AORN Interviews … William H. Wilcox:

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It is the AORN Journal's intention to share with our readers varying perspectives from thought leaders in management, nursing, medicine, and other spheres affecting the health care system. On January 16, 2009, AORN Journal Editor-in-Chief Patricia C. Seifert, RN, MSN, CNOR, CRNFA, FAAN, interviewed William H. (Bill) Wilcox, president, chief executive officer, and director of United Surgical Partners International, Inc (USPI). USPI owns and operates 167 short-stay surgical facilities in the United Kingdom and the United States that collectively perform about 750,000 procedures per year [http://www.unitedsurgical.com].

In this second of a two-part interview, the interviewer (AORN J) and Bill Wilcox (BW) discuss a wide range of issues related to differences between caregivers in the United Kingdom and United States, empowerment and assertiveness, nursing performance and value, retention issues and strategies, abusive behavior, patient safety, and opportunities for professional growth. Throughout the article, pertinent web sites are provided where readers can obtain more information.

AORN J: What can US nurses learn from British nurses and vice versa?

BW: Operating in two distinct markets enables us to share experiences and potential solutions to issues that arise in both, and there are regular exchanges in that regard though not to the degree I would like. Generally speaking, our UK management thinks US health care tends to lead on clinical and organizational developments, while in the US we admire our UK hospitals' records on patient safety. The benefit to our UK operations is that as a result they have access to our experience and knowledge and have the opportunity to consider developments and determine if they fit culturally. The benefit to the US is that it helps set our bar even higher on patient safety issues.

In terms of a global answer, it can be beneficial to compare across cultures because there may be fewer historical biases. For example, recently we held a teleconference between British hospital representatives and our corporate quality group to discuss and compare best practices related to wrong site surgeries—Joint Commission Universal Protocol to Prevent Wrong Site Surgeries. [http://www.jointcommission.org/PatientSafety/UniversalProtocol/] We found that our best practices put in place to prevent wrong site surgeries were very similar.

Essentially, our British facilities operate independently of our US facilities and are governed by British health codes, which are under totally different governance. But, as in this example, there are certainly areas of nursing practice that we have identified that may benefit each group through the sharing of information. It will be an area that we can continue to explore since we are an international company. There are many similar practices. As a result of our study, we received assurances that we were pursuing best practices.

AORN J: Can you share with us what a couple of those best practices may have been?

BW: The most notable fine tuning we've done is putting more of a focus on [The Joint Commission's] “time outs” in the preop area as opposed to the surgery suite itself. There's no question of the importance and appropriateness of it. In the US, some of our misses and near misses have occurred preoperatively, and although we haven't had that happen in the UK, both sides have stressed the preoperative piece in addition to what was going on in the OR. Of course, an emphasis on the surgeon marking the site had taken place in both countries.

AORN J: The Joint Commission has noted that poor communication is a significant cause of error. [http://www.jointcommission.org/NR/rdonlyres/ACAFA57F-5F50-427A-BB98-73431D68A5E4/0/Perspectives_Article_Feb_2008.pdf] Do you think that would resonate in the UK?

BW: Yes, but I hesitate because our UK facilities have had fewer issues with wrong site [errors] than our facilities in the US, and I think it's a combination of the nurses in the UK perhaps feeling a little more empowered than those in the US in terms of that communication and also perhaps the vigilance that the surgeons have—and the respect they have—for the importance of the time outs. That's speculation on my part.

AORN J: This raises the topic of “empowerment.” What is it about the UK nurses or the UK system processes or relationships that makes [nurses] feel more empowered to say, “Wait a minute, this is wrong”?

BW: I think it's embedded in the historical culture, and I think we've made significant advances in the US, although in my company we are still frustrated with the number of wrong sites, in which we include near misses or instances with no adverse outcomes. When we go back to review these, more than half the time we find that if someone in the OR had been more assertive, we may have avoided them. I don't want to make it sound like we have a lot of wrong sites—one would be too many. It's just a strong focus of our company.

