Council Improves OR Practice at Hospital for Special Surgery

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When perioperative nurses at the Hospital for Special Surgery in New York City encounter a practice or policy that can be improved, they don’t just complain about it. They fix it.

Over the past several years, the hospital has employed a shared governance structure that relies on staff nurses to spearhead improvements in the operating room. The hospital, recognized as a Magnet facility since 2002 by the American Nurses Credentialing Center, has established nursing councils, of which the hospital’s Perioperative Practice Council is the oldest and largest. The council has 30 members, 27 of them nurses and three of them surgical technicians, representing the main operating room, the ambulatory surgery department, central sterile processing, nursing education, and several other areas of the hospital.

At the heart of the shared governance concept is the goal of shared accountability and empowerment for nurses.

Ron Perez, RN

“It gives us a forum to address concerns that affect us,” explains Tashma Watson, RN, who has been at HSS for 2-1/2 years and has served on the Perioperative Practice Council for a year. In May, she became one of the council’s two co-chairs. “It gives us a form of empowerment so we can be involved,” she says. “It gives us a way to be involved with nurses from all areas of the perioperative setting, a chance for us all to work together to make changes that can benefit all of us.”

The Hospital for Special Surgery, on Manhattan’s Upper East Side, is a freestanding nonprofit facility that performed 23,000 surgeries in 2008. The council structure, and the perioperative council in particular, grew out of a recognition that the hospital needed to improve its preparation for surgical cases as it underwent significant volume growth several years ago, says Ron Perez, RN, JD, CNOR, assistant vice president for perioperative services, who has served on the council since its inception and co-chaired it until recently.

The council has evolved over the years, and Perez says turning over the chairmanship to staff nurses such as Watson on a rotating basis is the latest step in transferring leadership responsibility to the people most invested in the council’s recommendations: staff nurses.

Charlotte Guglielmi, RN

The council — one of four nurse-based unit councils and four oversight councils at the hospital — meets once a month and coordinates with other hospital committees, Perez says. When the nursing councils make practice or policy recommendations that affect physicians, for example, the changes must be approved by the relevant service-line committees. Opening these lines of communication has improved relations among physicians, nurses, and managers, those involved say.

“It certainly increases the team spirit,” Perez says. “I think (surgeons) recognize our involvement in the process and that we are empowered to speak up and make recommendations.”

One of the perioperative council’s projects is crafting a surgical safety checklist based on one published by the World Health Organization but tailored to HSS’s needs. Council member Elizabeth Goetz, RN, BSN, CNOR, a clinical coordinator in the hospital’s main operating room, says the checklist project and others like it that affect both physicians and nurses help build rapport between medical and nursing staffs. Nurses who are in control of their work environments also are likely to be more satisfied with their jobs, she says.

Elizabeth Goetz, RN, left, and Tashma Watson, RN, confer outside the inpatient OR suite of the Hospital for Special Surgery. HSS has 28 operating rooms on three floors of the hospital where more than 22,000 surgical procedures were performed last year.
Courtesy of Polina V. Yamshchikov | Hospital for Special Surgery

HSS administrators believe the activities of the Perioperative Practice Council have contributed to greater patient confidence in OR staff. On the hospital’s patient satisfaction survey, patients’ perception of safety in the OR rose steadily from fiscal 2007 to the first half of fiscal 2009, survey scores reveal.

Other recent accomplishments have included making changes to documentation to reflect the “universal protocol” for preventing wrong-site, wrong-procedure, and wrong-person surgery; implementing a printed operative consent form that has decreased errors related to illegible handwriting; and implementing a new surgeon read-back of implant specifications before surgical implant procedures.

Stephanie Goldberg, RN, MSN, NEA-BC, is the vice president for patient care and chief nursing officer at the Hospital for Special Surgery. Before coming to HSS several years ago, she worked at another Magnet hospital in New Jersey, and she currently is a Magnet surveyor.

“As the chief nursing officer of a Magnet institution, you know you have to have some institution or framework for nurses to participate in clinical decision-making,” she says. “Nurses who are taking care of the patient understand what the issues are and what the problems are and what they need to do to make patient care delivery better because they live it and breathe it every single day.”

Shared governance models such as the nursing council structure at HSS are considered the preferred model for practice, says Charlotte Guglielmi, RN, BSN, MA, CNOR, the president-elect of the Association of periOperative Registered Nurses and the perioperative nurse specialist at the Beth Israel Deaconess Medical Center in Boston. In 2000, some 1,000 hospitals in the U.S. had implemented some form of shared governance in their nursing departments, according to a July 2000 article in the AORN Journal, titled “Implementing a Shared Governance Model in the Perioperative Setting.” It is more difficult to pin down how many hospitals nationwide have perioperative nursing councils, but Guglielmi says such models are becoming more prevalent.

“I think it helps to foster the elements of high-performance teams,” she says. “High-performance teams communicate, high performance teams function in a learning environment, high performance teams become really patient-focused. They process care in real time, and they address issues in real time.”

As healthcare reform unfolds on a national scale, it also is becoming clear that high-quality, fiscally responsible, evidence-based care is going to be rewarded, and nursing practice councils help achieve those goals, Guglielmi says.

“These kinds of structures within nursing departments are going to continue to flourish,” she says, “because that’s where the solutions are going to come from.”

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