Poster Gallery 2015

24827_ORMC 2015 logo_PosterGallery






The OR Manager Conference Poster Gallery provides a forum for presenting completed research or in-progress research with preliminary results, and presents research, performance improvement projects, or clinical practice innovations visually using graphs, illustrations, or photographs. We strive to promote communication and collaborative research among nurses, provide opportunities for exchange of research and performance improvement, and explore advances in perioperative clinical practice.


Thursday, October 8 
1:00 p.m. – 2:00 p.m.
3:30 p.m. – 4:30 p.m.

Posters will be on display in the Exhibit Hall for the duration of the Exhibition. Poster authors will be available at the conference to answer any questions during the Poster Sessions.


Beginning Wednesday, October 7, OR Manager Conference attendees may review the posters and take an online quiz for 10.0 CE credit hours. Login details have been distributed via email.  To access the e-posters and online quizzes, click here.

If you need assistance accessing the e-poster gallery, please contact Brianna Bruce at or 301-354-1751.


"We're Having a Heat Wave": Improving Patient Outcomes through Perioperative Warming

Patricia Boettger, BSN, RN, CNOR, RNFA, Staff Development Nurse - Surgery, Nebraska Methodist Health System
Brittany Kauffman, BSN, RN, CPAN, Staff Development Nurse - Surgery Support, Nebraska Methodist Health System


Background Information:

• Forced air warming products were introduced and utilized at Nebraska Methodist Hospital in the mid-2000’s. This process was revisited in early 2014 after observation of inconsistent practice in regards to maintaining patient normothermia. A process needed to be implemented to effectively utilize best practice in preventing hypothermia in the operating room and improving patient outcomes.

Objectives of Project:

• Develop a standard process for perioperative forced air warming

• Improve patient normothermia by preventing redistribution hypothermia in the operating room

Strategies of Implementation:

• Preoperative, operating room, and recovery room staff were educated on redistribution hypothermia and the importance of perioperative warming.

• Working with product representatives, a new process was developed which incorporated pre-warming the cart, linen, and gown prior to the patient arriving in the preoperative area. This practice resulted in the patient maintaining their body temperature versus losing it to their environment through conduction and radiation. When the patient arrived in the operating room they experienced less redistribution hypothermia, decreasing their risk for temperature-related complications. After transfer to the recovery room, patient temperatures were maintained by continuing forced air warming. During transfer to patient care floors, the reflective technology of the forced air warming blankets continued to provide temperature control for patients.

• Surgical service staff team work and increased patient outcomes were noted through this process development.

Statement of Successful Outcomes:

• A new practice model has been developed to prevent redistribution hypothermia.

• We followed a prescribed model to observe current practice, re-educate staff on best practice, and implement a new process for patient warming and evaluation of patient outcomes. We were able to effectively measure improvement in patient outcomes.

“Make it Stick” – Using A Behavioral Model to Assess, Analyze and Sustain Long Term Performance Impact

Thomas Fee, MBA, CMC, Managing Partner, Verity Partners
Johanna Thomas, PhD, Partner, Verity Partners


The assessment evaluated whether current Operating Room (OR) antecedents (i.e., prompts and triggers including policies, formal goal systems, contracts, formal communication documents, training materials, interview guides, behavioral expectations, formal organizational structures, behaviorally based tools like guidelines and checklists) actually functioned to prompt desired behavior. Further, the assessment examined if antecedents that are required for high performance exist. The assessment also analyzed consequences i.e., things that anchor (e.g., recognition events, formal and peer to peer feedback, merit pay) behavior. Consequences are what occurs after the behavior, and encourages or discourages it from happening. Consequences may be positive or negative, that is they may reinforce the behavior (therefore increasing it) or they may punish it (therefore causing it to drop out). Behavior is always a function of its consequences and consequences need to be timely and consistent to affect behavior.  The ABC analysis was validated through interviews and outcome data (e.g., Gallup Survey results, staff assignments i.e., scheduled in dedicated teams, recruitment and turnover statistics, operational statistics). Methods for conducting the behavior analysis were consistent across the health system.

Overall, the health system was slowly evolving into a strategically measured behaviorally based enterprise; where behavior (actions) drive attainment of outcomes from the 2020 strategy to goals, priorities and day to day operations and from I CARE values to expected behavior and culture. This evolution was taking place because in today’s health care environment Value Based Purchasing and reimbursement are tied to human behavior and the outcomes (quality in particular) it generates. The importance of linking outcome measures to payment (reimbursement) is real – it’s about accountability and ensuring consumers are getting value for their health care dollar. The health system’s transition was midstream and certain performance and processes improvement projects (e.g., scheduling process, dedicated specialty teams, goal and outcome alignment) were reworked, expedited and implemented.

A Collaborative Approach to Improve OR Throughput and Cleanliness through Standard Work and Improved Processes

Bobbi McCoy, RN, OR Educator, Crestwood Medical Center
Shannon Leak, RN, BSN, Assistant OR Director, Crestwood Medical Center
Susan Bryce, RN, BSN, MBA, Assistant Chief Nursing Officer, Crestwood Medical Center
Kelly Christopher, N/A, Director, Environmental Services, Crestwood Medical Center


Purpose: Facilitate process improvements to decrease between-case (BC) turnover times and improve BC and terminal environmental hygiene (EH).

Content: In 2014, a multi-disciplinary team initiated a Lean Throughput Project including value stream analysis, data collection, best practices training and Rapid Improvement Event (RIE) at Crestwood Medical Center, which has 19 ORs and performs 1100 surgeries per month. Baseline data was collected on room turn time/motion, high touch object (HTO) cleaning, equipment storage/use, disinfectant material compatibility, contact time, and cleaning roles. The room turn time goal was met, but opportunities for improvement were identified; HTOs were not consistently cleaned, BC or terminal. EH equipment and linens were not conveniently located. It was not easy to tell when a room had been cleaned. Bleach disinfectant required a 10 minute contact time and damaged OR tables and other surfaces.

Strategies for Implementation: Phase 1 introduced room turnover kits, new point of use cleaning carts/tools, sporicidal hydrogen peroxide/peroxyacetic acid disinfectant with 5 minute contact time, fluorescent marker EH monitoring system, and training on EH best practices for all staff. Phase 2, a RIE, began one month after adjustment to new processes/products implemented phase 1.

Outcomes: Post-implementation data was collected as described above. The RIE provided clear communication, defined roles/responsibilities to eliminate rework and omission, and standard work processes for room cleaning, ensuring that team members entering the room during turnover immediately know what has already been cleaned. Best practices training and EH monitoring/feedback to staff resulted in 60% and 35% improvement in BC and terminal HTO cleaning, respectively. Room turn time decreased by 5 minutes. A turnover pack on the OR table in empty rooms is now the visual cue that the room is clean. A “Lean Board” was created to communicate results to staff. No mattresses have been replaced due to disinfectant damage.

Change in OR Functions by Incorporating a Business Model of Service Lines

Munira Amin, BScN, Administrator - Operating Room and SDC, Aga Khan University Hospital
Ehsan Ali, MBA, Manager, Aga Khan University Hospital


The competitive market of health care industry is forcing all healthcare leaders for transformation of the work considering the parameters of high quality and Cost effective care to patients. In a tertiary care hospital in a developing country with the change in leadership a new concept of “service line” as a business model was introduced. The aim of this business model was not only to streamline the existing functions but was also to share ownership of work amongst the consultants and their team. In planning phase of this service line concept a “Pilot” was designed for baseline evaluation of General surgery related Operating Room parameters, which would then contribute in creating “service Level Agreement” between OR/Anesthesia and General Surgery service lines. The findings of this service line pilot revealed that operating room parameters i.e. start time, turnaround times, Anesthesia Release Time, Surgical Preparation Time and Surgical Time could remarkably be improved, if better planning and monitoring is taken into consideration.

Comprehensive Perioperative Gap Analysis

Robyn Yackell, BSN, CNOR, CPHQ, CPPS, Dir. Safe Operative Practice, LifePoint Hospitals


Objective: Identify gaps in practice and processes for perioperative setting to prioritize improvement efforts.

Content: Comprehensive gap analysis and combined audit tool

Implementation: instruction and group calls supporting efforts

Outcomes: Improved compliance with QI by involving front line staff in process.

Containers at Point of Use: Handling, Transport, Inspection, and Reprocessing

Marcia Frieze, CEO, Case Medical


The primary purpose of the poster will be to teach the correct methods for utilizing and then reprocessing reusable sterilization containers at point of use.  The content and strategies for implementation will be a stepwise instruction on proper handling techniques, how to inspect the containers, how to pre-clean at point of use for improved cleaning and decontamination outcomes later, and recommendations for safe transportation from point of use to the Sterile Processing Department.  The transportation step reflects recent feedback from the Joint Commission regarding the labeling of clean vs. used instruments while in transit from point of use to SPD.  The intended outcome for this poster would be a better understanding of best practices with reusable sterilization containers at point of use and when transporting back for reprocessing.

Creating an Orthopedic Specialty Hospital Focused on Exceptional Patient Experience, High Clinical Quality, and Benchmark Level Efficiencies

LouAnn, BSN, RN, CNOR, Manager of Perioperative Services, Center for Orthopedic Medicine Tilghman, Lehigh Valley Health Network


In February 2014, Lehigh Valley Health Network (LVHN) opened the Center for Orthopedic Medicine as a surgical specialty hospital campus with a programmatic focus on total joint replacement, spinal surgery, and ambulatory orthopedic surgery.  Prior to opening the Center, most Orthopedic care was provided in a large, tertiary care setting around and among other high-acuity patient care.

LVHN Tilghman was created in response to market competitive dynamics and increasing orthopedic patient expectations for boutique-style, value-based care.  With significant collaborative input from orthopedic physicians, a physical and amenity-filled environment was created that focuses on efficiency, quality, and patient centered experience in a hotel-like environment that is staffed by a vested, specialized team.

Since opening, the Center for Orthopedic Medicine has focused on goals of significantly reduced length of stay, facilitation of high patient satisfaction scores, and extremely satisfied and engaged physicians and staff. The unit is designed with a comprehensive approach to patient care.

The care prior to surgery is equally as important to the staff of LVHN Tilghman as this care sets the tone for the care the patient while admitted to the hospital.  The units dedicated case manager starts the patient experience with a pre-admission phone call.  During this call she explains to the patients about the unit and reviews with them their personalized “Road-Map” for a successful surgical experience.  This includes discussions about their present condition and home situation along with information about the pre-op, surgical, post-op, and recovery process.   Patients are able to receive all surgery related services at the facility including Pre-admission testing, Laboratory tests, radiographic tests, and personal consultations with the Anesthesiology Team that will be participating in the surgery.  The preadmission process is run by the nursing staff in the peri-op division.  In an effort to ease patient anxiety and promote the patient centered experience these same nurses will welcome the patient on the day of surgery, be with them pre-operatively and again post operatively.  Pre-Surgical education classes are offered monthly and are instructed by the management team, including Perioperative Services, Patient Care Services, Rehabilitation Services, and Case Management . 

The lead by example approach of the management team provides daily mentorship to the staff through their direct presence on the working units.   Daily interdisciplinary huddles have become hard wired on the unit.  These huddles occur at the same time daily on the unit and give the entire team, physician, nurse, technical partner, therapist, pharmacist, and case manager, the opportunity to discuss the individual care of each patient on the unit, report on variances to the plan of care, and facilitate discharge planning.   Through a shared governance program, unit and department accountability is staff driven.  These staff lead interdisciplinary teams use a collaborative approach to care to ensure an optimal patient centered experience by:

• providing resources to assist patients in the navigation of the healthcare system

• providing an care environment that promotes a comprehensive interdisciplinary team that includes patients and their families

• providing respectful and timely communication with consistent and standardized work processes

• providing an inviting and welcoming environment that promotes healing, encourages progress, and dispels fears

• providing access to amenities to anticipate and accommodate patient and family needs.

