Operating Room – Recovery Room (OR-RR)

Operating Room – Post-anesthesia Care Unit (OR-PACU)

 

Nov 18, 2008

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Head, Corporate Planning Office

Manila Doctors Hospital

 

(One of three topics: Department of Surgery; OR; ER)

(Recommendation: Read first “Framework on Managing and Leading a Hospital Department”)

 

Short Course on Hospital Organization and Management of Selected Clinical, Ancillary, and Support Departments

Nov. 17 – 21, 2008

College of Public Health

University of the Philippines Manila

 

Let’s now tackle the Deparment of Operating Room – Recovery Room (Post-anesthesia Care Unit).  Operating Room are sometimes called Operating Theatre. The more popular term for recovery room nowadays is post-anesthesia care unit or PACU.

 

Operating rooms (OR) or Operating Theatres are areas in the hospital where operations, surgeries, or operative procedures can be performed, either for diagnostic or treatment purposes.  Recovery rooms (RR) or post-anesthetic care units (PACU) are areas where patients who have just undergone surgery, usually under general and regional anesthesia, are brought to for post-op and post-anesthetic monitoring and care prior to being transferred to another area in the hospital, such as wards, floors, intensive care units, etc. or sent home (as in an ambulatory operating rooms).  Activities in the PACU routinely include at least the following: vital signs monitoring; pain control; breathing monitoring and support; caring of tubes; and nursing care.

 

The RR or PACU is an inherent part of the OR.  Thus, when you say OR, it implies there is a RR or PACU.

 

Operating rooms or operating theatres may be classified into two types depending on whether they are providing services on an outpatient or inpatient basis.  Ambulatory surgical clinics or ambulatory operating rooms are those providing services on an outpatient basis while inpatient operating rooms are those providing services on an inpatient basis or for admitted patients.  Ambulatory surgical clinics are usually outside a hospital compound.  A hospital may have both inpatient and outpatient or ambulatory operating rooms. Outpatient operating rooms may be located in the outpatient department.  A main operating room or operating theatre in a hospital can be used for both inpatients and outpatients.  They are usually located away from the outpatient department.

 

A set-up of operating rooms in a hospital may be a centralized or decentralized one.   Decentralized one means there are several operating theatres, each dedicated to a particular surgical specialty or located near the specialty department.   Centralized one means there is only one OR complex in the entire hospital in one location shared by the different surgical specialties.    

 

As being commonly practiced, the administrative head of the OR and PACU is usually a nurse.  A committee, such as the operating room committe, committee on operating room complex, or operating room management team (ORMAT) is usually established to serve as the policy-making and coordinating body on all matters pertaining to the OR and PACU.  A surgeon or an anesthesiologist may be appointed to head the committee. In addition, an anesthesiologist, by the nature of the patients being brought to the PACU as well as its primary purpose of post-anesthesia care, may be appointed to supervise the operations of the PACU. 

 

The physician-users of the OR are those credentialed and accredited by the hospital administration to perform procedures or operations, in other words, to use the facilities of the OR.  Before, the physician-users are limited to “surgeons” and anesthesiologists.  “Surgeons” include the general surgeons, neurosurgeons, orthopedic surgeons, plastic and reconstructive surgeons, urologic surgeons, pediatric surgeons, thoracic surgeons, dental surgeons, otorhinolaryngologists, ophthalmologists, and obstetricians-gynecologists. 

 

Nowadays, non-surgeons who are credentialed and accredited to do procedures like endoscopy and minimally invasive operations, such as gastroenterologists, pulmonologists, and cardiologists, are now allowed to use the OR. 

 

After that introduction on the terminologies, nature, clients, types, and governance of the OR-PACU, let’s create a scenario to properly position ourselves for a more focused discussion.

 

Before that, remember our specific learning objectives on OR-RR are the following:

1. Identify the organizational and operational requirements of a hospital department  (specifically, OR-RR) in terms of philosophy, objectives, structure, staffing, operating policies and procedures, programs, and resources.

2. Identify common problems in the management of a department (specifically, OR-RR) and the commonly used approaches in controlling them.

 

Imagine you, a NURSE, are going to be appointed Head of an existing OR in a hospital (whether government or private).

 

Existing or new one?

Let’s use the scenario of an existing one as this is a more common situation.

 

Outpatient OR or inpatient OR?

Let’s focus on inpatient OR.  We will discuss outpatient OR along the way.

