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Ambulatory Surgery Center’s Process Improvement


According to a study by Farber (2010), approximately 12% of the US population (37 million people) is aged 65 years and above (p.313). Conservative estimates reveal that this population cohort will increase to about 71 million people or 20% of the nation’s population by 2030. As a result, the demand for outpatient surgical facilities is expected to increase in the future. These projections are corroborated by the American Hospital Association which reported that the demand for outpatient services increased from 20% to 60% between 1981 and 2006 respectively (Farber, 2010, p.313). Whereas the construction of more ambulatory facilities is underway to satisfy the escalating demand for outpatient care, provision of healthcare services have turned competitive as healthcare organizations face immense pressure to attract more patients to their facilities. Given the escalating demand for ambulatory surgery services, healthcare facilities have explored various way to improve low patient/family satisfaction score (Farber, 2010, p.313). It is against this background that the current paper will develop a plan (based on Kurt Lewin’s Theory of Change) that could be used to improve patient satisfaction outcomes with respect to services dispensed by ambulatory surgery centers.

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Kurt Lewin’s Theory of Change

Kurt Lewin’s Theory of Change asserts that “you cannot understand a system until you try to change it” (Weick & Quinn, 1999, p. 363) espouses three phases of change (unfreeze, change, and refreeze) that can be employed for quality improvement within ambulatory surgery centers. From an organizational viewpoint, change (espoused in Lewin’s theory) is defined as a collection of science-oriented procedures, strategies, values and theories directed at the premeditated change within the working environment of an organization with the aim of promoting individual and organizational performance. This change is achieved by adjusting work-related performance of employees within an organization (Weick & Quinn, 1999, p. 363).

Problem Identification

I initiated weekly meetings for my project with hospital’s leaders and ambulatory surgery center (ASC) and OR nurse leaders to evaluate potential areas for quality improvement (QI). The main goal of these meetings was to assess weekly survey scores of the hospital’s ambulatory surgery center and establish priorities for quality improvement. These meetings also sought to establish ways to enhance survey scores; adopt improvement plans with relevant ASC and OR nursing staff; study weekly PG data; and share the outcomes with nursing staff members. In addition, the relevant nursing staff members were provided with score analysis revealing the least scores at the beginning of the quality improvement plan. Impediments to QI consisted of ASC nurses’ lack of information regarding the facility’s use of PG surveys to enhance scores as well as patient/family satisfaction.

To begin, ASC and OR nurse managers appraised the hospital’s ambulatory surgery report for the third quarter of 2010 (3Q10) and identified five priorities for setting up a baseline. The five priorities identified (in order of merit) were: information regarding delays; response to complaints by patients/family; waiting-time in x-ray; information regarding the day of surgery; and simplicity of setting up an appointment. Lewin’s theory of change lends credence to QI because it provides models of processes that emphasize on the appropriate types of variables that must be observed and conceptualized. For instance, Lewin’s model of the change process can be used to evaluate various phenomena (in human systems) since it lends emphasis on elaboration and refinement (Schein, 1996, p.59).

We opted to focus on ways to improve the three priorities with the least scores: information regarding delays; response to complaints by patients/family; and waiting-time in x-ray. Press Ganey (PG) was used to compute average score in every category and establish the percentile yardstick rank of the hospital. The 3Q10 ambulatory surgery survey report (see table 1, appendix) revealed that the score levels in the three areas were below the 90th percentile target score. The OR nurse managers decided that remedial measures were required to achieve the targeted percentile score. Consequently, clinical educators and OR leaders formulated the objectives of the QI plan: scheduling the process; explaining a vision; determining main stakeholders; sketching a plan; adopting the plan; and gathering data using comment cards and PG ambulatory surgery survey instruments.

When I presented my report regarding the problem of low PG scores to the ASC and OR leaders, all relevant ASC nursing staff members were invited for a series of in-service meetings to brainstorm ways to enhance scores and patient satisfaction. Participants were encouraged to express their concerns and ideas. OR managers and educators assessed major organizational impediments (i.e. communication barriers among staff, incorrect medical procedures, and delays in surgical start-time) that would potential cause delays and result in patient dissatisfaction. In addition, the ASC managers evaluated the national patient satisfaction PG scores (which ranged from 90.6% to 91.4%) published by PG Physician’s and Outpatient Pulse Report in 2008. Our ASC report revealed similar trends (90.7% to 91%) for the previous fiscal year. The dedication of ASC and OR nursing staff members generated optimistic changes in the three categories targeted in our quality improvement plan.