Through these five key deliverables, the LVHN Tilghman team has been able to further focus on maximizing quality metrics such as HCAHPS, Press Ganey Score as well as staff engagement.

The Patient Centered Experience Council’s mission is to understand the perceptions of the patients experience from the patient’s perspective and make appropriate changes to enhance the patient experience at LVHN Tilghman.  During monthly meeting, this team comprised of members, representing various departments within the facility, meets to review patient feedback reports. The council invites past patients and their support person back to the Tilghman campus to share their experience with a small sub group.  The subgroup reviews the feedback with the department managers and the entire PCE team for appropriate action planning.  These real time interviews have assisted the team by identifying opportunities for growth and improvement within already established systems as well as providing insight into the development of new initiatives.  This council also monitors patient satisfactions scores for the post-op unit.  The team performs audits on response time for call bells, meals, and performance of hourly rounding.  Finally, the PCE Tilghman team recognizes colleagues that significantly impacted patient centered care as demonstrated through positive feedback received from patients and staff.  Recognition of peers from within the work group has shown to significantly impact staff engagement and is reflected in exemplary care that is provided to the patients.    The hard work and dedication of the Center for Orthopedic Medicine team has been recognized at an organization level, as the “Team Tilghman” has been selected to receive the LVHN Senior Management Council Patient Satisfaction Award for Inpatient Care from Lehigh Valley Health Network.


1. In just one year after opening, the inpatient unit at LVHN's Center for Orthopedic Medicine (COM) has the highest HCHAPS scores out of 38 inpatient medical/surgical and ICU departments within the network.

2. Of the 8 HCHAPS measured domains, the COM is nationally benchmarked at the 99th percentile for 5 of the domains for similarly sized hospitals.  The remaining 3 domains are no less than the 94th percentile.

3. Operating room turnover times for total joint replacement and spine procedures averages 20 minutes.

4. First case on-time starts for operating room cases is 98%.

5. Average length of stay for total joint replacement is 2.1 days at the COM.

6. Though not formally measured, physician satisfaction with the COM is extremely high.


Crisis-Sim Lab... Enhancing Patient Safety and Team Collaboration/Education

Tammy Courtney, RN, BSN, Assistant Director of Surgical Suite, Advanced Orthopaedics


Advanced Orthopaedics Surgical Suite has a strong focus on patient safety and the Crisis Sim Lab has helped the staff to meet their goal of providing strong team collaboration, especially during emergency situations.   It was recognized that the emergency process for an adverse event was not as coordinated and concise as it should be at Advanced Orthopaedics Surgical Suite.  Staff members had become somewhat complacent, meaning that they were satisfied with how things were and they were not able to recognize the potential dangers.    Staff members had a need for education and return demonstration with mock codes and other emergency drills instead of just going through the motions and doing what was expected.  Staff did not demonstrate true teamwork and communication skills.  They needed to be challenged, excited, and engaged. 

Advanced Orthopaedics Surgical Suite in conjunction with Virginia Commonwealth University (VCU) Department of Nurse Anesthesia, and North American Partners in Anesthesia developed an education session on effective communication, utilizing the Crisis Sim Lab.  The surgical suite operating room is set up with a computerized simulation mannequin and all of the video equipment, while another operating room is set up as a classroom with capabilities for staff to observe and hear the entire scenario.  Unlike a rescue mannequin, the simulation man is life like; the chest rises and falls, can respond to verbal stimuli, eyes open and close, can cry, jaw can clench, and throat can swell as well as all the characteristics of a human for all monitoring opportunities.  A brief overview of the program and a video was presented to the staff before the first simulation would take place.  The VCU faculty presented lecture content on effective teamwork and communication, the impact of stress on performance, and current threats to patient safety.  The scenarios were chosen and not revealed to any staff members.  Scenarios such as Malignant Hyperthermia, Fire in the OR, cardiac arrest, allergic reaction, SVT, and Can’t Ventilate, Can’t Intubate have been encountered by our staff in a safe learning environment.  The staff after each scenario returned to a classroom for debriefing to encourage positive team performance. 

From these scenarios, staff not only made changes to policies and procedures but have designed kits that worked in an emergency situations.   Staff displayed a great sense of teamwork and solidified the relationships with each other.  The team defined roles and figured out how to work together for the common good of the patient and their positive outcome. The staff after each scenario returned to a classroom for debriefing to encourage positive team performance.  From these scenarios, staff not only made changes to policies and procedures but have designed kits that worked in an emergency situations.   Staff displayed a great sense of teamwork and solidified the relationships with each other.  As a collaborative unit, we are able to communicate more effectively and work through any crisis that may occur here at the surgical suite, thereby providing a safer environment for our patients. Changes to the policies were made by the team that showed clear defined roles for all of the staff in the surgical suite.

Developing Change Makers by Educating Leadership

Thomas Fee, MBA, CMC, Managing Partner, Verity Partners
Johanna Thomas, PhD, Partner, Verity Partners


Developing and educating leadership to deliver effective change methods and become “change makers” proved to be more important than developing process improvement or consulting skills. When leadership used effective change methods during the initial phase of a project they were able to more effectively identify underlying project issues, outcomes and values and to define a simple and clear scope.  After completing twenty four “applied working sessions” leadership was better able to guide projects and teams, reduce ambiguity and focus on critical requirements by using a process to identify the key content and consequences, then use conversation and collaboration to clarify the scope.  The developmental approach integrated both analytic and behavioral tools to develop comprehensive but simple outcome definitions.

In the same time that it took to develop analytic ROI based project definitions and goals, leadership and project management was educated and developed in effective change methods and behavioral change techniques. Leadership and project management worked together and used these change methods to focus the scope and outcomes required by corporate and build both executive and team buy-in.  The approach identified, anticipated and integrated critical behavioral and cultural barriers to success.

Don't Let Another Drop Go To Waste - Minimizing Blood Transfusions on Total Joint Patients with The Use of TXA

Jillian DellaVecchia, RN, BSN, Manager Peri-operative services, AHS - OMC
Barbara Herrmann, BSN, RN, CNOR, Staff Nurse, AHS - OMC
Rita Lanaras, BS, RN, CNOR, Peri-Op business coordinator, AHS - OMC


Purpose: Best practice supports using Tranexamic Acid (TXA) on the Total Hip/Knee Replacement patient. The purpose of this study is to observe and evaluate tangible assessments with the use of TXA and the need for blood transfusion both intra-op and post-op. Perioperative auto transfusion systems are utilized on a significant number of Total Hip/Knee Replacement patients. Many of these patients additionally require transfusion of packed cells during their admission. When the patient does not require auto transfusion and/or PRBC's post-operatively, there is an increase in patient outcomes, patient satisfaction and reduction in cost.

Relevance/Significance: Blood salvage machines are utilized on a significant number of Total Hip/Knee Replacement patients. Many of these patients additionally require transfusion of packed cells during their admission. If the patient does not require the blood salvage with reinfusion and/or PRBC's post-operatively, an increase in patient outcomes, patient satisfaction and reduction in cost.

Strategy and Implementation: All Total Hip/Knee patients from January 2014 to December 31 2014 were selected. These cases were retrospectively reviewed to analyze how many patients received TXA, were re-infused from the Autotransfusion and/or received PRBC's during their length of stay. Graphs were created and distributed to multiple departments to communicate the results. Autotransfusion drainage and Hemoglobin and Hematocrit levels were measured.

Evaluation: Based on intraoperative blood loss measures, a significant percentage of patients who received TXA did not necessitate receiving packed cells or reinfusion of blood salvage blood during their hospital length of stay. A decreasing number of patients required an insertion of drains for blood salvage. Hemoglobin and Hematocrit levels did not drop below set Blood Bank guidelines.

Implications for Practice: The TXA patients had better outcomes because they did not require blood transfusions or drains. The recommendation is to eliminate use of drains and the Autotransfusion on TXA patients thus improving patient outcomes, streamlining processes, reducing cost, and enhancing patient satisfaction. The recommendation is to eliminate use of drains and perioperative blood salvage systems and limit transfusion of packed cells on TXA patients thus improving patient outcomes, streamlining processes, reducing cost, and enhancing patient satisfaction.

Effectiveness of Periop 101: A Core Curriculum™ to Increase Safety, Confidence, Competence, and Reduce Cost in the Orientation of the Novice Perioperative Nurse

Rosalyn McGrath, MSN, RN, CNOR, Nursing Professional Development Specialist Periop Services, UPHS-HUP


Purpose: The purpose of this action research project is to evaluate the effectiveness of Periop 101 as a learning platform for novice perioperative nurses in relation to safety, cost, confidence and competence. Many Perioperative leaders report difficulty in filling staff positions. In a high risk clinical area such as the Perioperative Area, a quality driven, evidenced-based orientation program is critical to safe patient care. Critical thinking skills must also increase in this environment due to the rapid pace and increasing acuity of patients. Nurse educators have a professional and ethical responsibility to ensure novice nurses gain the confidence and are competent to be successful in the Perioperative setting.

Method: An action research approach was used to survey the perioperative staff as the novices were rotating through their clinical specialties. Also, ongoing evaluations of competencies, test scores, self-evaluation, and practice errors were examined among the novices. A cost benefit analysis was also used to determine if Periop 101 is more cost-effective than a department based program. The findings in this study emphasize the effectiveness of an evidence-based, quality driven, orientation program. Novice nurses who transition from the novice to advanced beginner are competent, confident, satisfied, and committed to their organization. An area where further research is needed is in the effectiveness of the program over time.

Enzymes and their Actions: Catalysts to Enhance the Decontamination of Surgical Devices

Marcia Frieze, CEO, Case Medical


The poster will visually accomplish the following objectives in brief: define what enzymes are, discuss the importance of enzymatic cleaners for instrument processing, and list current official recommendations for using enzymatic cleaners.  Content will cover the types of enzymes used in cleaning surgical devices.  It will also teach the basics of how enzymes work, and how that applies to instrument processing by means of catalyzing the cleaning action.  Strategies for implementation will come from AAMI, FDA, & CDC guidelines, chiefly their recommendations for enzymatic instrument chemistries when processing endoscopes, and which steps in the decontamination process would benefit from enzymatic solutions.  The main outcome for this poster topic would be a better understanding of a significant class of instrument processing cleaning products.  A potential additional outcome would be improving Sterile Processing Department turnaround times by encouraging the use of safe, rapid acting, efficacious enzymatic cleaners for surgical devices.

Evaluating the Impact of a 360-degree Survey Feedback and Goal-setting Quality Improvement Process

Mary Wiggin Loux , DNP, RN, Associate Chief Nurse, North Shore Medical Center


PURPOSE/OBJECTIVES: Literature on healthcare safety identifies disruptive clinician behavior as negatively impacting patient outcomes. Nurse leaders in high acuity areas such as the operating room are challenged in effectively addressing negative staff behaviors. Individuals often do not recognize their own behavioral issues and deny the validity of negative feedback provided through traditional appraisal systems.  Implementation of 360 degree peer evaluations with surgeons has been correlated with measurable behavioral improvements, so expanding quality feedback to an inter-professional healthcare team is also expected to improve outcomes.