 

What are initial and eventual things you have to do as the newly appointed head of an existing OR-PACU?

 

First two requirements before you assume officially the headship of the OR-PACU

 

  1. Make sure you have an official appointment paper to be the head of the OR-PACU before you start doing anything.  (Chief of Hospital and Nursing Director, take note!)
  2. Make sure you have an official job description as head of the OR-PACU before you start doing anything.  (Chief of Hospital and Nursing Director, take note!)

 

The appointment paper gives you the authority.   The job description spells out your duties and responsibilities with corresponding authority.  The job description also serves as a basis of your performance evaluation.

 

The job description is very important to know the true and specific extent of your responsibility, jurisdiction and  power.  This will enable you to act accordingly especially in the light of overlapping and conflicting concerns with physician-users over a particular OR, especially in dedicated  ORs of specialty departments.  

 

Initial activities of a newly appointed head

 

Initial quick assessment of the OR-PACU

After getting your appointment paper together with a job description,

scan the department in terms of its authorized functions, structure, staff and staffing, policies and procedures, programs, and resources – through observation and inspection to get a quick assessment of the status of the abovementioned essential elements needed in the management of the department (present or not; if present, needs improvement or not; if improvement needed, prioritize and strategize; resources – source and level of difficulty)

           

Initial resuscitative and corrective measures if needed / indicated

Based on your initial quick assessment, if there is something very important and urgent that needs to be resuscitated and corrected, do so as soon as possible.

            Examples of important and urgent needs:

no staff to man the department

no resuscitative equipment in the department

lack of rooms to do surgical procedures and operations

lack of beds for the PACU

 

Eventual activities

 

Detailed assessment of the OR-PACU

When you have settled down as chair, usually in a month or two, do a more detailed assessment of the department again at least in terms of its authorized functions, structure, staff and staffing, policies and procedures, programs, and resources. Other parameters may be used like culture, values, practices, work habits, etc.  Identify the gaps and what needs to be changed or improved and then make a tentative plan on how to improve the present system, on how to manage the department, and on how to lead your staff.

 

Formulation and implementation of strategic and specific action plans

Formulate strategic and specific action plans with consultation and collaboration from your staff.  Then gradually but surely and effectively and efficiently implement them through technical and coordinating teams.  Don’t forget to include a system of evaluation of results of implementation of your strategic and specific action plans.

 

Essential things to consider for gap analysis, corrective actions, and for continual improvement

 

Authorized functions of an OR-PACU

 

There must be a document stating the authorized functions of your OR-PACU. 

It must be complete and clear with general and specific functions and it must be authorized by a higher office (ideally by the Chief of Hospital through the Nursing Director).

           

This document on authorized functions will serve as a steering wheel or guide for everything you will do in the department.  It describes the roles and responsibilities of your department in the context of the whole hospital.

It gives your department the authority to do what you should be doing. It will serve as a guide in determining what you need in your department to function properly and adequately such as in terms of structure, staffing, policies and procedures, programs, and resources.  It will serve as a guide in determining what programs, projects, tasks, and activities you can do to accomplish your functions, both on a long term and short term basis.  It will serve as a basis for evaluating your department’s performance, at the very least, whether you have been accomplishing your expected functions on a daily basis and annually.

 

The authorized functions contain at the very least the service functions of the department.  They can include training and research functions.

 

The formulation of service functions of a department is guided by the current expectations on the specialty of the department by the health care industry and medical profession; vision-mission of the hospital; expectations of the community where the hospital is situated; and benchmarking and trends in the hospital industry both locally and internationally.

 

There is a need to specify scope of functions because of rapid changes in the medical specialties and health industry; because of overlapping of specializations nowadays (General Surgery – Otorhinolaryngology; Neurosurgery – Orthopedic Surgery; Internal Medicine – minimally invasive surgery; etc.); to avoid confusion among staff and patients and public also; and to facilitate integration,  coordination, and collaboration within and among units (a challenge to chief hospital and nursing director).

 

Note: Some ORs include delivery rooms.   Some hospitals have multiple ORs in different locations.  Some have ORs for inpatients.  Some for outpatients only, such as ambulatory surgery.  Some include endoscopy services.  Thus, it is important to specify scope of functions based on the type of services to be offered by a particular OR.  

 

Whatever be the formulated authorized functions of a particular OR, they must be officially authorized by a higher office (ideally by the Chief of Hospital through the Nursing Director).

