Who's the boss at this surgery center? Nurses!

Team-based system places decision-making with staff

When El Camino Surgery Center in Mountain View, CA, shattered the traditional hierarchy and empowered staff nurses to make decisions, skeptics wondered if the new structure would bring meaningful change. But three years later, the surgery center serves as an example of how innovative management can improve cost-effectiveness without cutting the RN staff.

Nurses who once felt uncertain about the team-based management structure now set their own schedules and make sure staffing concerns are resolved. They evaluate new equipment, report on equipment failures, and work with physicians to standardize instruments. They have added new services, such as 23-hour care, and new procedures, such as anterior cruciate ligament (ACL) and shoulder repair. Those two procedures alone boosted gross revenue in 1995 by 2%.

They also have changed OR procedures to produce cost-savings, such as the more than $30,000 saved by changing drapings and supplies during D&C (dilatation & curettage) procedures. When ophthalmology nurses worked with physicians to standardize supplies and equipment, they saved 25% of the cost of cataract procedures.

"It takes a different way of looking at management," says executive director Nancy Webb-Kessler, RN, MS. "You have to work together with your staff, and it takes a different mindset."

Webb-Kessler acknowledges that such structural change is difficult, even for those who are getting more power to make or influence decisions. It's easier to take orders and blame someone else if a mistake occurs, she says.

But Webb-Kessler contends that fundamental changes in health care are necessary to meet new challenges of managed care and cost-containment. She rejects a "doom and gloom" attitude about the future.

Webb-Kessler's message: "Stop looking at what you can't do, and start looking at what you can do. Then [the possibility of change] starts to get exciting."

From the beginning, Webb-Kessler believed a less bureaucratic structure would help the surgery center maintain quality while cutting costs. El Camino Hospital opened the surgery center in 1991 as a partnership with physician investors because it needed a center that focused on the needs of ambulatory surgery patients. It has become an important aspect of efforts to improve cost-effectiveness. Almost 90% of El Camino Surgery Center's caseload is reimbursed by Medicare or managed care payers.

Yet Webb-Kessler has maintained a high RN-tech ratio, with 17 RNs and four OR technicians. In addition to herself, she has only three managers for a six-OR facility. The center sees about 500 cases per month.

"One of the driving forces is to keep the nursing staff because I truly believe they're the ones who can define and provide quality care," Webb-Kessler says.

When she drafted an organizational chart, she made patient care the focus, and put management at the bottom instead of the top. In fact, the number of managers has been cut while the RN staff remained steady. "It is the patients' needs and the staff who meet those needs who are the core of the organization," she says.

When the center first opened, Webb-Kessler and her colleagues just focused on the problems typical to a new facility, such as establishing basic policies and procedures and orienting a newly hired staff. Two years ago, four-person specialty teams were formed, such as the ophthalmic team or orthopedic/podiatric team. The techs work on teams with the RNs.

Webb-Kessler developed El Camino's structure based on innovative models used in other industries, as outlined in two books: Organizational Architecture and The Empowered Manager. (See source box, p.6) Cross-training was also a cornerstone; all nurses have a specialty area, but receive in-house training that enables them to work in other specialties.

"[Cross-training] is a job expectation," says clinical director Vikki Pearce, RN, CNOR. "If I have new people starting, the teams take responsibility for making sure they are cross-trained in that [specialty area]."

Pearce also makes sure that staffing in the OR includes one person who is strong in the specialty area and one who is weaker. For example, one OR may be scheduled with both ACL repairs and cataract surgery.

"We make sure that there's one very strong person in ACLs and one very strong person in cataracts to do that room," Pearce says. "They work together and share knowledge."

Team spirit didn't come easily

The bottom-up, team-work system wasn't easy to put into practice. First, the management team had to overcome a lack of cohesion and develop shared values, says Webb-Kessler. A consultant worked with managers during a daylong retreat and weekly meetings to build a commitment to what Webb-Kessler calls "a learning organization," a place where flexibility reigns and staff are responsible for setting goals and meeting them. Managers at the retreat discussed the center's core values, such as a commitment to total quality management (TQM), and specific goals. The center has continued to hold annual retreats with the "leadership council," which includes managers, the coordinators of human resources and purchasing, and three nurses chosen by the staff.