CONTENT: This project evaluated the sustainable impact of a structured 360 degree peer evaluation and debriefing process on workplace behaviors exhibited by 36 registered nurses and surgical technologists practicing in a community hospital operating room. Raters who provided baseline feedback provided follow-up data one year later. Longitudinal perception ratings were analyzed to determine if improvement had occurred in quality related behaviors.

STRATEGIES FOR IMPLEMENTATION:  Preparation and education of staff members prior to initiation of the entire process was essential. All raters were assured anonymity and per IRB requirements, all participants had the option of refusing participation. Raters scored subjects using a 1-5 Likert scale with 3.0 indicating no change from baseline and scores of > 3.0 indicating improvement. The facility pre-approved this project as quality improvement and Northeastern University granted formal IRB approval.

OUTCOMES:  Paired t tests examined pre- and post-scores. Statistically significant improvements in behavior were noted.  The aggregate improvement mean score from baseline was 3.59 (P < .001). The 95% confidence interval ranged from 0.36 to 0.82.  Improved 360-degree peer evaluations in healthcare may correlate with improved patient outcomes as well as team and patient satisfaction. Further investigation is needed in order to determine if these results are replicable and if the behavioral improvements associated with the process correlate with improved patient outcomes.

Examining Neurosurgical Surgical Site Infections

Jennifer Fencl, DNP, RN, CNS-BC, CNOR , Clinical Nurse Specialist, Cone Health


Background: Surgical site infections (SSI) are the most common type of infection for the surgical population, impacting morbidity and mortality rates.

Purpose: Assess SSI risk factors for spinal surgery, and deveop an SSI risk assessment tool considering pre- and intra-operative risk factors. Method: Utilizing similar methodology discussed in previous studies focusing on neurosurgery, a drill down tool was utilized reflecting risk factors contributing to SSI.

Results: In this sample, the strongest predictor of SSI was the type of intra-operative prepping solution utilized (p= .009) and how skin closure occurred (p= .006). In addition, the placement of drains (p= .001), glue utilized to repair dural tears (p = .041), and misappropriate antibiotic administration (p=.026) also demonstrated an increased risk of developing a SSI.

Excellence in Perioperative Services: RN Prompted Time Out

Mary Dobbie, RN, BSN, CNOR, CURN, Senior Nurse Clinician, NYU Langone Medical Center
Maria Fezza, RN, BSN, CNOR, Nurse Manager, NYU Langone Medical Center
Martha Kent, RN, MSN, NEA-BC, CPAN, Director of Quality - Perioperative Services , NYU Langone Medical Center


The purpose of this program is to illustrate the strategy, development, and implementation of the RN Prompted Time Out initiative that has enhanced patient safety. This was a path of discovery and learning that captivated the entire Perioperative Service to standardize our practice and empower our teams.

The goals of this initiative were to achieve standardization and consistent structure to the Time Out process throughout the institution thereby improving patient safety. The following top priorities were established: standardize practice, provide structure, increase patient safety, improve team communication, enhance teamwork, improve compliance, and promote empowerment.

The strategies for implementation included to create a team approach, gain administrative approval, provide education, and identify practice deficiencies and successes. The RN Prompted Time Out Script was developed in collaboration with RN leaders and staff members. The team effort used current surgical checklist and standards to create the script. Feedback was encouraged from team members to improve the process and ensure compliance.

Incremental implementation was rolled out to all 23 perioperative services sites. Educational in-services were conducted for each site. To ensure compliance, laminated checklists were placed in every OR/Procedural room, visits to individual units were conducted, and nurse managers were encouraged to have a presence in the OR/Procedural rooms and to provide mentorship and coaching.

Barriers that were identified included: change taking time, the need for constant reinforcement and mentoring by leadership, and MD buy in.

The culmination of these initiatives engaged the perioperative staff in improving patient safety and compliance. Through focused and concerted efforts, the hospital has implemented the RN Prompted Time Out Script. The process has led to improved team communication and empowerment of all staff members.

From Flashing to IUSS: A Team Approach

Henry A. Harrington, BS, MBA, CRCST, Manager, Sterile Processing Department, Lakeland Regional Medical Center
Mary Perry, RN, MSN , Manager, Surgical Services, Lakeland Regional Medical Center


Lakeland Regional Medical Center is a full service medical center and health system. As an 851- bed not-for-profit medical center, Lakeland Regional Medical Center (LRMC) is the fifth largest hospital in the state of Florida. LRMC has an average surgical case volume of over 1300 cases per month. We identified a huge need to improve our IUSS rates, which, when measured against the number of surgeries, were sometimes as high as 64% . Our project team consisted of Surgical Services and SPD leadership , in consultation with the Infection Control leadership. With new leadership in SPD, ownership of all surgical item reprocessing was assumed by SPD. We implemented a rigid documentation initiative of all IUSS events, to determine the underlying causes for our high rates. With careful monitoring, controlled access to IUSS locations, and re-educating all staff, we were able to reduce our IUSS events consistently to 1 %- 3%.

Immediate Use Steam Sterilization Reduction Initiative

Wendy R. Ferro-Grant, RN, MSN, MBA, HC, CNOR, Director Perioperative Services , Mission Hospital
Sharon Hadley, RN, Director, Integrated Medical Systems International, Inc.


Purpose/objectives: Demonstrate how to develop and improve sterile processing practices to reduce the use of Immediate Use Steam Sterilization.

The learner will:

  1. Identify key practices requiring improvement through using recognized national benchmarks

  2. Identify how to establish Key Performance Indicators (KPI)

  3. Recognize the essential role the executive leadership team has in collaboration and commitment to establishing a best practice in IUSS

  4. Learn the impact of collaborative decision making in response to IUSS


TJC and CMS unannounced surveys in October 2014 identified significant findings and gaps in sterile processing and infection prevention practices including the high use of IUSS leading to conditional certification. Key organizational leaders determined the need in partnering with an industry leader to develop a comprehensive high level disinfection and sterile processing centralized program.

Strategies for Implementation:

Partnered with sterile processing industry leader, Integrated Medical Systems International, Inc. (IMS), to identify gaps, develop strategies and implement interventions to reduce the use of IUSS and improve quality practices. Developed the role of OR Liaison who ensures quality is maintained in the transport and delivery of all surgical instrumentation, case carts have the appropriate instrumentation, turnover of instrumentation for to follow procedures, and communication/collaboration with staff and surgeons to address all instrument needs.  Created OR/SPD daily leadership huddles including anesthesia board runner to debrief on what went well, what opportunities were identified, and what instrumentation is required for the next day’s schedule.  Collaboration with surgeon, anesthesia, and staff to collaborate on options available prior to any decision to IUSS and final approval for using IUSS by the perioperative director and executive team member.


  • IUSS: < 1% sustained: (Industry standard = 12%

  • OR Friction: < 5% sustained (Industry standard = 5-7%)

  • Tray Errors: < 1% sustained (Industry standard = 1-2%)

  • Dirty Instruments: < 0.3% sustained (Industry standard= 0.3% – 0.6%)

  • First Case Carts Complete: > 85% sustained (Industry standard 80% - 85%)

  • Second case carts complete: > 85% sustained (Industry standard = 80% - 85%)


Implant Reordering Improvement Process

Penny Lipcsik, RN, MN, BScN, Value Stream Group Leader Planned Care, Brant Community Healthcare


As an OR performing approx. 9500 surgeries/year we realized that we needed to improve our reordering system for implants due to the increasing number of errors and missing items to complete sets. Incomplete sets at time of surgery caused delays and cancelled surgery and frustration for surgeons and staff. Also there were costly mistakes in ordering wrong items.

We wanted to develop a streamlined process for reordering implants that allowed us to have the implants to have the correct implants for surgery when we needed them. It would allow us to have the right staff ordering implants, with minimal amount of touches and work. 

We developed a working group to understand our problem and work through our immediate issues. The working group brought together OR, MDR, store’s, purchasing, continuous improvement and management. Ideas discovered and lessons learned were that the current process was very labor intensive.  We created a reordering process that starts in the OR with scanning that notifies purchasing of the order and is verified by MDR as a quality check. This also meets documentation standards. Because of this double check there is decreased errors in ordering, decreased delays for patients and decreased costly mistakes.

Implementing Successful Waste Management and Recycling Initiatives in the OR

Valerie Sosnowski, MSN, MHSA, RN, CNOR, Director Perioperative Services, NorthShore University HealthSystem
Matt Waskerwicz, MBA, MHSA, Sr. Director Business Services, Corporate, NorthShore University HealthSystem


Perioperative nurses are responsible for their environment and should promote sustainability practices in their daily workflows to reduce waste and preserve natural resources. This poster explains the methods and processes used to implement a successful recycling program in the operating room. It highlights a multi-disciplinary, collaborative approach to this issue and provides practical advice from the clinical, environmental, and business aspects on tactics that can be used to coordinate such a program in a hospital’s operating room. Some easy solutions to common problems in the OR can be identified that will encourage participation and cause minimal disruption in workflows. Identification of a perioperative nurse who can be a champion for the cause and has a passion for the recycling process is important. Education of all stakeholders will help to be a catalyst and will help to drive the success of a recycling program through collaborative engagement of key departments.

Improving Efficiency Targets and Improving Capacity

Gardito Ruiz, MHA, Service Line Programs Director, Children's Medical Center


Our health system had a strategic plan to recruit surgeons, develop new programs, and shift volume outside of the Main OR (MOR). Optimizing space, personnel, processes, and changing culture would be central to improving poor OR metrics and supporting the strategic plan. We used operations management to improve processes, develop metrics, and set clear expectations for resource allocation. The EHR afforded us the opportunity to share credible data with appropriate stakeholders. The results from 2006 to 2013 were: a) cases increased +42% from 19, 148 to 27, 200, b) block utilization increased +45% from 47% to 68%, c) on time starts increased six-fold (12% to 80%), d) case cancellations reduced three-fold (14% to 4%), e) MOR cases increased +3%, f) cases outside of MOR increased +134% from 5, 606 to 13, 143, and g) revenue increased +84% from $116M to $214M. Operations management and EHR allowed us to change OR culture and improve performance.

Improving RN Job Satisfaction

Michele Brunges, Nurse Manager, UF Health
Christine Foley-Brinza, Clinical Leader, UF Health


The purpose of this poster is to share ideas on how to improve RN job satisfaction in the perioperative unit. It will provide solutions on how to support a healthy work environment for all staff members and improve teamwork within the unit. The result will be to change the culture in perioperative unit from negative to a positive environment. This poster will provide multiple creative ideas that can be utilized to improve job satisfaction. Outcomes after implementing these changes will show increased job satisfaction measured by results from national surveys. Implementing these changes and increasing job satisfaction will stabilize the unit and decrease RN turnover rate.

Learning Objectives:

  • Describe methods to improve job satisfcation

  • Identify strategies to improve the culture

  • Define a healthy workplace environment

Integrating Leadership for Change – Operations, Medical and Engineering

Thomas Fee, MBA, CMC, Managing Partner, Verity Partners
Johanna Thomas, PhD, Partner, Verity Partners


Sustainable performance improvement in surgery services is affected by surgeon acceptance and adoption. Involving physicians and surgeons was essential to project success. Their guidance was critical during the information gathering and pilot stages of designing and modeling the new process and team approaches. Their involvement promoted personal investment in desired outcomes and promoted relationship commitment among team members.  Performance improvement initiatives (especially those that are management engineering led) need to engage surgery services leadership, surgeons and physicians early in the conversation, focus on consequences, build commitment through participation and foster team collaboration.  To effectively engage surgeons in leadership required careful integration of applied behavioral science techniques throughout the performance improvement cycle. Changing physician practice is about changing people (changing their behavior), not simply improving a process or activity for a short term gain.