 

 

Examples of authorized functions of an OR or OR-PACU  

 

General Function:

 

To provide quality operating room services to patients with potential and evident surgical disorders as well as to medical staff needing such services for their patients.

 

To provide quality operating room and recovery room (PACU) services to patients with potential and evident surgical disorders as well as to medical staff needing such services for their patients.

 

To provide quality services in the operating room.

 

Specific Functions:

 

Service:

 

  1. To provide quality operating room services to medical staff needing such services for their patients.
  2. To provide quality operating room and perioperative nursing services to patients with potential and evident surgical disorders.

 

  • To  provide quality delivery room, operating room and perioperative nursing services to patients with potential and evident obstetrical and gynecological disorders.

 

  • To provide quality operating room and perioperative nursing services to  patients with potential and evident gynecologic disorders.

 

  • To provide quality operating room and perioperative nursing services to  patients with potential and evident ophthalmologic disorders.

 

  • To  provide quality operating room and perioperative nursing services to  ambulatory patients with potential and evident surgical disorders.

 

 

  • To  provide quality operating room and perioperative nursing services to  patients needing endoscopic procedures.

 

Training:

 

·         To provide continuing professional education to all staff of the Operating Room and all concerned paramedical staff so as to maintain and improve quality of service.

 

Research:

 

·         To engage in research in the field of operating room services that will improve quality of service.

 

Structural or physical requirements of an OR-PACU

 

Based on the authorized functions and other ancillary functions of the OR-PACU, such as governance, training and research,  determine the structure or physical requirements.

 

Structural or physical requirements based on the usual authorized and expected service functions of an OR-PACU

 

On the basis of the usual authorized and expected service function, the basic structures or physical facilities needed are operating rooms (rooms or areas where the operative procedures will be being done) and recovery rooms (rooms or areas where patients after an operation can stay before they are either sent home or transferred to another area in the hospital, such as wards, floors, intensive care units, etc.)

 

There are several issues to consider when establishing or making available the above structures and physical facilities required by an OR-PACU.  These are, namely:         

 

·         Location within the hospital (lay-out and functional flow within the hospital)

·         Quantity

·         Size

·         Design

·         Equipment requirement

 

How to resolve the issues?  How to decide?

 

Resolution of the above issues will be dependent on the following general determining factors:

 

·         government regulations (particularly the licensing requirements of DOH Bureau of Health Facilities and Services) [http://www.doh.gov.ph]

·         quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as International Organization for Standardization or ISO and Joint Commission International or JCI) [http://www.philhealth.gov.ph]

·         usual and anticipated increase in patient load (cost-benefit considerations)

·         needs and expectations of the community

·         integration, coordination and collaboration with other units in the hospital for efficient use of physical resources – the physician-users and the various clinical medical departments

·         allowance for expansion (space availability)

·         value-added, vision-mission, and benchmarking considerations (sustainability purpose)

 

·         Location within the hospital (lay-out and functional flow within the hospital)

 

Refer to DOH GUIDELINES IN THE PLANNING AND DESIGN OF A HOSPITAL AND OTHER HEALTH FACILITIES, November 2004 [http://www.doh.gov.ph]

 

 

Outer Zone

OPD - OR

Second Zone

 

Inner Zone

 

Deep Zone

Inpatient OR

Service Zone

 

 

                        DOH Requirements:

 

20.3 The surgical service shall be located and arranged to prevent non-related traffic. The operating room shall be as remote as practicable from the entrance to provide asepsis.

 

20.4 The delivery service shall be located and arranged to prevent non-related traffic. The delivery room shall be as remote as practicable from the entrance to provide asepsis.

 

19. Zoning: The different areas of a hospital shall be grouped according to zones as follows:

 

19.1 Outer Zone – areas that are immediately accessible to the public: emergency service, outpatient service, and administrative service. They shall be located near the entrance of the hospital.

19.2 Second Zone – areas that receive workload from the outer zone: laboratory, pharmacy, and radiology. They shall be located near the outer zone.

19.3 Inner Zone – areas that provide nursing care and management of patients: nursing service. They shall be located in private areas but accessible to guests.

19.4 Deep Zone – areas that require asepsis to perform the prescribed services: surgical service, delivery service, nursery, and intensive care. They shall be segregated from the public areas but accessible to the outer, second and inner zones.

19.5 Service Zone – areas that provide support to hospital activities: dietary service, housekeeping service, maintenance and motorpool service, and mortuary. They shall be located in areas away from normal traffic.