AORN J: I appreciate your candor because from what I hear from nurses and physicians, it's important to be assertive, particularly when your goal is patient safety.

BW: Absolutely! Our mission statement is to treat each patient as if one of our own family. And there's not a person in that OR who would not make sure that the protocol is followed for their family member. That's why we keep hammering on this. I suspect that in five or 10 years, that commitment and culture of comfort with being assertive in the OR—especially as it relates to wrong site—will be much improved.

AORN J: There's evidence to show that assertiveness saves lives and provides a safety net.

BW: And it's generally in the nurse's nature to do what's necessary for patient safety, but we need to be ever vigilant.

AORN J: With [pay-for-performance (P4P)] initiatives [http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=1343&intNumPerPage=10&checkDate=&checkKey=2&srchType=2&numDays=0&srchOpt=0&srchData=pay+for+performance&keywordType=All&chkNewsType=6&intPage=&showAll=1&pYear=&year=0&desc=&cboOrder=date], how will health care organizations be reimbursed for nursing care? Is this a challenge for nursing individually and collectively, as well as organizations, due to nursing care historically being bundled into “room and board?” Are there opportunities for nurses and health care organizations to measure—and subsequently be reimbursed for—nursing care?

BW: I think it will be a while before unbundling nursing occurs to a meaningful degree, if ever. However, pay for performance is such a logical and appealing concept; I believe we should continue its development.

AORN J: How do you measure “performance”?

BW: We measure performance from clinical, service, financial, and statistical perspectives:

AORN J: How do you measure nursing performance?

BW: We measure it at both the team and personal level. The performance of all of our employees can be measured in a variety of tangible ways through processes that are in place at the facility level. The use of performance management plans and competency assessment tools that our nursing managers have available to them through our company's intranet web site are two examples. These are ways we measure individual performance. Additionally, monitoring continuing education is a tangential measurement.

A significant measurement of our nursing team performance is through analyzing the results of specific, targeted questions on our patient and physician satisfaction surveys. We trend these results and give feedback to the team. We also participate in the hospital quality reporting of patient satisfaction data. Of course, physician retention rates may also be an indirect measure, as many of our surgeons have stated, both on surveys and in personal communications, how critical it is to them to have nurses who know their routines and help them to be more efficient.

AORN J: Do you share your quality assurance results with staff?

BW: Yes, and also with our doctors and our health system partners. The peer review and the whole function of the [quality assurance] programs—that's all intended to be transparent. With over 160 facilities, there may be one that isn't, but it's our intention to be transparent.

AORN J: Your web site mentions the EDGE™ (Every Day Giving Excellence) program. Could you tell us how this affects quality and performance?

BW: It is intended to be a cornerstone of each facility's quality assurance program. It was developed to disseminate best practices, and most importantly, to provide a common language and promote benchmarking. I mentioned that two-thirds of our administrators are clinical, and we found early on in the industry that nurses tend to make the best bosses of our small facilities. In the “early days,” all we could talk about were the business aspects—the financial statements or the statistics. Administrators tend to think that whatever a person asks about is most important to the asker, so we were missing the whole clinical piece and the whole service piece. And that's when we determined we needed a language through which we could talk about what we really know is important. What really drives the business is the clinical excellence and the service excellence. When you look at our customers, the patients and the physicians, and see them as family members—that's what drives repeat business. And I'm not talking just in altruistic terms, but also in hard core business terms. What gets you more business is being the best, having the best nurses, and providing the most efficient and enjoyable experience. That's what makes us successful, so we had to come up with ways to measure the customers' view of our clinical excellence and also our service excellence.

USPI's EDGE is the company's strategy for continuous performance improvement in the areas of clinical, service, financial management, and leadership. It's a tool to assist in providing high quality clinical care; ensure patient safety; and provide excellence in service to our customers, which includes physicians, their staff, patients, and their families. It is a tool that allows for reporting, trending, and benchmarking of data with the goal of using data to continually improve processes at every level of the organization.