Integrating surgeons, physicians, surgery leadership and management engineering early in the process, taking the time to involve affected participants in the development greatly increased acceptance, adoption and goal attainment of surgery services performance improvements.  Collaborative leadership including surgeons and physicians is built not through committee meetings, but by careful behavioral changes adopted through active involvement in the project piloting and rollout phases. Collaboration led to more effective solutions being implemented for performance improvement

Learner-driven Onboarding: Putting the Evidence Together in Perioperative Services

Sueanne W Cantamessa, DNP(c), MSN, RN, CNOR, RN IV Educator, Houston Methodist Texas Medical Center


Evidence based practice process intervention for onboarding of new Perioperative and Peri-anesthesia nurses, based on a thorough review of the literature, will be a married state process or dyad. Competency will be learner driven. The married state intervention will be a pilot study at this time for the facility, with success to be adopted as protocol for all of perioperative services. Each dyad will be matched based on an established learning style inventory that all staff take upon hire into the department. Each new staff member will complete a SWOT personal analysis each week of the program to assist with determining learning needs based on experiences, education and generation. Participants in this program are called “residents” by the hiring facility protocol.


1. Each resident will participate in the selected program didactic, Periop 101 curriculum or Critical Care Nurses curriculum adapted for the post anesthesia care unit. These curricula are supported and facilitated by the center for professional development (CPD) through classroom, simulation and group discussions and games.

2. Both didactic programs commenced after resident hire in April, 2015 and continue through July, 2015.

3. Clinical coach volunteers are experienced and certified in the specialty area (Periop or Peri-Anesthesia) and will have classes and simulations of adult learning theory, learner driven concepts, critical thinking and professional integrity and comportment. Clinical coach role will be added to the clinical ladder program (Career Enhancement) as a specialty selection. Formal classes and focus groups will be conducted while the residents are in didactic training so that concepts and concerns can be reflected upon and thoroughly discussed prior to the match with the residents. Clinical coach education will start after program coordinator completes orientation to facility after June 15, 2015.

Post Intervention:

1. Completion of final Nurse Retention Tool and Readiness to Practice tool

2. Successful completion of final examination for didactic portion(s) provided through curricula providers.

3. Competency assessment by coordinator (educator) and clinical coach.

4. Publication of results of program and recommendations for the future.

Management for Daily Improvement (MDI)

Susan Sullivan, Nurse Manager PAT, SDS, OR & PACU. Clinical Information Specialist, Lake Health Medical Center
Kimberli Cole, Nurse Manager - OR and PACU, Lake Health Medical Center


The purpose of poster is to explain our use of the Management for Daily Improvement Board. The MDI board is the framework for helping us develop a culture of continuous daily improvement. We must continually improve if we are going to survive all the changes coming in healthcare.Content will include:

1. Rationale for use of MDI boards.

2. Process for MDI board usage.

3. Basic problem Solving skills used with MDI boards. Including Pareto analysis, the 5 why's, fishbone diagram, and A-3 thinking.

4. What we have learned.

Microwave Ablation for TRAP (Twin-Reversed Arterial Perfusion Sequence)

Jane Babela, RN, MSN, CNOR, RNFA
Courtney Stephenson, DO, FACOG
David A. Iannitti, MD
Cassandra Duren, MSN,RN,CNOR


Courtney Stephenson, DO, FACOG; David A. Iannitti, MD; Jane Babela, MSN, RN, CNOR, RNFA; Cassandra Duren, MSN, RN, CNOR; Lori Jacobs, BSN, RN, CNOR;  and Emilijane Raine, BSN, RN; Charlotte, North Carolina.

A clinical innovation study of Twin-Reversed Arterial Perfusion (TRAP) Sequence, also known as acardiac malformation or acardiac twinning, which is a rare pregnancy complication involving monochorionic-monoamniotic-monozygotic co-twins.  Aim for the study is to collect and analyze data through comparisons of microwave ablation TRAP sequence case studies. Study methodology will be performed by the following intraoperative nurses associated with the surgical procedure: Jane Babela, principal investigator, Cassandra Duren, Emili, and Lori Jacobs, clinical project team members.  Methodology for this study involves a retrospective review and collection of data from surgical cases by Dr. Courtney Stephenson and Dr. David Iannitti, involving use of microwave ablation technology to incapacitate the TRAP sequence. In addition, the team will acquire report data on the surgical patient outcomes post-procedure from Drs. Courtney Stephenson and David Iannitti. TRAP sequence occurs in approximately 1% of monochorionic twin pregnancies; 0.3% of all monozygotic twin gestations; and, 1 in 35, 000 pregnancies, each year.  In TRAP sequence, the fetus with normal development (pump twin) provides circulation for itself and to its twin sibling, who typically has acardiac and/or acephalic congenital anomalies, which are inconsistent with life.  The anomalous, co-twin receives blood via retrograde flow through placental arterial and/or vein anastomoses of the umbilical cord.  Untreated TRAP sequence can result in deleterious outcomes in the viable twin, such as: TRAP syndrome, high output cardiac failure and increased mortality rate.  In addition, undesirable outcomes for the mother include: early delivery due to premature rupture of fetal membranes, hemorrhage, infection, preterm labor and miscarriage.  Current therapies for TRAP sequences include: removing the abnormal twin, coagulating blood vessels between the twins, and ligating or cutting the cord of the abnormal twin via fetoscopy.  Microwave ablation, a minimally invasive surgical procedure, is performed to discontinue the abnormal blood flow to the recipient twin, thus decreasing the risk of harm or injury to the pump twin.  The perioperative nursing implication regarding Twin-reversed arterial perfusion sequence using Microwave Ablation is a patient-centered care initiative, which will provide greater insight about the use of this innovative clinical intervention to improve mother-baby patient outcomes and establish standards for evidence-based clinical practices in the surgical setting.

On-Time Surgical Start in the OR, Aga Khan University Hospital, Karachi, Pakistan

Kiran Sajid, RN, BScN, Clinical Nurse Coordinator, Aga Khan University Hospital, Karachi, Pakistan


Purpose: The purpose of the project was to improve the utilization of operating room by effective proper start time for the first procedure. This also helps the management to identify the causative factors that leads to delay start time in operating room. This practical approach helps to decrease the start time delay in ORs and facilitate on-time start. For this reason, the benchmark of 75% monthly was targeted.

Content: The descriptive quantitative data was collected by recording the wheel in time of every 1st patient scheduled in operating room. The inclusion criterion was the patients scheduled for elective list. The data collection excludes the patients that were booked on emergency/add on list.

Strategies for Implementation: The inference is that the list formation was improved by scheduling the first patient as inpatient rather scheduling daycare patients. Surgeons and anesthetists were contacted a day prior about informing the next day start time of operating slot. Patients were called earlier in preoperative bay to make sure the complete preparation.

Outcomes: The collected data was analyzed and demonstrated the causative factors in start time operative delays as late arrival of surgeon, anesthetist, and late admission of patients especially on the day of surgery, communication gap, and incomplete preop preparation of patients. In 2013, the start time was 58.4% that improved to 74% by April 2015.

Opening a New Pediatric Epilepsy Monitoring Unit

Kimbelry McEvoy-Dodson, RN, BSN, CNOR, FACHE, Associate Vice President, Children's Hospital Los Angeles
Cheryl Franco, Manager PCS Education - 6 WEST, Children's Hospital Los Angeles


Ensuring multidisciplinary program cohesiveness, clinical competence, and effective educational tools is critical for the success of bedside providers to deliver safe patient care when starting a new program. In 2014, Children's Hospital Los Angeles started a brand new epilepsy monitoring surgical unit on an already established inpatient unit of varying specialties. This poster will discuss the clinical considerations, multidisciplinary program management needs, and the educational learning tools used through the continuum to start the epilepsy monitoring surgical unit. Focus will be directed toward the nurse manager role in identifying staff needs and maximizing effective learning through the use of a multidisciplinary pathway.

Perioperative Diabetes Management

David Young, MD, Director of Presurgical Testing, Advocate Lutheran General Hospital
Lynn Nolan, BS, RN, CAPA, CPAN, Assitant Clinical Manger Perianesthesia, Advocate Lutheran General Hospital


At Advocate Lutheran General hospital the impetus to implement a perioperative glucose algorithm of care was based on the goal of decreasing surgical site infections (SSI), morbidity, and mortality. Multiple studies confirm that rigorous monitoring and glucose management in the ICU decreased hospital mortality by 34% and bloodstream infections by 46%. This principle was applied to the preoperative surgical setting with the goal of improving surgical outcomes. Evidence supports glycemic control in surgery. In order to achieve this goal a multidisciplinary team of physicians, pharmacists, nurses, and nurse educators reviewed the literature and collaborated to develop diabetic management goals. Target glucose levels were determined, and algorithms, protocols, and order sets were developed. A robust resource manual was created, and education for nursing and anesthesia staff was completed. This education included clear and consistent scripting of patient preoperative instructions. In 2014, 89.8% of diabetic patients at Advocate Lutheran General were admitted to the PACU with a blood glucose level between 71-180mg/dL. The incidence of hypoglycemia for diabetics on the protocol in 2014 was 0.006%.

Physician Preference Card Maintenance Program

Lesia T. Very, MSN, Clinician, UPMC Presbyterian Shadyside Hospital


In the current healthcare environment, increasing efficiency and controlling costs have become paramount in the healthcare market. All hospital departments are striving to meet these goals through various measures. The operating room is an area where cost containment delivers a financial reward. An investigation into utilizing the physician preference card as a change agent for efficiency, cost containment and physician/staff satisfaction was launched at the University of Pittsburgh Medical Center Presbyterian Shadyside Hospital. The physician preference card provides the operating room staff with vital information concerning the needs of a specific surgical procedure. Keeping this information up-to-date has proven challenging for clinicians responsible for this task. A detailed look into some of the challenges experienced by the OR staff demonstrated that improvements were needed in the maintenance of the preference cards. The goal of implementing a preference card maintenance program was to secure increased physician and staff satisfaction while ultimately leading to increased efficiency and cost containment. The Surgical Processing Department (SPD) and Supply Chain Management also benefit with fewer items to order, stock and handle.

A survey was given to the OR staff asking for opinions on the greatest sources of frustration concerning the preference cards. With 50% responding, the overwhelming responses were outdated information and inconsistent formatting. Collaborative efforts were made with the clinicians to standardize a format. Frequency of updating the preference cards has increased. The introduction of custom service supply packs through SPD assisted in the reduction of an average of 15 supply items from each preference card. SPD was able to decrease the time taken to fill each case cart by an average of 10 minutes. Positive feedback was provided by the OR staff. This project lays a foundation for continued improvements in the OR focusing on efficiency and cost containment.

Post Procedural Transition of Care

Susan Sullivan, RN, Nurse Manager OR, PACU and PreAdmission Testing, Lake Health
Kimberli Cole, RN, BSN, Nurse Manager OR and PACU West, Lake Health


Purpose: Post Anesthesia Care Unit (PACU) was experiencing throughput delays resulting in increased length of stay, increased staff overtime and decreased staff, patient and family satisfaction.


1. To reduce the average LOS for the PACU patient.

2. To identify and reduce throughput delays.

3. To reduce staff overtime.

4. To increase patient, family and staff satisfaction.

Initial state:

• PACU Phase I LOS significantly above benchmark.

• Throughput delays.

• Decreased staff satisfaction resulting in staff turnover.