 

20 Function: The different areas of a hospital shall be functionally related with each other.

 

20.1 The emergency service shall be located in the ground floor to ensure immediate access. A separate entrance to the emergency room shall be provided.

20.2 The administrative service, particularly admitting office and business office, shall be located near the main entrance of the hospital. Offices for hospital management can be located in private areas.

20.3 The surgical service shall be located and arranged to prevent non-related traffic. The operating room shall be as remote as practicable from the entrance to provide asepsis. The dressing room shall be located to avoid exposure to dirty areas after changing to surgical garments. The nurse station shall be located to permit visual observation of patient movement.

20.4 The delivery service shall be located and arranged to prevent non-related traffic. The delivery room shall be as remote as practicable from the entrance to provide asepsis. The dressing room shall be located to avoid exposure to dirty areas after changing to surgical garments. The nurse station shall be located to permit visual observation of patient movement. The nursery shall be separate but

immediately accessible from the delivery room.

20.5 The nursing service shall be segregated from public areas. The nurse station shall be located to permit visual observation of patients. Nurse stations shall be provided in all inpatient units of the hospital with a ratio of at least one (1) nurse station for every thirty-five (35) beds. Rooms and wards shall be of sufficient size to allow for work flow and patient movement. Toilets shall be immediately accessible from rooms and wards.

 

Accessibility to patients and to interfacing patient care units is the main and initial guidepost for determining the location of the operating rooms.  The physical location of the unit structure per se within the hospital complex is the initial determinant of accessibility.  The other determinants for location of the unit structures  include sterility zoning, privacy zoning, traffic zoning, and inter-relationship with other units in the hospital. 

 

Aside from actual physical location, directional signages, elevators, and connecting bridges, ramps and tunnels can be used to promote accessibility.

 

·         Quantity  

 

Quantity of operating theatres and number of operating rooms within each theatre are primarily influenced by cost-benefit considerations, that is, usual and anticipated increase in patient load vis-à-vis revenues and expenses.  The availability of spaces is also a determining factor.

 

NOTE: As a rule, an OR complex or centralized OR is more cost-beneficial than several ORs located in different locations within the hospital compound.  There is sharing of equipment and functional areas and there is multiple tasking of personnel resulting in maximal utilization of spaces, equipment, and personnel.

 

NOTE: There is usually one PACU in every operating theatre.  There are usually several operating rooms with an operating theatre.

 

·         Size

 

Refer to DOH GUIDELINES IN THE PLANNING AND DESIGN OF A HOSPITAL AND OTHER HEALTH FACILITIES, November 2004 [http://www.doh.gov.ph]

 

Space: Adequate area shall be provided for the people, activity, furniture, equipment and utility.

 

Surgical and Obstetrical Service

Area in sq m

Major Operating Room

33.45 

Delivery Room

33.45

Sub-sterilizing Area

4.65

Sterile Instrument, Supply and Storage Area

4.65

Scrub-up Area

4.65

Clean-up Area

4.65

Dressing Room

2.32

Toilet

1.67

Nurse Station

5.02/staff

Wheeled Stretcher Area

1.08/stretcher

Janitor’s Closet

3.90

 

There must be ADEQUATE SPACE to enable the operations to be performed effectively and safely; for the staff to function effectively and efficiently; and to allow patients, personnel, beds, stretchers, and wheelchairs to move freely and safely.  The quantity of operating rooms required as well as equipment requirements also determine size.

 

·         Design

 

Refer to DOH GUIDELINES IN THE PLANNING AND DESIGN OF A HOSPITAL AND OTHER HEALTH FACILITIES, November 2004 [http://www.doh.gov.ph]

 

A hospital and other health facilities shall be planned and designed to observe appropriate architectural practices, to meet prescribed functional programs, and to conform to applicable codes as part of normal professional practice.

 

 

Minimum service areas in an OR to be included in design:

                       

-  Major Operating Room

-  Recovery Room

-  Sub-sterilizing Area / Work Area

-  Sterile Instrument, Supply and Storage Area

-  Scrub-up Area

-  Clean-up Area

-  Male Dressing Room and Toilet

-  Female Dressing Room and Toilet

-  Nurse Station / Work Area

-  Wheeled Stretcher Area.

