You’re not the boss of me’ — or are you?

By Stephen W. Earnhart, MS
President and CEO
Earnhart & Associates, Dallas

Same-Day Surgery Manager

The title of this column is a lyric in the theme song of the popular TV sitcom titled Malcolm in the Middle. Does it bring back memories? The fact is, it’s starting to become a real issue in the operating room. Who really is the boss? Who is in charge? Who is the final decision maker? Some of you know — and others think you know — but in reality, most don’t. The answer to all these questions and many more can be found in that little known document that all of us should be required to read and comprehend, but we don’t. I did a spot check of 25 staff members over the past month, and 23 had never heard of it. The document is the medical staff bylaws. In it, you will find another section called rules and regulations of the medical staff.

You need to read it. I’m sure most of you will be surprised by its contents. The good news is that every licensed and certified surgical facility has one (required), and the bad news is that 80% probably are outdated. All credentialed surgeons are required to read it, understand it, abide by it, and sign it as a condition of receiving privileges to work in your facility. But do they?

If you tend to be the bossy type, you will love the reading because you can walk around and tell people what to do and have some clout to back you up. Of course, if you are that type, most people probably don’t like you to begin with and won’t care what you say. But its intention is sound. I’ve taken some situations that have come up recently to share with you; you decide what is the proper course of action. You might want to consider some of the questions a topic at a staff meeting.

1. It is late in the day, and one of your surgeons calls you and says he has a patient in his office who drove a very long way to see him and he would like to do a simple, quick procedure right now. (Yeah, I know. It’s probably not "simple" and certainly not "quick.") What do you do? The patient is going to be severely inconvenienced (or so you are told and have to believe for the sake of this example) by driving back home and then coming back two days from now to get on the schedule. (Oh, I forgot to mention: It’s snowing.) The surgeon tells you if you don’t put the patient on, he will take the case down the street to another facility that understands the needs of the patient, or he will change the case to an "urgent" case and do it anyway.

2. A staff member walks into your office and tells you he is being sexually harassed by your favorite surgeon. Where do you go, and whom do you call? Or do you do anything? Should you just document the complaint and send the person back into the room with the surgeon — potentially in harm’s way? Do you know what to do?

3. A staff member in anesthesia passes a patient in the holding area who appears to be in "distress." She discovers the patient is a "local only" case and thinks the patient should be medically evaluated before going into the operation room. She locates and discusses the situation with the patient’s surgeon, who tells her that the patient is fine. He is doing the patient under local only, he is not using the services of anesthesia, he is doing the procedure anyway, and she should mind her "own business." ("You’re not the boss of me now. . . .") The discussion turns into a shouting match. Who is right? Are you sure?

4. An anesthesiologist on your surgical staff (but not on the staff of anesthesia) does pain management cases. The case is over, and the patient is in the recovery room waiting for a ride home. The "surgeon" (anesthesiologist) used local sedation. Your medical director refuses to stay with the patient and says, "it is the responsibility of the anesthesiologist who did the case" to stay with the patient, not your anesthesia staff. Really? What do you think?

5. A plastic surgery patient shows up 30 minutes before her case (on time) and is told that the cash up front required by the center is $1,800. She becomes indignant and tells your front desk staff that her surgeon (your busiest plastic surgeon) told her that she could pay for the procedure in three payments and that she was not going to pay anything now. Your staff member approaches the surgeon and explains the situation to him. He freaks out and confirms the patient’s story and is yelling to get her processed and into the operating room. Sitting down in your office with an ice bag on your head, you are fighting a killer of a headache when your front desk calls you in a panic. What do you do?

I’m sad to say these are all real examples.

In the next issue, I will share how your peers handled these situation — rightly or wrongly — and what happened. I suggest you read your medical staff bylaws in the meantime.

(Editor’s note: Earnhart & Associates has free surgery center benchmarks. Visit this web page: Earnhart and Associates is an ambulatory surgery consulting firm specializing in all aspects of surgery center development and management. Earnhart can be reached at 5905 Tree Shadow Place, Suite 1200, Dallas, TX 75252. E-mail: