Tuesday, August 16, 2011

Ninth Chapter

Ninth Chapter


In which we see how uneasily the crown lies on the head of the OR

   Chicky sat down at her desk and sighed deeply. She had just returned from a meeting of the OR committee. As always it was a trial by fire, with the surgeons in an uproar. It was a misconception to think of them as a group. They were actually a pack of rabid individualists, each pursuing his own goals and the devil take the hindmost. Trying to get the committee to move in the same direction was like trying to herd cats. Cats that varied from grumpy to angry.

   When Chicky first took over the OR, the problem was scheduling the surgeon’s procedures. Space on the OR schedule was given on a first come first served basis. This had led to numerous problems. Surgeons would book fictitious patients when they did not actually have one, so as to save a favored time in the schedule. Often they would then call in a change, putting a real patient in when one came along. If they didn’t have a real patient, they would simply cancel the fake one. Sometimes they would forget to cancel the fake patient and much time would be lost trying to locate the fake, and a hole in the schedule would result, and there would be lots of difficulty in trying to rearrange the schedule at the last minute. Sometimes the fakes were easily spotted: Clark Kent, John Smith and Jane Doe were frequent entries on the schedule. The first effort to deal with this situation was the Chief of Surgery’s idea. Patients could only be entered on the schedule after they were registered with the hospital and assigned a medical record number. This led to some more counter tactics: posting patients who had been patients in the past, so there was a valid MR number. Or posting a patient who was actually in the hospital but would not be coming to the OR for surgery. The most egregious example was when Dr. Syriani booked a patient, then forgot to cancel when he didn’t have a real one to substitute. Many phone calls were made trying to locate the patient in the hospital, and on the last call it was found that the patient in question had died a week earlier. This led to many jokes about Dr. Syriani’s bedside manner, and that he made a specialty of operating on dead people.

   Chicky’s idea for solving the scheduling problem was to assign each surgeon a block of time that would be held for him up until twenty four hours before surgery. No need to fill in with fake patients, dead or otherwise. The problem the idea posed for the surgeons had to do with when the blocks of time would be. They all wanted to start first thing in the morning, and time in the afternoon was not as desirable. After all, what every surgeon wants is to have an OR staffed and ready for him twenty four hours a day, never mind that he would only use a small fraction of that time. An MBA candidate did a thesis which showed that the cost of maintaining an OR at the ready was about $120 a minute. This included all the overhead, such as HEPA filtration in the air handling, heating and cooling, electricity, salaries for nurses, techs and anesthesia, depreciation of equipment and instruments, generating and maintaining pressurized steam for autoclaves, gasses piped in such as oxygen, compressed air, nitrogen, nitrous oxide, and many other items. This study was published in a number of medical and nursing journals and made the all-time hit parade for OR managers. The surgeons were less than impressed. After all, it didn’t cost them anything. Chicky always wondered at the privileged position surgeons enjoyed. What other profession was there that someone else hired all the help, bought all the tools and equipment, carried all the overhead, and then begged you to come use it for free?

   It took a year and a half of intense politicking to get block time approved. The surgeons of course were the most vocally opposed to the idea. Chicky was barbequed at several OR committee meetings before block time was implemented. The surgeons with the largest case loads got the prime start of the day time and the smaller case loads the less desirable afternoon time. The gaming of the system was not over however. Now surgeons booked their cases for shorter than actual time to get more into their block, or exaggerated the time so as to fill their blocks. This meant that afternoon blocks were delayed because morning blocks ran over, afternoon blocks ran over, and staffing budgets were out of whack because a lot of overtime was needed to cover the overages. Conversely, when times were exaggerated to fill blocks there were holes in the schedule. It was often remarked that the OR schedule was in the running for the Pulitzer Prize for fiction. Chicky lost two very good nurses because they couldn’t get their children out of day care by the time the daycare facility closed.

   Molly came to the rescue by writing a computer program that tracked the times need by a surgeon for a given procedure. It took the times for the last ten times he did the procedure, tossed out the longest and shortest time and averaged the remaining eight. This was the time entered in the schedule when a surgeon booked a case. Cases that ran over the block were put on an add-on list, and worked into the first available spots, usually when block time was unused twenty four hours before the day of surgery. Alternatively, it was put in the surgeons next block. True emergencies bumped block time, but these were surprisingly small in number. This worked out very well, the overtime came within budget, the nurses, techs and anesthesia providers were happy with much more regular working hours, and even the surgeons were a lot happier after they got used to it.