-  Janitor’s Closet

 

Zoning inside OR in consideration of asepsis promotion:

 

Zone I – outer – most unsterile zone

Zone II – middle

Zone III – inner – most sterile zone
 
 

 

 

 

 


Operating Room/Treatment Room located and arranged to prevent non-related traffic through the room

 

Dressing Room/Dressing Area arranged to avoid exposure to dirty areas after changing to surgical garments

 

Whatever be the design, foremost it must promote FUNCTIONAL and ASEPTICAL FLOW of patients and staff and one that will promote effectiveness and efficiency and safety in achieving the service functions of the OR-PACU. It must create a healthy and esthetic atmosphere and environment for patients, public, and staff. 

 

Structural or physical requirements based on other ancillary functions of an OR-PACU such as governance, training, and research

 

•         Office for the head of unit

•         Conference room

•         Library

•         Computer system, IT, with Internet access

 

Equipment and material requirements based on the usual authorized and expected service functions of an OR-PACU

 

OR requires equipment and materials needed for operation.

RR requires equpment and materials needed to monitor and care of post-operative patients recovering from anesthesia.

 

Essential equipment and materials:

•         Anesthesizing equipment

•         Operating equipment

•         Supplies for anesthesia and operation

•         Monitoring devices

•         Drugs, parenteral fluids, and gases

•         Recovery room beds

 

Operative equipment and materials are those primarily used in an operation, such as surgical supplies (gauze, drains, plasters; etc.); surgical instruments (knifes, clamps needle holders, etc.); and surgical equipment (lights, suction machines, electrocautery machines; etc.).

 

DOH minimum requirements

 

See minimum licensing requirements for equipment and instrument of a hospital (Level 1 to 4) in the OR-RR [http://www.doh.gov.ph]

 

OR

Minimum Requirement

Air-conditioning Unit

1/OR

Anesthesia Machine

1/OR

C/S Set

1

Instrument Table

1/OR

Laparotomy Set

1/OR

Laryngoscope with Blades

1/OR

Major Surgical Instrument Set

1/OR

OR Light

1/OR

OR Table

1/OR

Ortho Instrument Set

1

Oxygen Unit 1/OR

1/OR

Spinal Set 1/OR

1/OR

Sphygmomanometer – Adult Cuff

1/OR

Sphygmomanometer - Pediatric Cuff Set

1/OR

Stethoscope

1/OR

Suction Apparatus

1/OR

Wheeled Stretcher

1

 

 

RR (PACU)

Minimum Requirement

Air-conditioning Unit

1

Bed with Guard Rail

1

Oxygen Unit

1

Suction Apparatus

1

Sphygmomanometer - Adult Cuff

1

Sphygmomanometer - Pediatric Cuff Set

1

Stethoscope

1

 

There are several issues to consider in the management of equipment and material requirements of an OR-PACU.  These are, namely:

 

·         Who determines the equipment and material requirements of an OR-PACU? (what and how much to store)?

·         Who gives the supply?

·         Who does the inventory?

·         Who regulates the supply (quality, safety, and durability considerations)?

 

 

·         Who determines the equipment and material requirements of an OR-PACU (what and how much to store)?

 

The DOH

The physician-users

The department of surgery 

The department of anesthesiology

Other clinical medical departments who are allowed to use the OR

The nurse in charge of the OR-PACU

The central supply and stockroom

 

DOH

See minimum licensing requirements for equipment and instrument of a hospital (Level 1 to 4) in the OR-RR [http://www.doh.gov.ph]

 

The physician-users

The surgeons and anesthesiologists are the primary users or, more specifically, the prescribers of what and when to use the equipment and materials for their patients.  Thus, heads of the nursing service areas, pharmacy, central supply, and stockrooms should consult the surgeons.  The other medical specialists who are allowed to use the OR should also be consulted.  If not, there will be wastage due to unused equipment and supplies.

 

The nurse in charge of the OR-PACU

The pharmacy

The central supply and stockroom

 

The heads of the OR-PACU, pharmacy, central supply and stockrooms can also determine what and how much to store for use by the physician-users or surgeons but this should be done in coordination with, if not authorization from them. 

 

Based on the inventory and usage data, they can determine what and how much to store.

 

·         Who gives the supply?

 

The hospital management and at times, higher office, especially in government hospitals.

 

·         Who does the inventory?

 

The OR-PACU, pharmacy, central supply and stockrooms and even a higher office, such as an auditing office or finance department.

 

·         Who regulates the supply (quality, safety and durability considerations)?