• Decreased patient and family satisfaction due to holding in PACU.

• Increased overtime over budget.

Target state:

• Patient Safety and quality of care will be improved by having patients transported out of PACU within 60 minutes.

• Eliminating bottlenecking in the PACU will prevent delays in next case starts.

• Efficient PACU throughput will eliminate extra labor expense from holding post-operative patients.

Gap Analysis:

• OR does not know what bay for patient.

• Delays in receiving Post Op orders for care.

• Excess motion to desk to answer phone.

• Undetermined if bays are clean after patient leaves.

• Facilitator with assignment can't assist in managing flow.

• No clear point of contact for communication.

• Transport not notified timely.

• SDS beds not available.

• Nurses covering bays on opposite sides of PACU.

• PACU nurses leaving unit to transport patients.

Rapid experiments:

• Facilitator working without assignment and running PACU to meet targets and communicate with SDS Facilitator.

• Visual Management at bedside with timers and control board.

• PACU phones rolled to OR control desk.

• Proactive bed assignments for next day TCI's.

Strategies for implementation:

• Completion plan.

• Development of standard work for RN facilitator and RN staff nurses.

• 6S equipment and PACU bays.

• Developed Bedside Visual Management boards.

• Developed PACU tracking board.


• Decreased PACU average LOS.

• Decreased throughput delays.

• Decreased staff turnover rate.

• Increased patient and family satisfaction.

• Decreased overtime.

Pre-Anesthesia Testing (PAT) Clinics - Why and Why Not

Lisa Kerich, PA-C, Vice President Clinical Services, Pre-Op Anesthesia, EmCare Anesthesia Services
Linda Caccamo, MS, MBA/MHA, Sr. VP Anesthesia Services, North Division, EmCare Anesthesia Services


PURPOSE/OBJECTIVE: Providing better service to patients through careful and appropriate pre-operative optimization and medical management leads to better outcomes and improved patient satisfaction.  When patients are properly prepared for surgery, provider satisfaction also improves and surgeons are able to operate on-time without any significant delays or interruptions. 

CONTENT: In today’s current healthcare environment, hospitals of all sizes experience a variety of issues surrounding proper surgery preparation.  Many patients are being sent to surgery without proper optimization of medical conditions.  In addition, surgeons may or may not order the appropriate lab test, x-ray, ECG, or consult for clearance.  Further complicating matters, very few patients are receiving the proper pre-anesthesia evaluation.  High risk patients (ASA 3 or 4) may not receive the evaluation recommended by the American Society of Anesthesiologists.  All of these shortcomings typically result in a high number of case delays and cancellations.

STRATEGIES FOR IMPLEMENTATION: EmCare’s PAT Clinic aims to ensure that all patients are properly prepared for surgery prior to their surgery date.  When the decision is made to perform surgery, the surgeon’s office scheduler will book the operating room (OR) and make an appointment for the patient with the PAT Clinic.  This initiates the following process, established with agreed timelines and accountability.

OUTCOMES: Implementing the PAT Clinic model significantly improves the peri-operative experience for patients, staff members at surgeons’ offices, as well as hospital staff.  The most notable benefits include improvements in patient and staff satisfaction, patient safety, throughput and efficiency; reductions in same day surgical cancellations and delays by as much as 60 percent; streamlining the surgery check-in process; standardization; and patients who are medically optimized prior to surgery. 

Primitive OR Work Style Transformation

Munira Amin, BScN, Administrator - Operating Room and SDC, Aga Khan University Hospital
Ehsan Ali, MBA, Manager, Aga Khan University Hospital


OR in a tertiary care hospital in a developing country had scheduling functions which were in placed decades ago by surgeons giving them flexibility in planning their OR slots with their own feasibility. These ORs are functioning on the primitive pattern of block scheduling which had capacity to receive booking till an evening before the day of surgery. This lead to either underutilized ORs or unplanned overutilization resulted in decreased quality care. Moreover, this unorganized activity also showed a decline in surgical volumes and dissatisfaction amongst surgeons with high volumes. Considering these parameters, hospital’s higher management took a decision for changing “the way of their work”, identified problems and rectified. The strategies included modification in working pattern of Saturday elective list, titrating underutilized ORs with more volumes specialties and emphasizing patient preparation before getting them booked for surgery. These changes brought a big cultural transformation.

R-E-S-P-E-C-T: Find Out What It Means To Me in the Operating Room

Renee Russell, BSN, RN, CNOR, Director of Nursing Perioprative Services, Harris Health System
Khaleela Brister, BSN, RN, CNOR, Clinical Resource Nurse Perioperative Services, Harris Health System
Louly Williams, BSN, RN, CNOR, Nursing Clinical Manager Operating Room, Harris Health System


Retained surgical items are 100% preventable, yet continue to occur 2, 000 – 4, 000 times a year. Multiple factors contribute, including repetition and distractions. The surgical count video was developed to raise awareness of retained surgical items, empower the surgical team to identify and resolve unsafe practices, and provide education utilizing humor. Using humor as an educational strategy has shown to increase attention and interest to information. A review of literature supports that humor can be a successful strategy for motivating and engaging nurses in learning.

A music video was put together including members of the surgical team highlighting the importance of no interruption during counting. Lyrics were written/ sang over the background music of RESPECT by Aretha Franklin. The video was presented at executive and operating room staff meetings.

Surveys were sent out to operating room personnel regarding their experience of viewing the video. The survey included five statements about the video with choices for Likert-type responses from one (strongly disagree) to five (strongly agree). There was a 48.8% response rate (22 of 45). Responses ranged from 60 - 90% positive on each question.

Reducing Surgery Scheduling Errors

Donna S Watson, PhD, RN, MSN, CNOR, FNP, Director, Medtronic
Kenn Daratha, PhD, Associate Professor, Washington State University
Cynthia F. Corbett, PhD, Interim Dean, Washington State University
Gail Oneal, PhD , Assistant Professor, Washington State Universtiy


Purposes/Aims: The purpose of this patient safety research is to determine whether team training with bundled interventions for surgeons and multidisciplinary staff involved with surgery scheduling will improve the accuracy of surgery scheduling, thereby minimizing scheduling factors that contribute to the occurrence of wrong site surgery (WSS).

Rationale/Conceptual Basis/Background: Despite decades of patient safety research, medical errors occur at an alarming rate and may result in life-threatening disabilities, extended hospitalization, or death. Preventable egregious medical errors include wrong patient, wrong site, and/or wrong procedure surgery. Approximately 40 WSS occur weekly in the United States. Position statements, guidelines, and checklists have failed to decrease the incidence of WSS. Moreover, The Joint Commission has reported 39% of WSS examined began with a surgery scheduling error. The incidence of surgery scheduling errors range between 0.41% to 5.3%; however, research and preventative measures are limited.

Methods: Pilot results will be presented utilizing quasi-experimental research, prospective data collected from a Washington State Health Care System. The scheduling department schedules an average of 100 surgery cases daily.

Results: Expected results include insights for incidence and types of surgery scheduling errors and effectiveness of bundled team training as an intervention to reduce surgery scheduling errors.

Implications: This novel and innovative patient safety research is needed to identify effective patient safety strategies to minimize surgery scheduling errors and patient risk. The expected outcome of this research is to provide evidence that an additional layer of protection may be added to minimize the risk of wrong site surgery by strengthening the processes that occur on the front end of the patient experience beginning with surgery scheduling. The study results have the potential to influence local and national standards, guidelines, and position statements to promote safe patient care throughout the perioperative surgical continuum.

Reducing the Incidence of Spinal Fusion SSIs

Mary Beth Riegel, RN, BSN, CNOR, OR Nurse Manager, Howard County General Hospital
Sharon Rossi, RNC, MS, Senior Director - Perioperative Services , Howard County General Hospital
Sylve Masih, RN, BSN, CNOR, OR Service Line Coordinator, Howard County General Hospital
Barbara O'Connor, RN, MSN, CIC, Infection Control Manager, Howard County General Hospital


The Howard County General Hospital Spinal Fusion infection rate was significantly higher than the Johns Hopkins Medicine benchmark of 1.5%. Surgical Site Infections (SSIs) represent serious safety risks for patients, resulting in readmissions and additional surgeries. The cost to treat SSIs places a substantial financial burden on the health organization, patients, and providers. The Spine Infection Performance Improvement Committee was formed in December 2013 in an effort to reduce the incidence of Spinal Fusion SSI rate at HCGH from 5.85% to less than 1.5% by FY 2015.

Pre-Hospitalization Improvements included:                                                                                                                                                                         

*Standardized testing and treatment as needed for MRSA

*Standardized pre-op teaching including pre-surgical showering using CHG                 

*Development of a spine surgery information booklet                                                                    

*Reinforcement of teaching/showering by Ortho PA and RN via phone calls

On the day of Surgery, the following Pre-Op Improvements were made:

*Standardized pre-op teaching                                                                                        

*Surgical clipping performed in pre-op                                                                  

*Surgical site cleaning with CHG cloths                                                                          

*Pre-op antibiotic selection                                                                                              

*Focus on hand hygiene with audits

Intraoperative Improvements involved:                                                                    

*Inclusion of surgical attire and head coverings, adequately covering hair and ears            

*Creation of Entry Exit logs to eliminate unnecessary traffic / Entry into OR only allowed through restricted hub                                                                                      

*Re-dosing of antibiotics was every 4.5 hours                                                                  

*Change of gloves at sterile field after draping, prior to implants, and every 90 minutes                                                                                                                                                     *Standardization of drapes that included the use of an ioban drape across the buttocks

*Surgical prep training assured consistent technique in all cases

*Access by vendors was monitored to limit unnecessary talking and traffic               

*Focus on hand hygiene                                                                                                  

Environment of Care Improvements included:                                                                                

*Terminal cleaning schedule                                                                                            

*Between-case cleaning with focus on high touch areas                                

*Inspection of ORs                                                                                                              

*New technology with UV cleaning                                                                      

*Standard process for work/repairs conducted in ORs with use of ICRA, Hepa cart, and terminal cleaning following all work                                                                                                                               

Postoperative Care Improvements included:                                                                                                                                                            

*Dressing management                                                                                                                

*CHG baths for 3 days post-op/or until day of discharge                                              

*Improved discharge planning

The analysis of Spinal Fusion surgical site infections at HCGH has shown a decrease from 6.8% in 2013 to 2.4% in 2014. Currently in the year 2015, we are seeing an infection rate of 1.5%.

Rendering Manually Cleaned Medical Devices Safer to Handle

Kaumudi Kulkarni, Microbiologist, Healthmark Industries


Manually cleaned devices are generally perceived to be not as safe to handle, as the mechanically cleaned instruments. Many sterile processing personnel even take the added step of wiping the manually cleaned items with alcohol after they have been sent through the pass-through window. Manual cleaning is required for devices that are temperature sensitive, non-submersible or those that have size limitations. Rigid endoscopes including arthroscopes and laparoscopes that have power cords, lenses and electronics components are often manually cleaned for the same reasons.

There is a novel concept that adds a level of safety to handling manually cleaned devices on the clean side of the sterile processing area. This no-touch technology does not replace manual cleaning, but supplements it. The concept is to pass the manually cleaned devices from the decontamination side to the clean side through an ultraviolet (UV) disinfection system that is placed in the pass through window! This way, the manually cleaned devices are further disinfected before they come to the clean side. This concept is similar to the well-established use of UV radiation to disinfect hospital rooms.