   Now the issue was on-time starts in the mornings. Chicky and Molly had been collecting data on delays to first case starts and the reasons for the delays and who was the person responsible for the delay. Out of 336 first cases in the study, 161 were delayed. 153 were delays due to surgeon problems, such as patients showing up without History and Physicals (H&Ps), admission orders, or surgical permits: all of these were clearly things that the surgeons should have taken care of. There were 6 delays caused by the nursing staff, and they all had to do with equipment problems, three of the six were considered to be problems that could have been avoided. There were 2 delays on anesthesia’s tab, both due to serious medical problems that had to be resolved before surgery could take place. Chicky didn’t need a crystal ball to know that she would need to bring the barbeque sauce to the next OR committee meeting. The surgeons were not going to be willing to consider that they were the chief cause of morning delays.

   The next thing on Chicky’s list for the day was the yearly evaluations of her staff. This was a very complicated business, as the hospital had implemented a “merit based” system for raises, computed from the scores on the evaluations for each nurse or technician. In reality, it was a forced distribution system. If it had been a true merit based system, the amount of money to be awarded in raises would not be fixed. The reality was that Chicky got a sum that would provide all her people a 2% raise. So if she gave someone 3%, she had to give someone else 1%. So the scores had to be juggled to make everything come out even. Chicky knew that her people had worked hard all year, and having had this “merit based” system spun up to them in staff meetings and flyers posted to their homes by the HR department, they would be expecting a payoff. It was going to be a big disappointment. Maybe she should just order a case of BBQ sauce.

   While she was contemplating the “merit based” fiasco to come, there was a knock on her door. Chicky called out “come on in”. Linda entered the office, and closed the door behind her. She looked very upset. Chicky motioned to her to sit and extended the jar of jelly beans she kept on a corner of her desk. Chicky often joked that instead of jelly beans, her jar should contain capsules of Prozac. Linda shook her head, declining, and launched right in. “It’s about Connie.” She went onto relate how she knew that Connie had been having a lot of problems lately, and had been drinking hard. In fact she had shown up for work today visibly impaired. “I don’t want to get her fired or in trouble, but something has to be done.” Now the policy of the hospital was that any employee suspected of intoxication was to be taken to the ER and blood drawn for a toxicology screen. If drugs or alcohol were found, they were to be terminated on the spot. However, if an employee went to employee health and turned themselves in, admitting to a dependency problem, they would be sent to rehab, and could keep their job. Chicky decided to go out on a limb. “Bring Connie to my office” Chicky instructed Linda.

   When Linda returned to the office with Connie in tow, Chicky told Linda to wait outside, and had Connie sit down. Chicky got the aroma of alcohol on Connie’s breath as she started to cry. Chicky gave her a tissue. She reached into her book case and removed one of the many three ring binders there. Chicky thumbed through it, and reaching the section she was looking for and gave it to Connie. It was the section of the HR manual detailing the policies about dependency. “I want you to read that carefully before you say anything to me. “ Connie made as if to speak, but Chicky cut her off “Don’t talk, read” she said to Connie. Connie read. “Now,” said Chicky, “do you want to go to employee health?” Connie nodded yes. “Do you know what you have to do?” Connie nodded again. Chicky went to the door and told Linda “I just had you come to my office, and you don’t know anything about what is going on with Connie, comprende? Don’t answer that. Please escort Connie to employee health.” After they departed, Chicky sat back in her chair and breathed deeply, letting it out slowly, repeating it again and again, waiting for the relaxation to start. She knew that a similar situation with one of the anesthesiologists last year had not turned out well, and hoped that this would turn out better.