 

Approval of requests by physician-users, surgeons and head of OR-PACU has to pass through a body or office which will study the requests for acquisition.

 

Physician-users and surgeons may request sophisticated and expensive equipment, instruments, and materials for their use.  Decision for approval, aside from the logistical considerations, should be guided by government regulations, quality standards requirements, cost-benefit considerations, value-added, vision-mission, and benchmarking considerations; and financial viability.   (Surgeons should promote returns on investment on equipment requested.)

 

Equipment should have preventive maintenance and calibration at planned intervals to ensure accuracy and safety in their use and longer life span.  

 

EQUIPMENT/INSTRUMENT

Licensing requirements of DOH Bureau of Health Facilities and Services on equipment / instruments [http://www.doh.gov.ph]

 

4.1. All equipment and instruments necessary for the safe and effective provision of services are available and are properly maintained.

4.1.1. Records of equipment are maintained and updated regularly.

4.1.2. A preventive maintenance program ensures that all

equipment are maintained and/or calibrated to an appropriate

standard or specification.

4.1.3. There is a plan in place for essential equipment replacement.

4.1.4. Personnel are competent when using equipment in line with

manufacturer’s instruction/operational manual.

4.1.5. Operational manuals of all equipment and instruments are

available for reference and guidance.

 

In the mangement of equipment, be guided by the following:

 

Licensing requirements of DOH Bureau of Health Facilities and Services on equipment / instruments [http://www.doh.gov.ph]

 

Quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as ISO and Joint Commission International or JCI) [http://www.philhealth.gov.ph]

 

Staff requirements of an OR-PACU

 

            Loosely speaking, staff requirements of an OR-PACU include the physician-users required to promote financial viability and sustainability and the nursing staff required to administer it effectively and efficiently (also to promote financial viability and sustainability of the OR-PACU).

 

            For an effective functioning of an OR-PACU, at least the following kinds of staff are needed:

 

1.      Surgical specialists

2.      Anesthesiologists

3.      Nurses and nursing attendants

 

Note: Surgeons and anesthesiologists per se are not under the jurisdiction of the OR-PACU or the nursing head.  However, they are important members of the OR-PACU staff as they are the primary users and important contributors to the financial viability and sustainability. Thus, integration, cooperation, and collaboration among these different staffs must come into play for an effective functioning of the OR-PACU.

 

            General determining factors on staff requirements of an OR-PACU    

 

The basic issues are qualification (competency) and quantity.

 

Resolution of the above issues will be dependent on the following general determining factors:

·         government regulations (particularly the licensing process of DOH Bureau of Health Facilities and Services)

·         quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as ISO and Joint Commission International or JCI)

·         usual and anticipated increase in patient load (cost-benefit considerations)

·         needs and expectations of the community

·         integration, coordination and collaboration with other units in the hospital for efficient use of human resources

·         value-added, vision-mission, and benchmarking considerations

 

In fulfilling the staff requirements, be guided by the:

 

Licensing requirements of DOH Bureau of Health Facilities and Services on equipment / instruments [http://www.doh.gov.ph]

 

Quality and professional standards requirements (particularly the PhilHealth Benchbook and international standards such as ISO and Joint Commission International or JCI) [http://www.philhealth.gov.ph]

 

            Department of Labor and Employment (DOLE) requirements

 

For physicians and non-physician staff, DOH has the following basic staff requirements:

 

3. Personnel

The health facility appoints and allocates personnel who are suitably qualified, skilled and/or experienced to provide the service and meet patient needs.

3.1.1. Each personnel is qualified, skilled and/or experienced to

assume the responsibilities, authority, accountability and

functions of the position.

3.1.2. Professional qualifications are validated, including evidence

of professional registration/license, where applicable, prior to

employment.

3.1.3. An organized medical and nursing staff shall be responsible

for the quality of patient care and for the ethical conduct and

professional practices of its members.

 

Quantity of Staff

 

DOH has the following prescriptions:

For Physicians:

            100 beds and below = 8

Every additional 50 beds = additional 3

 

The physician must not go on continuous duty for more than forty-eight (48) hours.

           

For Nurses and Nursing Attendants:

Supervising Nurse

            50 beds and below = 1;

51 –100 beds = 2;

101 – 150 beds = 3

151 beds and above = 4

Supervising Nurse (Critical Care Units)= 2

Head Nurse = 1:15 Staff Nurses

Staff Nurse = 1:12 beds at any time

Staff Nurse (Critical Care Units = 1:3 Critical Care Unit beds at any time

Nursing Attendant/ Midwife = 1:24 beds at any time

Nursing Attendant/ Midwife (Critical Care Units = 1:3 Critical Care Unit beds at any time

 

For every three (3) Nurses or Nursing Attendants/Midwives, there must be one (1) reliever.

