Managers guard patient care as managed care forces cost cutting

11% of SDS readers say patient care is seriously impaired

It’s forcing you to contain costs. It’s spilling over into infection control, length of stay, staffing, and other areas. It’s managed care, and it’s not going away. So where do you draw the line in cutting costs vs. maintaining quality of care? This question is heavy on your minds. According to exclusive data gathered by Same-Day Surgery in our 1997 reader survey, 11% of respondents believe managed care has seriously impaired patient care. More than half (57%) of respondents said managed care has somewhat diminished patient care.

And same-day surgery managers aren’t the only ones concerned: In October, a presidential advisory commission made up of managed care and consumer groups suggested a proposed bill of rights that could lay the foundation for future federal laws. Patients denied medical coverage by insurers should be able to challenge that decision, the commission suggested. In addition, Sens. Edward Kennedy (D-MA) and James Jeffords (R-VT) are working on a managed care consumer protection bill.

"There are three fears that are driving health care: cost, quality, and safety," says Terry McLean, RN, CPAN, immediate past president of the Thoroughfare, NJ-based American Society of PeriAnesthesia Nursing (ASPAN) and a nurse in the post-anesthesia care unit at Portland (OR) Veteran Affairs Medical Center.

"I think what you’re seeing [is that] cost is being weighed more heavily in terms of importance than safety or quality — not in all places, but in some places," McLean says.

Same-day surgery managers are caught between a rock and a hard place, he says. "They’re put in a position of being mandated that they work under budgetary constraints. On the other hand, they have to be in charge of providing safe, quality care and meet the standards of whatever area they’re working in."

These same-day surgery areas that have been hardest hit by managed care:

Staffing cuts.

"Nursing’s primary task is in providing safe, quality patient care," McLean says. "How we do this and still meet the expectations of the economic climate is a good question. One way we don’t feel is the correct way is to replace licensed RNs with less skilled personnel."

When 50 members of ASPAN were surveyed at the 1996 meeting about their top concerns in ambulatory perianesthesia nursing, the seventh highest concern listed was the decrease in licensed personnel, says Nancy King, RN, CAPA, TQM coordinator at Columbia The Surgery Center in Cleveland, OH, who conducted the survey. (For top 10 list of concerns, see p. 155. For more information on unlicensed assistive personnel, see Same-Day Surgery, July 1997, p. 81.)

Sicker patients.

In the ASPAN survey, the No. 5 concern listed by nurses was an increase in patient census/acuity without increase in staffing. Until recent years, same-day surgery managers would see American Society of Anesthesiologists (ASA) I classification patients almost exclusively and perhaps an occasional ASA II patient. "Now we’re seeing ASA III and ASA IV," King says. "We have patients come in that aren’t in optimum health."

Equipment stretched.

When patient comes to an ambulatory care setting, all patients expect to have the same type of treatment, says Kathryn Schroeter, RN, MS, MA, CNOR, operating room educator at Froedtert Memorial Lutheran Hospital and adjunct clinical facility member at the department of bioethics at Medical College of Wisconsin, both in Milwaukee.

However, sometimes items designed for one use are reprocessed. (For more information on this topic, see SDS, June 1997, p. 69, and September 1997, p. 118.) And some equipment may be used for a purpose other than the manufacturer’s original intent. "Managed care is forcing the hand of same-day surgery managers due to cost savings," Schroeter says.

Preadmission testing cuts.

In the ASPAN survey, the No. 4 concern listed was preadmission testing requirements. Chest X-rays and EKGs are being performed less often, and blood work is minimal, if it’s done at all, King says. "It’s unchartered territory," she says.

The ASA in Park Ridge, IL, is considering preanesthesia testing guidelines that are expected to reduce by 50% the number of preoperative tests performed, according to L. Reuven Pasternak, MD, MPH, vice chairman for clinical affairs in the department of anesthesiology and critical care medicine at The Johns Hopkins Medical Institu-tions in Baltimore. Pasternak serves as chair of the task force that is developing the guidelines.

The guidelines will be voted on at the 1998 meeting.

5 tips from SDS managers

In the light of these pressures, what’s a same-day surgery manager to do to maintain quality? Of course, there’s the obvious step of following national standards from groups such as the Denver-based Association of Operating Room Nurses and ASPAN. Here’s some other advice from your peers (for staffing suggestions, see story, p. 156):

1. Be informed and get involved.

Keep up with the current issues by reading and networking with your peers, Schroeter advises. "Being aware of what’s going on is the first step," she says. "If you aren’t aware, you can’t make any dent in it."

Become involved in the committees at your facility, McLean suggests. "I think they should be on the risk management committees, they should be on quality care committees, and they should be involved in financial considerations to have a voice as an advocate for the patient and to ensure safe standards are able to met."

2. Establish protocols for equipment and supplies, and consider sharing.

Make everyone aware of your protocols for equipment and supplies, Schroeter suggests. "Say, ‘We’re not going to use this type of supply,’ or ‘Do this consistently with a new patient, because everyone deserves the same standard of care,’" she says.

But you still need to save costs, correct? Consider sharing equipment with another facility, says Nancy Burden, RN, CAPN, CAPA, director of Trinity Outpatient Center in New Port Richey, FL, and author of Ambulatory Surgical Nursing (W.B. Saunders, Philadelphia). Trinity Outpatient Center shares a harmonic scalpel with another facility in its health care system.

"Where the line is drawn is what can be safely transported without it getting broken or out of calibration," Burden says. "We do not transport lasers or microscopes because of their delicate nature."

The center has avoided spending $120,000 on equipment in the last year and a half because of this sharing arrangement, Burden says.

3. Prepare your patients before surgery.

In the ASPAN survey, the No. 6 concern listed by nurses was the need to start discharge planning from the time the patient is scheduled for surgery.

Preparing patients before surgery is critical, King says. For example, with arthroscopy patients, find out whether they have a significant number of steps to climb and whether they have any loose rugs on the floor. "So often, those things are dropped," King says. "The patient is in recovery, ready to go home, and now there’s a concern."

Educate patients about arranging for a ride home, as well as the medication and supplies, such as ice packs, they may need, she advises.

4. Look outside the box.

"Look beyond, ‘That’s the way we always do it,’" Burden says. "We ask, ‘Why?’"

For example, a procedure that traditionally has been performed in an OR may be efficiently and safely performed in an endoscopy suite at a lower costs, she says.

And don’t stick to tradition when it comes to dealing with managed care either, Schroeter suggests. "Make a proposal to managed care and ask, ‘Would you negotiate this?’" she says. "I’ve found them receptive. The health care consumer is their customer. They want to stay viable as an organization, and you want satisfied customers, not problems."

5. Designate an employee to supervise quality.

King’s position as TQM coordinator at her facility is a relatively new one. She describes this position as a trend and says payers are the reason. "Third-party payers want to see reports and outcomes. They want to know: Why should we go with you? What numbers do you have? If you can’t measure it, if it’s not documented, you didn’t do it."

Once you take steps to emphasize quality, stand your ground, King advises.

"Probably the most important thing that we really stress at our place, through all of these — even patient education and discharge criteria or time and preadmission test changing — is not lowering the quality," she says. "Especially as nurse managers, that’s really where we have to play an important part. We have to maintain standards of quality and make sure patient care isn’t compromised."