   In preparation for the OR committee meeting, Chicky was running through the on-time report with Dr. Hunter, the Chief of Surgery. He agreed with her that it was going to get a contentious reception. Chicky shared with him part of the data collected that was not included in the report. It showed that an overwhelming number of the surgeon related delays were accounted for by only eight surgeons. Another group of twelve had only one or two attributed delays, and another group had none at all. “I want to get all the bluster out front and let the steam out before making these figures known” confided Chicky. “You notice that the biggest offenders are also the ones who make life difficult?” Dr. Hunter agreed: “The way forward as I see it is to ease this in at a later meeting, but only after I have let it be known to some of the guys who always come in with their ducks in a row. Maybe we could get some peer pressure built up before we make this public, and get the committee to come up with some ideas to remedy the situation.” “Then you and I will not have to come off as the heavies and the opposition to the community of surgeons” said Chicky. They nodded to each other. Since the block time plan had created a stable and realistic schedule, Dr. Hunter had come to trust Chicky and worked very closely with her.

   It was eight weeks later, and Chicky was driving past the tall stone pillars and large wrought iron gate of a country estate that had become one of the better private rehab clinics. She was there to meet with the Director of the clinic to prepare for Connie’s upcoming discharge and return to the work place. The hospital had arranged for the best for Connie. After parking in the shaded and landscaped parking lot, Chicky walked up the short flight of stairs to the ornate doorway. The impressive manor house had been built at the end of the nineteenth century by a robber baron who had made his fortune in making saws and other hand tools, and later on arms and ammunition for the Spanish-American war. It had gone into decline in the sixties and was bought by a foundation and renovated into a clinic specializing in drug and alcohol rehab for those of means and requiring discretion. She was met by a receptionist and shown to an office, every horizontal surface of which was piled with journals and papers. The director of the clinic arose from the organized chaos and introduced himself. He got right down to business and detailed the requirements for Connie’s return to work. It was all pretty much as Chicky expected except for one thing: Connie could not work in an area where there were any controlled drugs, nor could she have access or administer them. This told Chicky that Connie’s problem was not just with alcohol, a surprise. When Chicky questioned the director on this, he dodged the question, and reiterated those conditions. This was going to be a problem. Chicky said she would get it worked out and was given a copy of the schedule for follow-ups that Connie would have to keep. Chicky also had to report the whole business to the state board of nursing. They would have additional requirements that would have to be met.

   Chicky created a position to put Connie into. Connie would be calling all the surgeon offices and following up on getting all the H&Ps, permits, copies of x-rays and lab work either mailed or faxed into Connie's little office, where she would collect the paper work into files to be delivered to pre-op on the day of surgery. Hopefully, the surgeons would see this as a customer service initiative instead of nagging. She would also contact the patients on the day before surgery and go over things with them. She would also make follow up calls to patients to check up on how things were going for them. This not only would meet the conditions for Connie’s return but should solve a good many of the delay issues as well. The OR committee had not been able to get past arguing about the delays. The public relations aspects would please the hospitals marketing department. That had been a big help in selling this position down on mahogany row. And it would also help the bottom line of the OR as well, since at $120 a minute, it could cover the cost of Connie’s position by reducing unproductive OR time. But most important to Chicky, it meant a chance at recovery for Connie as well. Still, the fact that drugs had been involved, and that no shortages in the inventories had been noticed, bothered Chicky in the back of her mind. When things had gone this way with one of the anesthesiologists, there had been drugs missing from the inventory, vials of drugs that had been watered down, and two rounds of rehab had failed. It had ended with a funeral. As it was, Chicky was going to have to report on Connie to the state nursing board weekly. Connie would also be subject to weekly and random drug testing. Chicky sat back in her chair and started to breathe in deeply, letting it out slowly…..


bradley43 said...

I'm surprised at the lack of teamwork on the surgeons part. Is this a problem at many hospitals?

Orfyn said...

Surgeons have their own private practice, by themselves or more frequently these days with one or more partners. They tend to look at the hospitals and nurses as being there to serve them, rather than as team members. Of course this is less of a problem at some hospitals and more of a problem at others.

bradley43 said...

Thats a crying shame. Lets hope that turns around sometime.

Orfyn said...

Thanks for reading my stories Brad, and thanks for the comment

bradley43 said...

No problem. Your stories are great.

Anonymous said...

Great stories. They really have the feel of tales told around a table by a group of people, and informative as well. Keep it up!

Orfyn said...

Thank you so much for taking the time to comment. I really enjoy the feedback, it helps a lot. I want to be informative, so that there is appeal to the non-medical community, as well as enough insider stuff for the medical community.