Skin in the Game: Intraoperative Pressure Ulcer Prevention

Susan Hodgin, MSN, RN, CNOR, Patient Care Manager, Neurosurgery, Vanderbilt Medical Center
Candi Haggard, BSN, RN, CWOCN, Wound, Ostomy Continence Nurse, Vanderbilt Medical Center
Sheena M. Weaver, MD, Anesthesiology-Division of Critical Care Medicine, Vanderbilt Medical Center


The CMS deemed Stage II/IV pressures ulcers as “never events” in 2008. Hospital acquired pressure ulcers can increase a patient’s length of stay and 30 day re-admission rate and mortality. The purpose of this Quality Improvement Initiative was to determine the unique risk factors for patients acquiring pressure ulcers in the perioperative environment, specifically patients placed in the prone and park bench position; perform a process analysis; address key factors contributing to the development of pressure ulcers; implement strategies to reduce the risk of pressure ulcer development and evaluate the outcomes. This poster contains a description of the problem, review of the current literature, a discussion of risk factors unique to perioperative patients, and implementation of applying multi-layer dressings to the areas of risk for pressure ulcer development. Patients undergoing neurosurgical spine procedures in the prone position and patients undergoing craniotomy for tumor procedures in the park bench position where surgery was expected to be greater than six hours were identified. Multi-layer foam dressings were applied to bony prominences and areas where moisture were a concern. Staff education in-services and hands-on training were performed initially and periodically thereafter to reinforce learning and compliance. A multi-disciplinary work group was formed to gather data from chart reviews and evaluate outcomes. Application of multi-layer foam dressings to bony prominences prior to positioning decreased the incidence of pressure ulcer development over bony prominences. Application of multi-layer foam dressings to patient’s chins decreased the rate of skin injury to zero. The cost of the dressings was offset by reducing the incidence and treatment of pressure ulcers in these patients so much so that the six hour limit was removed and all neurosurgery patients placed in prone or park bench position have these dressings applied.

Specimen Management in Endoscopy and the Operating Room

Laura Gaminde, BSN, MBA, CNOR, Director, Surgical Services, Methodist Mansfield Medical Center
Melissa Miller, RN, CNOR, Nursing Clinical Coordinator, Methodist Mansfield Medical Center
Kathy Ripley, RN, CGRN, RN GI Lab, Methodist Mansfield Medical Center
Marvyn Davis, RN, PM Charge RN - Operating Room, Methodist Mansfield Medical Center


PURPOSE/OBJECTIVES: Reduce specimen management issues r/t incorrect labeling, incorrect test documented, and incorrect fixative for specimens obtained in our Endoscopy Procedure Rooms and Operating Rooms.

Gastrointestinal endoscopy and tissue acquisition are fundamental to the diagnosis and management of diseases of the digestive system. The proper collection of tissue specimens is required for accurate pathological diagnosis. Identification errors involving lab specimens may involve misidentification of a patient, the patient’s specimen or the site from which the specimen was obtained. Such errors may result in significant patient inconvenience/incorrect diagnosis or harm.

Similarly, AORN provides guidance and practice standards on specimens obtained in the Operating Room. Just as the Time Out is done prior to incision, a similar process was developed when obtaining a surgical specimen.

CONTENT: Procedure developed similar to procedural Time Out and, when possible (if not possible at the time of collection, the MD will confirm and verify orders for specimen at the time of debriefing, before leaving the procedural room/O.R.), confirmed at the back table, by the Circulating RN and GI/Surgical Tech., along with the surgeon/proceduralist, with the following information, labeled:

Patient Name, Date of Birth, MR#, Specimen name/source, Ordering MD name, Preop./Postop. Diagnosis, Referring MD (to receive copy of report), Requested Lab/Pathology Order, and Medium (fresh/frozen/formalin)

STRATEGIES for IMPLEMENTATION: Unit-based Council discussion at Staff Meetings, modeling by front line Staff in Endoscopy and O.R., education at daily Safety Huddle (to hardwire new process)

OUTCOMES: Reduction of specimen and labeling errors; monthly random chart audits (30/month) to evaluate process improvement effectiveness and outcomes leading to a goal of zero errors (data trended and graphed out) related to specimen management

Standardizing Instrumentation: Is the Juice Worth the Squeeze?

Anisa Xhaja, MHA, Lean Analyst/Project Manager, UAB Care, Perioperative / Orthopedic Conditions, University of Alabama at Birmingham Hospital
Sandra Daily, Director, Perioperative Services, University of Alabama at Birmingham Hospital


In 2014, UAB Hospital began a program called UAB Care, which is a program to improve quality, increase efficiency and decrease costs. This is a condition-based, physician-led initiative that develops, implements and measures adherence to evidence based practice and selected, but appropriate operational best practices. UAB Hospital chose orthopedic trauma and joint conditions as two of the first areas to address. One of the main initiatives within these conditions was the standardization of OR packs and instrument trays. The authors will share their approach used with surgeons, their cost savings methodology and situations in which standardization did not lead directly to cost savings. They will also share how they were able to sustain the changes that were made to the perioperative Orthopedic environment.

Stop, Collaborate, and Listen: Keck Time Out

Patrice Clayton, BSN, CNOR, OR Interim Manager, Keck Medical Center of USC
Ariel Oakley, RN, Staff RN, Keck Medical Center of USC
Amy Archuleta, RN, Staff RN, Keck Medical Center of USC
Maritess DeLeon, RN, Staff RN, Keck Medical Center of USC


Problem: According to The Joint Commission, “the purpose of the time-out is to conduct a final assessment

that the correct patient, site, and procedure are identified.” In creating a culture of safety, Keck

has identified a commitment to performing a proper time-out. Barriers to implementing an

effective time-out include: a lack of consistency, lack of clear roles and involvement, and a lack of

communication between healthcare providers. Specifically regarding availability of implants and

equipment along with functionality, and two-part procedure lack of protocol.

Purpose: Propose revision of current time-out practice that supports improved consistency of practice,

greater team communication, and promote involvement of each member of surgical team. The

proposed time-out protocol will be based on research findings to identify barriers to proper/effective

timeout through survey of staff and address those barriers through follow up measures.

• 1, 300-2, 700 wrong site surgeries (WSSs) occur annually in the U.S.

• 85% of WSSs analyzed had inadequate planning

• 72% of WSSs had defects in the “Time-Out”

(American Association of periOperative Nursing, 2013).

• WSS is the 2nd most reported sentinel event. (Sadler, 2014)

• Surgical teams who use checklists are 74% less likely to skip a potentially life saving step during

an intraoperative crisis (Sadler, 2014).

A consistent and effective time-out practice is National Patient Safety Goal UP.01.03.01, making

this revision important to improving patient outcomes.

Sub-Specialty Teams within the Neurosurgery Service

Terry Emerson, MSN, RN, CNOR, Nurse Manager, Johns Hopkins Hospital


Purpose:        -

-To increase surgeon and staff satisfaction

-To promote consistency of team members in order to enhance skills, increase efficiency, encourage effective communication, and develop collaborative relationships with all members of the intraoperative team

-To become experts in the sub specialty in order to streamline processes, contain cost, and support surgeon’s needs



  • Surgeon/staff satisfaction

  • Consistency of team members

  • Familiarity with supplies/equipment

  • Enhanced skills/expertise

  • Collaborative approach to efficiency

  • Recruitment tool for nursing and surgeons

  • Opportunity to do what one does best on a daily basis

  • To achieve optimal levels of personal/professional performance and accomplishment

  • To promote a safe environment for our patients which focuses on positive outcomes


  • Building appropriate teams and recruiting proper team members

  • Increased mental, physical, and emotional demands

  • Competency

  • Additional responsibilities

  • Teaching hospital culture


  • Define sub-specialty teams

  • Literature review for support

  • Education to the team members

  • Presentation by surgical faculty to support initiative

  • Allow for team members to choose  1st and 2nd choice of sub specialty membership

  • Commit to post orientation transition program

  • Hire into sub specialty teams moving forward

  • Solicit team leaders

  • Establish guidelines

  • Provide protected time for formal updates to the entire service

  • Insure updates within sub-specialty are shared with all members of the Neurosurgery service



  • Staff and surgeon satisfaction surveys

  • Average case time for common procedures within each subspecialty

  • Average turnover time

  • Cost per case for specific surgeons within each subspecialty                       

Surgery Room Turn-Overs: Cleanliness and Timeliness

Elaine Gibson, BSN, RN, CNOR, OR Manager, IU Health Goshen Hospital


Our hospital was concerned the Operating Rooms (ORs) were not properly cleaned during turn-over between cases. We had a prior 'Lean Event' which improved cleaning the equipment going in and out of the ORs; but this did not cover items left in the OR. The cleaning process during OR turn-over resembled chaos with numerous colleagues doing the work and rework, and inconsistency in following the Association of Operating Room Nurses (AORN) Standards. Equipment that remained in the ORs were tested at an average of 73% for cleanliness. It took an average of 41 to 51 minutes of total work time per room for turn-over time. We wanted to improve our quality of cleanliness and the process. We wanted the work to be standardized and repeatable with the same accuracy every time; and with better colleague utilization. We mapped out cleaning zones, educated colleagues, and kept data for measurements. Problem solving was a part of this process. At the end of 120 days, we became consistent in our process with a 97.6% average for cleanliness and decreased the average total work time to 29.10 minutes during the room turn-over.

Team-Based Approach to Patient Care through Simulation

Lina Lapid, MSN, RN, CPAN, PACU Clinical Educator, Cedars-Sinai Medical Center
Inigo Noriega, MSN, FNP-BC, RN, CNOR, OR Educator Program Coordinator, Cedars-Sinai Medical Center


Introduction/Background: We are currently faced with rapid changes in the nation’s healthcare delivery system due to the tremendous expansion of knowledge and technologies. Simulation based training provides a venue delivering team and skills based experiential education. New technologies are intended to enhance patient care and lower patient mortality. Team-based simulation improves clinical knowledge through confidence and performance. The IOM, Crossing the Quality Chasm (2001) reported the posted threats to patient safety and implications in the work environment. One of the six challenges proposed to redesign the system is to create strategies to support staff in ongoing acquisition of knowledge and skills.

Quality Question: Can team-based simulation be used as a strategy to support OR/PACU nursing staff in their ongoing acquisition of knowledge and skills?

Method: Educators of the OR/PACU, Anesthesia and ER departments implemented disease/procedure specific pathways using advanced technologies in our Simulation Center. Our overarching goal is not only to teach clinical assessment skills, procedures, management of emergencies and use of technology but foster a team-based approach. This ensures that patient care is coordinated across disciplines, understanding the goal and expectations to provide safe patient care.

In 2014, the Anesthesia Department, OR/PACU and Emergency Department collaborated to create case scenarios that replicate real cases. The healthcare team can better relate and learn from real cases and debriefings after each simulation rather than abstract interpretation. This process gives the participants an opportunity to reflect and share their experience during the simulation which then provides a milieu for interactive discussion among the disciplines. Participants completed a course evaluation at the end of each team-based simulation.


The overall course evaluation results demonstrated the following:

• OR - 95% responded that the simulation enhanced their learning more than a class or video

• PACU - 85% strongly agreed that the simulation helped improved their situation awareness and decision-making ability

• Anesthesia -100% agreed that the interdisciplinary training will improve communication in OR Anesthesia residents

• Emergency Department - 100% met their goal to simulate management of trauma patients

The Effect of Pre-Procedure Calls on an Endoscopy Unit

Marianne D. Saunders, MSN, RN, CNOR, Nurse Manager, Hospital of the University of Pennsylvania


Outpatient Endoscopy Suites experience high numbers of patient no-shows and cancellations. Depending on the procedure, preparation can be complicated, unpleasant, distasteful, embarrassing, and disruptive of one’s daily routine. Colonoscopy is one endoscopic procedure that involves the ingestion of a purging agent and evacuation of the bowels. The prepping process can be daunting for some individuals, influencing their decision to make or break their appointment. Gastroenterology nurses can take an active role in educating patients on adherence to procedural instructions. Through use of pre-procedure phone calls, nurses can positively influence patient outcomes and decrease the no-show rate in the Endoscopy Suite.