 

Critical Care Units include all Intensive Care Units (ICUs) and Post-Anesthesia Care Unit (PACU)/Recovery Room (RR).

 

Competency of physician-users

           

DOH has the following prescriptions for a level 4 and level 3 hospital accreditation:

 

For Physicians in Clinical Service:

 

The Department Head must be Diplomate/Fellow of a Specialty/ Subspecialty Society.

 

Consultant Physicians are must be Diplomates/Fellows of a Specialty/Subspecialty Society.

 

 

Coordination of nursing staff with physician-users

 

For an effective functioning of an OR-PACU, there must be integration, cooperation, and collaboration between the nursing staff and the physician-users.

 

The best way to effect this is through a policy-making and coordinating body in the form of a committee, such as the operating room committe, committee on operating room complex, or operating room management team (ORMAT).  A surgeon or an anesthesiologist may be appointed to head the committee. In addition, an anesthesiologist, by the nature of the patients being brought to the PACU as well as its primary purpose of post-anesthesia care, may be appointed to supervise the operations of the PACU. 

 

Policies and procedures in an OR-PACU

Operations Manual

 

To provide order, to promote standardization, to facilitate communication, to promote effectiveness and efficiency, and to provide a guide to present and future staff, among other things, policies and procedures must be in place. 

 

These must be collaborated by the nurses and physician-users through the operating room committee and authorized by it and a higher office.

 

These must be aligned with those of the hospital.

 

These should be reviewed and revised periodically.

 

The presence of policies and procedures is a requirement for licensing by DOH, accreditation by PhilHealth and other accrediting bodies like ISO and JCI.

 

There must be policies and procedures on

Governance

Service (Patient Management)

            Clinical practice guidelines in the OR and PACU

            Clinical pathways in the OR and PACU

            Surgical nursing care

General nursing care

           

Training

Research

 

In patient management, clinical practice guidelines and clinical pathways are useful in standardization of procedures as well as in the promotion of efficiency.

 

Clinical practice guidelines – systematically developed statements, built on synthesis of evidence, which provide formal recommendations about appropriate and necessary care, intended to assist practitioner and patient to make decisions about appropriate health care for specific clinical circumstances.

 

Clinical pathway – an interdisciplinary plan of care that outlines the optimal sequencing and timing of interventions and expected outcomes for patients with a particular diagnosis, procedure or symptom.

 

The following are useful references in making policies and procedures:

 

PhilHealth Benchbook, Joint Commission International, and Investors in People Standards

 

Established clinical practice guidelines of the Philippine College of Surgeons and Philippine Society of General Surgeons relevant to the management of patients in the operating room (such as the Patient Safety in Surgery – Sign in, Time in, and Sign Out)

 

Established clinical practice guidelines of the Philippine Society of Anesthesiology

 

Established clinical practice guidelines of the Operating Room Nurses of the Philippines

 

 

PhilHealth Benchbook [http://www.philhealth.gov.ph]

 

            A reference manual originating from PhilHealth containing accreditation standards that will evaluate processes that hospitals and professionals use to provide health care and evaluate outcomes that occur as a result of health care provision.  It is essentially a benchbook of quality health care that will be used as a yardstick against which the quality of care rendered by PhilHealth and its accredited health providers and professionals will be measured.

 

            Seven groups of standards:

            Patient Rights and Organizational Ethics

            Patient Care

            Leadership and Management

            Human Resource Management

            Information Management

            Safe Practice and Environment

            Performance Improvement

 

Joint Commission International Accreditation Standards for Hospital (JCI)

[http://www.jointcommissioninternational.org]

It is a reference manual produced by the Joint Commission International, an international arm of The Joint Commission (USA) containing accreditation standards on quality and patient safety.

            Patient-centered Standards

                        Access to Care and Continuity of Care

                        Patient and Family Rights

                        Assessment of Patients

                        Care of Patients

                        Anesthesia and Surgical Care

                        Medication Management and Use

                        Patient and Family Education

            Health Care Organization Management Standards

                        Quality Improvement and Patient Safety

                        Prevention and Control of Infections

                        Governance, Leadership, and Direction

                        Facility Management and Safety

                        Staff Qualifications and Education

                        Management of Communication and Information

Investors in People Standards [http://www.investorsinpeople.co.uk]

Accreditation standards on improving organizational performance through better planning, implementation and evaluation of learning and development programmes across the organization.  It is essentially a framework for delivering organizational improvement through people.

