Same-Day Surgery Manager

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

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

We discussed last month who is really in charge of the center and how you respond in certain difficult situations. I gave real examples of such situations, and the reader was to formulate a plan and then compare it to how the real center responded. Here are the actual outcomes:

1. It is late in the day. One of your surgeons calls you and says he has a patient in his office who drove a very long way to see him. He says he would like to do a "simple, quick" procedure right now. What do you do? The patient is going to be "severely inconvenienced" by driving back home and then coming back in two days to get on the schedule. (It is 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.

Outcome: This surgery center administrator explained to the surgeon that she understood the uniqueness of the situation but that the last case of the day must be out of the operating room by 3 p.m. as described in the medical staff bylaws. He replied, "I am an investor in the center, and I will just call it an urgent case and get it on right now." The administrator explained that "urgent" cases were not performed in the surgery center anyway, but she would call the medical director and see what they could do. She asked the surgeon to give her five minutes to call him back with an answer. The surgeon said not to bother as he was on his way to the center with the patient right then.

The administrator called the medical director and explained the situation. She knew that the bylaws of the center call for the medical director to be the person to handle peer compliance, not the administrator. The medical director sighed and said, "OK, let him do the case, and I will reinforce the rules with him at a later date." According to the administrator, the medical director never did confront the surgeon.

What would you have done in this situation? Most of the people I asked said that they would not have provided the staff for the case or would have admonished the surgeon for the break in protocol. I think the administrator in this situation acted correctly. She reminded the surgeon of the rules, but she deferred to the appropriate source for the ultimate decision. (Editor’s note: For more information on dealing with difficult physicians, see Same-Day Surgery, June 2000, p. 71, "Do you have a difficult physician in your OR?")

2. A staff member walks into your office and tells you that your favorite surgeon is sexually harassing him. Where do you go, and whom do you call? Or do you do anything? Should you simply document the complaint and send the staff member back into the room with the surgeon — potentially in harm’s way? What do you do?

Outcome: Men can be sexually harassed as well as women. You must have a policy on the proper protocol. Once it occurs, it’s too late to try to determine what to do. In this case, the administrator told the surgeon that the employee had complained to her about her "advances." The surgeon had the employee terminated for another reason. The employee is suing the center, the administrator, the surgeon, the medical director, and the board of directors of the center. The reason? Procedure was not followed.

Always follow these steps:

  • Record the complaint.
  • Protect staff.
  • Investigate.
  • Act firmly.
  • Monitor the situation. 

(For information from Earnhart on how to handle sexual harassment, see SDS, September 1998, "How do you handle sexual harassment?")

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. The staff member locates the patient’s surgeon and discusses it with him. He 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. . . .") It turns into a shouting match. Who is right? Are you sure?

Outcome: Everyone loses when something goes wrong with a patient. In this case, the certified registered nurse anesthetist called the medical director (an anesthesiologist) and explained the situation. The director called the surgeon and told him the case could not be done until the patient was evaluated. The surgeon took the patient out of the center to another center where he had privileges and did the cases there that afternoon. The patient did fine — but imagine what could have happened! The first center did the right thing by denying the case.

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 that "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?

Outcome: In this case, the anesthesiologist is doing a procedure (not anesthesia). Even though the case is under local sedation, the contract with the anesthesia department (who employs the medical director) requires that their staff stay until the last patient leaves the center. The nurse manager on duty called the chief of the anesthesia department at home and told him the situation. While he was upset about the circumstances, he honored the terms of the contract and told the medical director to stay with the patient.

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 (and 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?

Outcome: The administrator allowed the case to be done but reported the infraction at the next board meeting. She was within her rights to cancel the case if she did not receive payment up front. She elected to break the rules under the circumstances and let the case proceed. (The front-desk staff were furious with the administrator for not "backing them up.")

The surgeon apologized to the administrator for acting out the way he did. He told her that he was put into a bad situation, and he did not want to look bad in front of his patient. He explained that he would "follow the rules" going forward. The same thing happened the following week. A front-desk staff member resigned. Life goes on.