The purpose of this action research is to develop a process to communicate with patients prior to their procedure and address the barriers to arriving to their scheduled appointment. This requires an appreciation of their knowledge base of the procedure as well as the preparatory instructions. Patients’ comprehension plays a vital role in the success of their endoscopic procedure.


Phone calls were made to patients two to three days prior to their procedure. Review of the electronic medical record will provide a guide for the nurse caller to assess the patients’ medical history, discuss and document concerns, and communicate to key medical team members in preparation for the endoscopic procedure.


A weekly electronic report of patient no-shows and cancellations was compared to identical data prior to intervention of phone calls. The report demonstrated a decrease in no-show and cancellation rate of patients arriving for their endoscopic procedures.


Pre-procedural calls can identify knowledge deficits and enhance preparatory behaviors. Improved knowledge is likely to bring about a commitment to compliance and a decrease in the no-show and cancellation rates.

The Missing Link: Connecting Process Improvement to Strategic Financial, Quality and Service Outcomes

Thomas Fee, MBA, CMC, Managing Partner, Verity Partners
Johanna Thomas, PhD, Partner, Verity Partners


As hospitals focus on Value-based Purchasing their performance improvement efforts must connect traditional process-based measures to organizational outcomes-based goals.  A surgical performance improvement team mapped their standard dashboard measures (e.g., on time starts, turnaround times, delays) to critical SCIP, HCAPHS and financial outcomes.  This effort identified the missing measures and minimized or eliminated metrics that did not impact corporate outcomes.  Redesigning the metrics and dashboard to provide relevant daily metrics and standards helped align staff decision making and performance efforts to achieving overall corporate outcomes.

Mapping operational surgical metrics to corporate outcomes, redesigning and implementing the surgical dashboard made surgical performance improvement more comprehensive and meaningful. Staff now better understand their impact on critical corporate outcomes. The redesigned dashboard is a more relevant leadership tool and staff are more responsiveness to process improvements that drive corporate success, impact reimbursement, patient satisfaction and quality outcomes.

The Operating Room Circulating Zones (T.O.R.C.Z.)

Joseph L. Brown, RN, Circulating Nurse, University of Texas MD Anderson Cancer Hospital


Purpose: An opportunity was observed for improvement in OR pre-operative set- up, particularly among new graduate nurses and OR nurse residents. Specifically, these were observed to set-up the OR without a standardized process that could lead to potential for missing items or devices necessary during the procedure. To standardize and improve this process both for nursing professional practice and the safety and efficiency of the OR setting for patient care, an innovative approach to standardizing OR room preparation was developed.

Content: To achieve this goal a circulating nurse developed operating room circulating zones, focusing on each area of the OR suite systematically to ensure that all devices and materials were consistently prepared by the nurse prior to surgery. Five zones were established which included:

1) the surgical bed area which includes everything needed to prepare the surgical bed and lighting;

2) area to the right of the bed which includes suction set-up and Bovie equipment;

3) area at the foot of the bed which includes the preparation table and any items needed to take care of the patient;

4) area to the left of the bed which mirrors zone 2;

5) the viewing zone which includes any towers for patient monitoring.

Implementation: Once the zones and their contents were systematically defined this circulating nurse implemented education for new nurses, operating room residents, and colleagues to standardize practices for OR preparation. Informational materials defining the various circulating zones as well as hands-on mentored education were provided. Outcomes were measured through auditing of the OR preparation and through informal feedback from staff members regarding comfort with the preparation process using this methodology.

Outcome: This methodology may also prove beneficial for new OR nursing staff familiarizing themselves with the OR setting to ensure consistent, safe practice. The educational content is cost-effective and may be implemented across OR settings and for diverse procedure preparation.

The Pursuit of Preference Card and Inventory Perfection to Achieve Excellence in Patient Care

Treena Dockery, MT, MBA/HCM, CLM , Process Improvement Consultant , University of Colorado Health
Carla Thorson, MSN, APRN, ACNS-BC, CNOR, CNS-CP, Content Manager, Center for Nursing Leaders, AORN


Assessment:   OR specialty coordinators lacked standard processes for updating preference cards, medical staff lacked a formal process for onboarding providers, expectations of staff to provide revisions after cases was unclear and lacked accountability. 

Implementation:   Standard work was created for the OR specialty coordinators and staff RNs to update preference cards and utilize electronic health record functionality as a mechanism to submit real time changes to improve efficiency and accuracy.   Standardized room stock was evaluated by staff and Central Supply to determine optimal room inventory needed for a 36 hour period resulting in a standard process for resupply and accurate accounting and inventory management.

Outcomes:  Reduced number of inactive preference cards in three months by 1, 550, which reduced workload of coordinators by 21%.  Accuracy of supplies on cards reduced the number of calls for soft goods by 40%.  Standardized room stock saved $32, 500 for 13 OR Suites as well as $10, 278 in excess suture inventory.  Donated/expired product decreased by $172, 500 or 63%.  

Implications for perioperative nursing:   Recaptured OR minutes for nursing presence during case increased physician satisfaction with improved accuracy of preference cards and established standard work process for continual updates.  Improved charge capture due to accurate preference cards.  Standard room stock and supply process improved par level accuracy and management.

The Two Day Work Week: An Innovative Approach to Perioperative Staffing

Janet Larsen, RN, BSN, MBA, Director, Perioperative Services, Glens Falls Hospital
Catherine Brambley, RN, BSN, CNOR, Nurse Manager, OR/CSP, Glens Falls Hospital
Laura Pfeifer, RN, BSN, CGRN, Nurse Manager, PACU/GI Center, Glens Falls Hospital


Recruiting and retaining talented Operating Room (OR) and Post Anesthesia Care Unit (PACU) registered nurses (RNs) is a challenge for one community hospital in Upstate New York. Low employee engagement resulting from vacancies compounded by lack of applicants for OR positions.  Glens Falls Hospital Perioperative Nursing Leadership engaged direct care nurses in the development of an innovative staffing model: “The Two Day Work Week” to reduce the RN vacancy rate and improve staff morale.

Implementing a “Two Day Work Week” also known as a weekend track program (WTP) allows hospitals to eliminate contract labor, stabilize staffing, and improve employee morale.  WTP is attractive to nurses going back to school, raising young children or looking for better work life balance.  To the best of our knowledge, this is the only Perioperative WTP in the region.   


  • Fill vacant RN positions with experienced RNs

  • Empower nurses to design their own staffing models

  • Provide optimal patient care by ensuring consistent, quality staffing 24/7, and align weekday staff with specialty services.

  • Attract experienced OR/PACU RNs by offering flexible schedules.

  • Support organizational strategic plan by growing surgical volume.

  • Improve staff satisfaction and morale


  • Weekend Track- labor cost analysis and model design

  • Benefits of nurse designed staffing plans

Strategies for Implementation:

  • Executive Team proposal and approval

  • Surgeon/Anesthesia Buy in

  • Marketing - Focused advertising campaign

  • Hiring process- Peer interviews

  • New hire orientation and assimilation


Given this program is in the infancy stage, less than one year, outcomes are still being evaluated. However, the following measures are being monitored for program success.

  • Improved staff morale and retention

  • Enhanced week day staffing

  • Decompression of elective OR schedule (access for add-ons on weekends)

  • Decreased labor costs and use of agency staffing

TIC TOC: Decreasing Turnaround Time (TAT)

Susan M. Scully, MSN, RN, CNOR, Clinical Supervisor, The Children's Hospital of Philadelphia
Maureen Mallon, MBA, BSN, RN, CNOR, Nurse Manager, The Children's Hospital of Philadelphia


Observations verified that when compared to other pediatric hospitals, our turnaround time (TAT) was higher than the national average. Our goal was to institute successful tests of change (TOC) that would decrease turnaround time by 10%.

We started by focusing on the three services with the highest volume of cases yielding the largest opportunity for change. The surgical services included, Orthopedics, ENT, and General Surgery. Each surgical service performed its own TOC and if successful we would evaluate the feasibility of spreading the TOC to other services.

First, ENT implemented a TOC which included bronch tables being taken to decontamination by a Core Technician instead of the Surgical Technologist; as well as a debrief between nursing, anesthesia, and surgery at the end of the case deciding on appropriate time to return to the room. General Surgery trialed the core techs gathering necessary equipment for upcoming cases; while Orthopedics trialed priority set tracking for faster sterilization and having an Anesthesia Technician stand at the patient’s bedside during extubation. In addition, we were able to raise staff’s awareness of how much time elapsed during the turnaround process by having a clock automatically start as soon as the patient was marked as out of the room.

Some of the TOC were successful, and some were not. The debrief process proved to be successful in ENT, and was then trialed in General Surgery. After success in General Surgery, the process was spread to all surgical services. In addition to decreasing TAT, the debrief process is opening lines of communication between three disciplines that previously worked in silos. In Orthopedics, the use of an Anesthesia Technician at the patient bedside during extubation also proved successful to decrease TAT in that service.

Time Out Process: Can it Guarantee Quality Care?

Munira Amin, BScN, Administrator - Operating Room and SDC, Aga Khan University Hospital
Shafqat Shah, BScN, Head Nurse, Aga Khan University Hospital
Saima Bano, BScN, Asst. Head Nurse, Aga Khan University Hospital
Muki Bano, BScN, Nurse Instructor, Aga Khan University Hospital


Standardized quality care is always a challenge in growing hospitals where the focus is not only in enhancing quality but also on revenue generation. OR is a vulnerable place for patients where they are at the mercy of healthcare personnel. Monitoring and keeping track of patient care is one of the biggest challenges where nurses are supposed be advocates on patient’s behalf. Internationally, for promoting safe patient care, Joint Commission has defined certain patient safety goals to be implemented out of which “Time Out” process is related to prevention of wrong patient, wrong site and wrong procedure. In a tertiary care hospital in a developing country, compliance of these strict principles and change in culture was a challenging task. The whole process of time out was incorporated with Surgical Safety Guidelines by World Health Organization, and policy was revised and process was implemented. To implement the processes for which Surgical Safety campaign for a week was organized. Later, audits were conducted for reinforcement and “time-Out” champions were created. Although change of mindsets and practices of surgeons and physicians lead by nurses was a challenge but with the support of Hospital Executives, it was successfully established.