Standards

  • Business strategy
  • Learning and development strategy
  • People management strategy
  • Leadership and management strategy
  • Management effectiveness
  • Recognition and rewards
  • Improvement and empowerment
  • Learning and development
  • Performance measurement
  • Continuous improvement

 

 

Programs of an OR-PACU

 

Based on the authorized functions, programs and projects can be designed to achieve the functions and then continually improve the department.

 

General programs and projects consist of the following:

            Programs on Governance

            Programs on Improving Service

            Programs on Teaching

            Programs on Research

 

Examples of programs based on functions:

 

Functions

Parameters / indicators

Programs / Projects

To provide quality services in the operating room.

With structured program in the management of patients

 

With implementation of Project Cost-Effective Management (Health-Process-Evidence-based Clinical Practice Guidelines)

 

With structured quality-monitored service program

 

Recovery Rate – 90%

Mortality Rate – 5%

Morbidity Rate – 5%

 

Customer Satisfaction Rating  ≥ 85%

 

Not more than 3 written and valid complaints per year

Project Excellent Service

 

Project Cost-effective Management (Health-Process-Evidence-based Clinical Practice Guidelines)

 

Project Customer Satisfaction

To provide quality training for its staff with the view of ensuring provision of quality service.

With structured quality-monitored training program for staff

 

Project Excellent Education and Training

 

Project Customer Satisfaction

To provide quality research among its staff with the goal of ensuring provision of quality service.

With structured quality-monitored research program

 

Action researches with impact on quality service – at least one a year

Project Excellent Research  (Project Action Research Program / Continuous Quality Improvement )

 

 

Resources in an OR-PACU

 

Resources include infrastructure, equipment, people and other logistics needed for the operations of the organization.

 

The assumption is always there is a limit to resources.

 

In a private hospital setting, resources come from revenues of operations of the department.

 

In a government hospital setting, resources come from allocated tax payment and are usually limited. 

 

The head of the department should determine how much he needs based on his planned programs, where he can get them, and how to get them.  This is the challenge to his leadership and managership.

 

 

Common problems and solutions in an OR-PACU

 

Categories

Common Problems

Suggested Strategies

MAN

Consultants

Residents

Colleagues in other units

Chief of Hospital

Competencies

 

Number

 

Integration, coordination, collaboration

Leadership and managership

 

Investor in People Standards

 

Managing your boss

 

Use of an operating room committee with multi-professional memberships

SYSTEM AND METHOD

Lack of systematization

Lack of standard procedures

Use DOH requirements

Use quality standards (PhilHealth Benchbook and JCI)

Policies and procedures

Clinical practice guidelines

Clinical pathways

MACHINE/EQUIPMENT

Lack of management system

Lack of calibration

Lack of preventive maintenance

Policies and procedures

 

MONEY

Other resources

Limited

Leadership

Innovativeness

TRENDS

Rapid changes - difficulty in coping

Knowledge management system (constant tracking and continual education)

Benchmarking

Innovativeness

 

Managership of the head of an OR-PACU

 

 

 

Leadership of a head of an OR-PACU

 

As a leader, you must lead and coach your staff in formulating the vision-mission statements, core values, quality policy, and quality objectives of your department. 

 

The vision-mission statements, core values, quality policy, and quality objectives must be aligned with those of the hospital or cascaded from those of the hospital.

 

The formulation of the governance statements and objectives should be an outcome of collaborative activities of all the staff as much as possible in order to faciliitate accomplishment driven by sense of ownership and spirit of commitment.

 

Example of a vision statement of an OR-PACU:

           

We envision our OR-PACU to be

 

a model (or an excellent or an outstanding) OR-PACU in the community (or in the Philippines) providing quality and safe services.

 

After formulating the governance statements of the department, as a leader and manager, you must lead and coach your staff in formulating a 3 to 5 years strategic plan and an annual management action plan.  There must be monitoring and evaluation of the implementation of the plans at planned intervals, end of the year and at the end of your terms.  It is only after getting the results of the evaluation can you and your chief of hospital and nursing director really say whether you have been a good leader and a manager.