Next, Webb-Kessler had to educate the staff. El Camino hired a consultant with expertise in TQM to help build team skills, and staff are able to take paid non-clinical time for teamwork projects, such as data collection or evaluation of new equipment. Pearce and Webb-Kessler acknowledge that this team-based structure requires a commitment of time, resources, and patience.

"Frequently, I was the person doing cases to get them out to learn," Pearce says.

Each year, the surgery center sets performance goals, and teams set their own related projects and goals, including setting their budgets. For example, as a part of the effort to improve cost-effectiveness, the ophthalmology team worked with 12 physicians to standardize drugs, instruments, and the phacoemulsification machine used in cataract procedures, producing a cost savings of 25%.

To make the teams function effectively, they need specific targets and assigned responsibilities, Webb-Kessler says. The teams meet a couple of times a month while setting goals, then team members work individually on projects and report to the team leader, she says. Additional meetings are held only as necessary. Each meeting has an agenda, and each project has a timeline.

"Once they've set their targets, they don't have the need to meet often," says Pearce. "They just communicate working day-to-day together."

El Camino's teams are charged with the following duties: equipment evaluation, supply and inventory management, staff training, current practice evaluation, communication within the surgery center, liaison with medical staff, cost evaluation of cases, identification of equipment failure, and staff development.

Teams are also involved in data collection and cost and outcomes studies that have become a foundation for El Camino's efforts to control costs.

Every month, staff nurses and techs provide Pearce with a report of what team work they've done, how much time they spent doing it, and the breakdown of that time. During slow periods, staff members work on their projects.

"It becomes real obvious who's been contributing to the team and who's not," says Pearce, who adds that the team system works only if everyone becomes involved.

'Can-do' attitude produces accomplishments

El Camino's environment has led to a change in staff attitude from "it's not my job" to "we can do it," say Webb-Kessler and Pearce. Accomplishments of the teams include:

* The gynecology team changed the set up for D&Cs when they realized that the same procedure was being handled differently when performed in a physician's office. After polling doctors to determine their reaction to proposed changes, the nurses scaled back the draping and switched to less expensive supplies. They have saved $30,000 in one and one-half years.

* The orthopedic team developed procedures and staff training for new procedures, such as ACL repair, which had not been performed at El Camino. The team worked with physicians to begin offering the procedures at the surgery center and arranged for trials and selection of new instruments. The change increased the center's caseload, resulting in a 2% growth in gross revenue.

* The schedulers team started a monthly program to honor someone (usually in a physician's office) who helped make the schedule run more smoothly. They send a certificate and a letter to the physician and the individual's supervisor. The employer gives the certificate to the individual.

Saving time pulling supplies

* The center core team rearranged the inventory of sterile items so they could be stored in the order they are listed on the preference cards. Nurses and techs now spend less time pulling the necessary supplies.

* Full-time nurses take turns each month drafting the schedules for the OR. They balance all the issues that Pearce once struggled with, such as fairness in assignments. When the caseload is down, nurses volunteer to take time off without pay.

By its nature, a "learning organization" is always evolving, says Webb-Kessler. Even as El Camino's nurses continue to learn how to work together, the center is preparing to teach others, she says. Webb-Kessler is making plans for her staff to lead seminars on team development.

Meanwhile, some staff members who didn't feel comfortable with the new organization have left, she says. She is proud of those who remained to help redefine same-day surgery management. "They had what it took to try to look at the world differently," she says. *

For more information on the team-based management structure, contact:

* Nancy Webb, Executive Director, El Camino Surgery Center, 2480 Grant Road, Mountain View, CA 94040. Telephone: (415) 961-1200.

For a written resource on the organizational structure, refer to:

* Organizational Architecture. By David A. Nadler, et al. Jossey-Bass Publishers: San Francisco; 1992. Cost is $29.95 plus $4.50 for shipping and handling. Or The Empowered Manager. By Peter Block. Jossey-Bass Publishers: San Francisco; 1986. Cost is $29.95 (hardcover) and $20 (paperback) plus shipping and handling of $4.50. (hardcover) or $3.50 (paperback). For ordering information on either book, contact Jossey-Bass Publishers Customer Service, 350 Sansome St., San Francisco, CA 94104. Telephone: (415) 433-1767. Fax: (800) 605-BOOK