AORN J: What are quantifiable indices of a nurse's value?

BW: I do not think we are particularly progressive in this area of quantifying value. However, we do pay bonuses at the facility level and those bonuses may be impacted by particularly good or particularly poor patient safety and other clinical or service measures. Nurses have always been and will continue to be instrumental to USPI's strategy to be a leader in the delivery of quality care to our patients. Nurses' contributions are critical to every facet of the organization, from the bedside to the boardroom. We have established a Clinical Excellence Committee that focuses on recognition of superlative clinical service. This entity also established a corporate level Nursing Recruitment and Retention Council, which researches and facilitates implementation of industry best practices that encourages nurses to perform and to be successful in every phase of their professional nursing careers. This has been effective in recognizing the importance of retention and recruitment of the best and brightest nursing staff USPI has in place.

AORN J: You mention retention. What are necessary components of a successful RN retention program?

BW: Leadership is key. Ensure strong and positive leadership at each facility and ensure healthy respect and relationships with the medical staff. These are the most important things. It is very evident in facilities where this exists. It doesn't have to be this huge camaraderie. Rather it's the mutual respect that is the most important common denominator.

It's also critical to have a substantive quality assurance program. Involve the RNs in developing a retention program; this has worked for us and helps identify nurses who will fit into our culture, as well as those who will not fit. Offer opportunities for career development and continuing education. Recognition of excellence and employee appreciation are also important.

Most of the literature related to this topic points out that nurses want to work in an environment that is safe, and one that promotes quality in health care delivery. That sounds cliché but it is the foundation on which an effective retention program should be built. We have and continue to focus on building a framework for a culture of safety within all USPI-managed facilities. The framework states that “USPI encourages a fair and just culture embraced by leadership where every employee is accountable for assuring the safety of every patient.” This allows physicians and co-workers to focus on safety issues and identify and report all events, near misses, and hazardous conditions and helps to implement performance improvement.

We have a poster in every facility that has the following statement: “Understanding that a Culture of Safety Requires Partners to be Invested, Interested, and Involved.” Responses to a USPI culture of safety survey conducted in all USPI facilities in August 2007 underscored the fact that nursing staff desire a safe work environment and value it as an important factor in job satisfaction. Recognizing the contributions that nursing staff provide on a daily basis should be underscored as well. Through our USPI Clinical Excellence Council, we recognize the achievements of our nurses and nursing support staff on an annual basis by having each facility nominate, for company-wide recognition, outstanding staff members from four key areas:

Recognition programs such as this can be instrumental in retention efforts as well as motivating nursing support staff to become interested in a career in nursing.

AORN J: There has been increasing concern about “lateral violence.” Are there specific measures that USPI uses to reduce harassment, bullying, and other forms of abusive behavior?

BW: To be frank about it, it wasn't even on my radar screen until three or four years ago. What we've done to attack the issue is to communicate with our employees and doctors. [AORN leader] Bev Kirchner [RN, BSN, CNOR, CASC] came to our nurse manager conference to talk about it. The importance of the problem resonated with us. We followed that up throughout our company with a dissemination of an amendment to our code of conduct that we asked each of our facilities to adopt—both employees and the medical staff. The amendment also includes a “disruptive and inappropriate behavior” policy. It's part of that whole movement we discussed earlier—you want that same type of relationship between employees and the doctors that reflects mutual respect—not only in time outs but also we want each employee to feel empowered to speak out and to help each other avoid any disruptive or inappropriate behavior. This must apply not only to our employees but also to our surgeons and anesthesiologists. And you know, in these comfortable environments in small businesses—and people working in high-stress environments—for years in the operating room there has been this very collegial sense of camaraderie. But when you have a certain actor that goes over the line, that needs to be reined in. It needs to be A) recognized and B) challenged. So we're trying to arm people with that, but keep the spirit that makes this such a wonderful place to work. It could easily swing too far the other way, but we are willing to take that risk.