Transforming the Culture in the Ambulatory Surgery Center through Quality Improvement Strategies

Nancy Hickcox , MSN, RN, CNOR, Director, Surgical Services, UPMC Shadyside
Sherri Jones, MS, MBA, RDN, LDN, FAND, Improvement Specialist, UPMC Shadyside
Sally May, MSN, RN, CNOR, Unit Director, Ambulatory Surgery Center, UPMC Shadyside


In 2014, our health system administered surveys to all employees. Results of the Ambulatory Surgery Center (ASC) surveys revealed low staff morale and several areas for improvement. ASC employed the use of Improvement Specialists to develop a structured improvement plan. The purpose was to improve practices as well as culture of ASC to support high level quality care/safety and create an environment for staff to thrive. Two objectives included: 1) standardize nursing practice, 2) increase staff vitality. Two frontline staff focus groups were formed. The first group developed a standardized practice and documentation module for the Pre/Post-Op area, including a comprehension test which all Pre/Post-Op nurses and new hires are now required to do. The second group developed a Behavioral Charter outlining expectations of staff working in ASC. The charter was introduced at a unit-based council meeting, in which all ASC staff (including nurses, secretaries, OR Techs, etc.) were instructed to review and sign. Next, a validated staff vitality survey was administered anonymously to staff, including surgeons. Survey responses totaled 46 (almost 100% of staff), including 8 surgeons. Question responses were ranked by score, and trends were identified. In addition, in-person deep dive sessions were conducted by Improvement Specialists for staff to provide further input. Results of the vitality survey and deep dives were formalized into a report and presented to ASC management. Management reviewed the proposed improvement strategies and identified priorities. We are in the process of implementing these additional improvement strategies, but heard anecdotally staff feels the culture has improved. Although too early to tell, it’s predicted improvements in ASC’s culture will translate into increased patient satisfaction scores. Future plans include repeating the staff vitality survey in six months to monitor if improvement strategies resulted in higher response scores, and thus an increased staff morale and vitality.

Trauma Model for Urgent/Emergent Rooms

Terry Emerson, MSN, RN, CNOR, Nurse Manager, Johns Hopkins Hospital



-To retain staff

-To better align staffing with Anesthesia resources

-To increase frontline staff job satisfaction

-To provide consist coverage of the urgent/emergent rooms

-To insure proper competency and ownership


Contributing Factors for Change

  • Previous model

    • Evening/Night shifts

    • 8 hour shifts

    • Responsible to cover weeknight/weekend call

    • Identity was defined as a “relief” shift

    • Responsible to work weekends shifts

    • Averaged 1 weekend off in a 6 week schedule

    • Weekends were also covered by staff from other units without ownership for the Urgent/Emergent rooms environment

  • Retention

    • Hired 10 new RN/ST’s

    • Within 18 months all but 2 were left on staff

    • Cost for 6 month orientation approximately $28, 000.

  • Other factors

    • Limited knowledge base due to turnover

    • Inefficiency of the Urgent/Emergent room utilization

    • Competency challenges

  • Data collection

    • Retention

    • Cost of orientation

    • Compliance Level 2 urgent/emergent cases meeting 2 hour time frame

    • Available call shifts vs anesthesia resources

    • Call utilization for the weekends


  • Created proposal

    • Ownership/Accountability of the Urgent/Emergent rooms on a 24/7 basis

    • 12 hour shifts

    • Self scheduling

    • All weekend and Holiday coverage

    • No call

    • Consistent staff and competency

    • Energized and engaged team members

  • Met with Perioperative Leadership to gain support/approval

  • Presented model to other services for support

  • Addressed barriers

  • Met with surgeons for input

  • Increased recruitment

  • Provided team building exercised

  • Rolled out model in September, 2014 with daily celebrations



  • Staff and surgeon satisfaction surveys

  • Retention (decrease expense of orientation)

  • Level 2 urgent/emergent case compliance

  • Decrease call utilization on weekends   

Utilization of Surgeon Specific Teams (SST's): The Baylor University Medical Center Experience

Doug Robinson, MBA, BSN, RN, CNOR, OR Manager, Baylor University Medical Center


Purpose:  Leadership of the Baylor University Medical Center (BUMC) perioperative department offers surgeons the ability to work with a limited group or team of operating room (OR) nurses and techs during their designated block times in an effort to increase quality, efficiency, and volume.


  1. Team Selection: With surgeon input, staff members were invited to join teams that they already had experience with. Team members were chosen from dayshift staff as well as evening shift to provide team consistency.

  2. Team Lead: Each surgeon has a staff RN team lead that acts as the surgeon liaison and is empowered to fix issues on the spot with help from leadership as needed.  They round monthly with surgeons.

  3. Metrics:  Teams were given goals to meet such as:

    1. Decrease turnover time by 10%

    2. Increase first case on time starts by 20%

    3. No sentinel events

    4. 100% SCIP measure compliance

    5. 90% team consistency, staying late if last case within one hour of end of shift

    6. Patient Satisfaction goal

    7. Decrease in cost per case for certain procedures by 10%.

  4. Bonus: SST team members receive a bi-weekly bonus based on role if all metrics are met in the previous two week period.  The entire perioperative staff receives a bonus if 2% contribution margin increase is met over previous fiscal year’s quarter.

Strategies for Implementation:

Data provided on block utilization and case volumes was used to roll out with initial surgeon group. Leadership met with each surgeon to fully explain program and to go over staff that would be on team. Training also done with staff recruited for the surgeons.  Team leads received training on their role as team lead.  (Evaluations rolled out to surgeons and staff that assessed team dynamics and surgeon leadership.

Utilizing Simulation Scenarios Involving Interdisciplinary Teams for Improving Patient Safety

Terry Sullivan, RN, MN, CNOR, Staff RN, UF Health Shands Hospital
Michele Brunges, RN, MSN, CNOR, Nurse Manager, PACU, UF Health Shands Hospital
Christine Foley-Brinza, RN, MSN, Clinical Leader, PACU, UF Health Shands Hospital
Diane Skorupski, MS, RN, CNOR, NE-BC, AVP PeriOperative Services, UF Health Shands Hospital


This poster describes a quality improvement, inter disciplinary, project focusing on increasing patient safety in the perioperative setting.

Simulation teamwork training of perioperative personnel at UF Health Shands Hospital can be facilitated by using Virtual Humans (VHs) who replaces unavailable team members.

Two simulation scenarios were developed for “Speaking Up”, by staff, when patient safety is compromised:

-When blood Type & Screen data is unavailable prior to surgical incision

-When a surgical count discrepancy occurs before closure of the surgical incision

Over 200 UF Health Shands Hospital perioperative registered nurses and surgical technicians have received training with this pioneering learning technology.

Preliminary results indicate that OR personnel accept VHs as substitutes for real human team members, use the same negotiation tactics with a VH as they would employ with a human, and that VHs can serve as role models to humans.

Two additional simulation scenarios will be developed: using VHs for preventing Wrong Specimen in Tube (WSIT) and performance of the Surgical Universal Protocol.

The learning objectives of each simulation scenario are aligned with the UF Health Shands Surgical Safety Initiative.

There has been no known incident of retained surgical items (RSI) since Virtual Human-enabled team safety training began in September 2014.

Count Simulation Scenario objectives:

1. Recognize situations where patient safety is in jeopardy by the action or inaction of team members or breach of hospital and patient safety protocols

2. Choose appropriate responses to person(s) (human or virtual) according to Surgical Count Policy, conducive to teamwork, in situations where patient safety is compromised

3. Identify specific actions to prevent patient harm in situations where the count is incorrect

4. Correctly perform the elements of the Surgical Count Policy

Which Hospitals Succeed in Keeping Operating Room Costs for Total Knee Arthroplasties Low? How Significant is the Variation Across the US?

Mary Ann Clark, MHA, Senior Vice President, Intralign


Statement of the Problem

The trend toward bundled payments in orthopedic care is not slowing down. Hospitals and other providers must learn to do more with less and improve outcomes by better managing the care process. Limited data exist on true hospital-level costs of primary total knee arthroplasty (TKA) procedures. It is important that hospitals understand their own costs and trends and how they compare to others in their market to know what’s possible and establish cost containment goals to maintain or grow the orthopedic service line.


Data included FY 2010 - 2013 Medicare Provider Analysis and Review (MEDPAR) Files and Medicare Cost Reports. TKA cases were identified using ICD-9 Code 81.54. We excluded hospitals and regions with less than 100 procedures. Outcomes measured included hospital-specific procedure volume, charges, costs, reimbursement, and net margin. Costs were calculated using Medicare methodologies. Baseline univariate statistics are reported.


We examined the various primary TKA inpatient cost components and found that the implants and supplies category typically consumed the greatest resource use at each hospital, with cost variation between $3, 616 and $11, 428 across hospitals. The remaining other OR-related costs consumed the second largest portion (3, 045 - $9, 600). OR-related costs vary significantly across hospitals, comprising on average 45% of the total cost for all hospitals.


Our study is the first to report on actual hospital-specific costs of Medicare TKA procedures. Wide disparities in hospital-level costs and profitability for TKAs exist across US hospitals. Downward pressure on reimbursement and shifts to value-based payment necessitate better management of costs. The most significant and highly variable driver of inpatient TKA costs operating room costs. Going forward, hospitals need to take a proactive approach to truly understanding and then addressing drivers of operating room costs.

Work Life Balance

Ignacia N Joyner, BSN,RNII., Periop RN, Children's National Medical Center
Alisa Bruce, BSN,CNOR,CPN,FNA, Peri-Op RN, Children's National Medical Center


Self-scheduling practices for Pediatric Registered Nurses in the Operating Room produced viable solutions such as; flexibility in staffing, and most importantly work life balance. Integrating Rosswurm & Larrabee's Change Model within the OR created positive transformation, and outcomes within the nursing environment.  We applied this Change Model with steps that identify posing a question, linking the problem with solutions, using evidence, and following recommendations from credible sources to gain a solution. The process of creative thinking, trust building between management, and staff took some time; professional growth emerged for the team members.  Team examined the pre-existing fixed scheduling structure and researched opportunities for shift switches among RNs with fixed shifts.  Creation of flexible shifts that would provide alternative work schedules.   The addition of flexible shifts gained alternatives and better work-life balance.

Statement of the problem: In the Pediatric Operating Room setting, will staff self scheduling create work life balance without compromising care?

Purpose: To examine the affects of self-scheduling on work life balance, for the Pediatric Registered Nurse in the Operating Room.

Significance/Theoretical base: Examining work life balance implementing self-scheduling, and stress reduction for the Pediatric Operating Room RN, while adapting Rosswrum’s and Larrabee’s Change Model.

Design/Methods: Qualitative data used in a single site.

Results/Discussion: A scheduling committee was established to foster collaboration. Key stakeholder involvement includes Management, Patients, and/or Union Association, and direct care nurses.

Implications: Having the ability to fit in self care needs with the predictability of their schedule while not leaving the unit understaffed or feeling guilty.

Conclusions and recommendations: Identify ways Self-scheduling creates work-life balance and flexibility in the Pediatric OR setting. Identify benefits of direct care RN involvement in planning, monitoring, reviewing, and modifying practices in scheduling. Decision making, recruitment and retention are established.

Working Towards a Pressure-Free USC

Patrice Clayton, BSN, CNOR, OR Interim Manager, Keck Medical Center of USC
Jeanelle Mountford, RN, Staff RN, Keck Medical Center of USC
Shaylin Hoye, RN, Staff RN, Keck Medical Center of USC
Megan Kelly, RN, Staff RN, Keck Medical Center of USC


Due to increasing pressure-related skin breakdown during operative procedures, there has been an emphasis on performing proper positioning techniques. Improper positioning can lead to pressure ulcers and other pressure-related skin breakdown. Patients at high risk for skin breakdown may require increased pressure-reducing modalities. Evidenced-based research has shown that the use of soft silicone multi-layer foam dressings can decrease pressure sites and consequently decrease incidence of pressure-related skin breakdown (Santamaria et al., 2013).  A standardized, evidenced-based protocol for use of soft silicone multi-layer foam dressings could reduce the incidence of pressure-related skin breakdown.


To implement a standardized, evidenced-based protocol for use of soft silicone multi-layer foam dressings to decrease the incidence of pressure-related skin breakdown.

Target Population

Patients undergoing operative procedures who are designated as high-risk for pressure-related skin breakdown.

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