt
—
—
—
—
Future work
TBD
9
Standardize OR table and mattresses and identify surgeon preference options, specialty beds excluded
Mike
Michaela
—
—
—
—
Future work
TBD
10
Schedule all eye cases in same room (room 21 if possible or colocate with supplies)
Joyce
Merit
—
—
—
—
Future work
TBD
11
Dedicated cystoscopy room setup
Joyce
Merit
—
—
—
—
Future work
TBD
12
Check preference cards daily for accuracy and update, leverage current superusers
Danni
Linda
—
—
—
—
Future work
TBD
Abbreviations: CSR, central sterile reprocessing; OR, operating room; PDSA, Plan, Do, Study, Act; PST, patient support technician; TBD, to be determined.
Table 2 Outcome measurement
Practice Management/Role of the Medical Director
Abbreviation: ASC, ambulatory surgery center; N, nausea; PACU, postanesthesia care unit; PD, post-discharge; TO, turnover; V, vomiting.
535
536
Merrill
Fig. 7. Monitored Anesthesia Care (MAC) patient disposition and staffing algorithm. PACU, postanesthesia care unit; SDP, same day program.
postoperative nausea and vomiting (PONV) rate would also bear further observation, searching for emulative methods, particularly with regard to the kinds of cases performed by surgeon G. CARE PATHWAY DEVELOPMENT: REDUCING ERROR AND IMPROVING QUALITY BY REDUCING VARIATION
The use of standard care pathways has been decried as cookbook medicine, which subverts the value of clinical autonomy and judgment. In reality, care pathways are the cornerstone of evidence-based medicine, drawing on the literature, expert opinion, and, most notably, the outcomes of local practice.6 The use of standard algorithms allows the reduction of variation responsible for error.7 Care pathway creation has reduced waste and cost, thereby improving margins in operating rooms.8 In outpatient anesthesia, we take care of a narrow profile of procedures and patients and should take advantage of this because a narrow cohort of patients can be expected to respond relatively cohesively to similar therapies. Algorithms based on the literature and checked over time by local outcome assessment can be expected to produce improved outcomes and reduce error. The use of safety events to drive algorithm creation can be an extremely successful means of improving safety for patients and a sense of teamwork for caregivers.9 One example of a recovery room algorithm to manage patients who have had monitored anesthesia care is shown in Fig. 7, whereas an algorithm for adult PONV prevention appears in Fig. 8. An algorithm for anesthesia and surgical team interactions and procedures associated with breast reductions and liposuction that was created in response to a patient safety event (severe hypovolemia, unrecognized) is available in Appendix 1. One value of sustained outcome measurement is to support the ongoing improvement of quality and safety required by facility accreditors, which is the responsibility of the medical director. A significant aspect of this work is the development of evidencebased policies. SUMMARY
The history of the ambulatory surgery center begins with Ralph Waters’ inspiration to create a different kind of facility that catered to the needs of patients and the surgeon in a manner that the hospital could not. His emphasis on quality of care and service excellence should be echoed in the modern medical director’s role. Today’s medical
Fig. 8. Adult PONV prevention algorithm.
Practice Management/Role of the Medical Director
537
538
Merrill
director should actively manage the systems, policies, and providers using quantifiable outcomes of care and systems as well as planned process-improvement events. This work will ensure the medical director’s ability to lead the center to excellence in care delivery, safety, and, by extension, the metrics of successful accreditation and finances. REFERENCES
1. Waters RM. The down-town anesthesia clinic. Am J Surg 1919;33(7):71–73(S). 2. Argyris C, Schon D. Organisational learning: a theory of action perspective. New York: Addison-Wesley; 1978. 3. Available at: http://www.vnews.com/home/6122247-95/surgeons-take-criticallook-at-their-process. Accessed March 17, 2014. 4. Kenney C. Transforming health care: Virginia Mason Medical Center’s pursuit of the perfect patient experience. New York: Productivity Press; 2011. 5. Gorenflo G. Achieving a culture of quality improvement. J Public Health Manag Pract 2010;16(1):83–4. 6. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71–2. 7. Redberg RF. Getting to best care at lower cost. JAMA Intern Med 2013;173(2): 91–2. 8. Cima RR, Brown MJ, Hebl JR, et al. Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg 2011;213:83–92. 9. McDonald TB, Helmchen LA, Smith KM, et al. Responding to patient safety incidents: the “seven pillars”. Qual Saf Health Care 2010;19(6):e11. APPENDIX 1: EXAMPLE OF A MULTIDISCIPLINARY ALGORITHM OF CARE RESULTING FROM A SAFETY EVENT Surgical Team
Preoperative Surgeon orders preoperative hemoglobin (Hb) On arrival in the preoperative area, a point-of-care Hb (outpatient surgery center) or blood draw Hb test (same day program) should be performed as a baseline. If anemia is present (Hb