AORN J: The Joint Commission put out their Sentinel Event Alert about a situation wherein abusive behavior was seen as leading to a patient injury [http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm]. There has been some talk about delaying the Joint Commission's implementation of the new standard, but it seems to be clear that a move toward strengthening an environment where people are comfortable doing the right thing, such as you have done, is beneficial.

BW: There's going to be some balancing. It's like a lot of things, and I put Sarbanes-Oxley [ie, a federal law that regulates financial practice and corporate governance, http://www.soxlaw.com] and the Health Insurance Portability and Accountability Act [HIPAA] [ie, a federal law that protects patient confidentiality, http://www.hhs.gov/ocr/privacy/index.html] in that same category. If you look at the spirit and the message behind it and embrace it, then generally 80% to 90% of it makes you better. If you look for the message behind it and look for the message that's relevant to you, most of these things have a lot of substance in them. And you know, the patient safety implications of abusive behavior—tolerance of it—can lead to unforeseen and unwanted outcomes.

Our primary focus has been to raise awareness through discussions on the subject and to develop and ask each facility, including medical staff, to incorporate an “abusive behavior” policy into their overall code of conduct and compliance program. We have worked with the accrediting bodies to develop a recommended policy and distributed that to each facility's governing board and medical staff for adoption. Additionally, we have had nursing leaders from AORN speak at our Director of Nursing Conference on this subject.

AORN J: What do you see as the patient safety implications of abusive behavior?

BW: Tolerance leads to unforeseen and unwanted outcomes.

AORN J: How does USPI work to improve patient safety, workplace safety, and staff safety?

BW: Our whole framework for a culture of safety touches on each of these topics [patient safety, workplace safety, and staff safety]. By ensuring that each facility's medical executive committee and governing board are actively involved in the decision-making process and have approved a policy and/or process that all staff can understand and follow is critical in laying the framework for a culture of safety philosophy. The processes are developed and supported by USPI senior leadership and then there is an expectation that all members of the team are held accountable to one another to support the culture of safety philosophy and processes. It is important for staff to know that leadership is supportive and that any reported occurrences will be investigated quickly and responsibly by leadership. We are not perfect by any means, but we are committed to vigilance and improvement.

AORN J: You mention nurses are the best bosses in certain areas, and that having clinical expertise is valuable. What skill sets and other expertise or knowledge capital could nurses bring to the board room/executive level?

BW: Skill sets would include

Additional expertise would be the communication of our core business: taking care of patients and providing core services to surgeons—that is all carried out by our employees and primarily by nurses. We have a Board of Directors that recognizes that and is very interested in that and so we present our EDGE measures at each meeting. When we have our monthly operating reviews, they aren't just financial. They start with the question, “What is happening at your facility from a clinical perspective and from a service perspective (looking at things that differentiate us) to the doctor from a clinical perspective to a doctor from an efficiency perspective?” It's not just “burns” and “wrong sites” and “prophylactic antibiotics.” It's also, “Did you start my case on time and did you have a fast turnover? Was the case set up appropriately?” And similarly, from the patient's side—both the clinical and service side—“How did we do?” Then on a quarterly basis, all of our benchmark scores and outcome measures go to senior managers and to our Board of Directors' Audit Committee. Then it's presented in summary form to the Board. Board members are very in tune with the strategy that goes back to providing excellence through our nurses. That's the only way that we can provide a high level of care.

Nurses have, and continue to be, contributors at every level of the USPI organization. Almost two-thirds of our facility administrators have clinical backgrounds while one-third of our regional and division management are clinical. USPI also utilizes nurses in key roles such as in development and planning of de novo and acquisitions. Using their clinical experience in the early development of new centers and other development projects offers opportunities to create work environments that are staff- and patient-friendly and maximize use of resources. Our senior nurse is a member of the company's senior leadership and, along with our medical director, is active in reporting outcomes to the Audit and Compliance Committee of the Board, as well as to the Board.

AORN J: Part of USPI's professional development benefits include [masters of business administration (MBA)] sponsorship programs. How would participants of that program be able to apply the business administration skills that they learn? How would the MBAs help the company's bottom line?

BW: This is a relatively new program and not yet widespread, but in terms of people who can take advantage of it, it depends somewhat on their level and role within the organization. This is a program we put in place in an attempt to retain and develop rising stars who have ambition beyond their current path. For clinicians, that could mean expanding their roles into broader leadership, which in today's world requires a greater expertise in financial management, organizational approaches, and general systems theory.

We also support and recognize the benefits of a Certified Administrator of Surgery Center (CASC) certification program, and have had good results from that program as well. [http://www.aboutcasc.org/information.htm] Many nurses have taken advantage of that as well.

AORN J: The USPI web site [http://www.unitedsurgical.com] also mentions “Role-based Training.” Can you tell us more about that program?

BW: This is training that has been developed specifically for certain roles within our company and facilities, which also makes it easier for any employee who may be interested in moving into another role to start preparing themselves by participating in the available training. Examples of specific roles are facility administrators, business office managers, directors of nursing, and regional management.

AORN J: What partnerships and relationships should nurses develop to position themselves for executive level roles?

BW: Within USPI facilities, we believe our nurses should have opportunities to be involved in varying facets of their facility operations. Our nurse managers are encouraged to mentor nurses under their supervision and assist them in developing a career path that interests the nurse. The identification of potential nurse leaders among the rank and file of our organization is a critical factor in fostering professional development of staff and a key factor in assisting an organization as diverse as USPI to develop our future leaders. It is critical that a nurse who desires a career path that includes executive level roles seeks out a mentor within his or her organization. There is no better time for a career in nursing than right now and, as I stated previously, more and more nurses are finding rewarding positions at the top of the organizational chart.

AORN J: How do nurses in the organization contribute to the fiscal health of USPI?

BW: They are critical. Perhaps the most critical as they control directly or indirectly four significant areas:

As far as physician retention, physicians state that consistency and competence of nursing staff is highest among their satisfaction ratings.

Almost two-thirds of our facility administrators have clinical backgrounds while one-third of our regional and division management are clinical. The financial and clinical successes of the many facilities with nursing leaders at the helm provide a clear signal that their contributions matter to the organization. Our nurses work closely with our physician partners and understand the importance of maintaining clear channels of communication with our physicians and patients. The excellence we strive for cannot happen on a consistent basis without competent, caring, and motivated nurses in key leadership roles in each of our facilities.

AORN J: On the web site under “Our Culture,” it states that USPI's EDGE program is designed to serve “[USPI's] customers, our physicians and their staff, our patients and their families.” Who are USPI's “customers?” Would that include USPI staff?

BW: We don't call our staff our “customers,” but that is mostly a vernacular distinction. We regard our employees as our “most precious asset.” We know we can only achieve our mission through our hands-on employees. Within the company, our home offices exist to support the facilities, so that staff can provide excellence to our patients and physicians. And through them that culture really lives. And the recognition that they get about the company's dependence upon them, I hope, is consistent and I know meant to be a very appreciative view.

AORN J: You're talking about having a culture wherein people can feel free to treat their patients as if they were family members whom they love. How do you develop such a culture? What are the strategies you use to promote this type of culture?

BW: I think the main thing is communication and putting the appropriate leadership in place that embraces that culture. With nurses, specifically, that's like singing to the choir. People become nurses because they have that caring capacity and what we try to do is reinforce that culture—that culture will provide growth through excellence and unquestionable business ethics and a work environment that's professional, productive, and enjoyable. For us, being a company of small businesses, we depend so much on management at the local facility. The wonderful nature of nurses themselves—with the appropriate leadership at the facility—helps to spread that culture.

AORN J: Thank you for taking the time to talk with us.

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