Plan of Action

My QI plan is based on Lewin’s theory of change since his assumptions regarding change are compatible with my proposed plan. His assumptions include: goal assumption (movement is in the direction of a defined end-state); progressive assumption (movement from an inferior state to a superior state); linear assumption (movement is in a forward direction, from inferior state to superior state); separateness assumption (movement is premeditated and administered by humans, not system); and disequilibrium assumption, where movement entails disequilibrium ((Weick & Quinn, 1999, p.372).

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There are various approaches used for QI in ambulatory surgery centers. For instance, SBAR (Situation, Background, Assessment, and Recommendation) is a controlled communication system used to package patient data in a conventional format (Haig et al., 2006, p.167). Since the information is well-framed, pertinent and brief, SBAR is an excellent instrument for updating patient information. SBAR has been employed successfully in ambulatory setting to relay important information to patients/family thereby reducing waiting time. However, SBAR is susceptible to communication mishaps, especially when incorrect data is captured and relayed to waiting patient/family members (Barenfanger et al., 2004, p. 802; Sutcliffe, 2004, p.186).

Whiteboard is also frequently used in ASC as visual communication system to relay crucial information about patients (Mohr et al., 2004, p.34). The whiteboard system has a daily program relating to surgical procedures for each patient. ASC and OR nursing staff use the whiteboard frequently to relay crucial medical information to patients/family in real-time (Chaboyer, 2008, p.137). However, whiteboard system has some aspects that can potentially result in communication blunders (i.e. patient flow faults) and increase the time taken to relay information to anxious patients and family members. In addition, some complex features of the whiteboard system can hamper staff productivity, especially if it is not updated in real-time (Chaboyer, 2009, p.138).

Clinical Team Leadership and Membership is another approach used for quality improvement in the ambulatory surgery environment. Teamwork is an important facet of this approach since both ASC leaders and nursing staff members must work together as a team to ensure that change is implements in an effective way and improve patient/family satisfaction (Salas et al., 2007, p.62; Burke et al., 2005, p.11). Lewin’s theory of change also lends credence to the role of teamwork in implementing change. He asserts that an individual ought to be rewarded for his/her valuable contribution as a team player (Schein, 1996, p. 61). Under the teamwork approach, ambulatory surgery center leaders and nurses within the ambulatory environment have an ample opportunity to comprehend problems (unfreeze), develop goals for change and adopt the best approach (refreeze) to improve patient satisfaction. Nonetheless, lack of leadership skills and competition among team members can potentially increase waiting-time and result in patient dissatisfaction (Burke et al., 2005, p.11).

Although whiteboard system and Clinical Team Leadership and Membership are effective tools, SBAR approach stands out as the best instrument for QI in ambulatory setting. By implementing this approach, I expect to increase the score levels (above 90%) of the three priority areas identified earlier: information regarding delays; response to complaints by patients/family; and waiting-time in x-ray.


As mentioned previously, the unfreezing stage is where the resistant forces are established and a plan is devised to alleviate or reduce them. During this stage, staff meeting is held where the proposed change is presented. Staff members who are against the proposed plan are identified and their arguments against the change are also considered. In the second phase (change), ASC nurses will be trained on how to implement the proposed change in order to reduce waiting-time and improve patient satisfaction. During the refreezing stage, we will continue with the strategies identified in the moving stage so that these new procedures are permanently adopted within the ambulatory surgical setting to reduce patient/family delays.

According to Lewin’s theory of change, the successful implementation of the proposed change starts with identifying the driving forces to push the resistant forces toward change (see figure 1). In this scenario, the driving forces toward change are ASC leaders and hospital administrators. The resistant forces are ASC doctors and nurses who have hectic schedules and must create time to attend weekly meetings in order to adopt the proposed changes. It is worthy to mention that doctors and nurses who have been practicing for many years are extremely resistant to change.

  • An in-service meeting for staff members was held at the beginning of the implementation phase to notify them about the low scores on Personal Issues Category/Patient’s Satisfaction. A brochure was developed with vital information about patient’s surgery/procedure and issues they need to know, both in Spanish and English. This brochure is to be given to the patient/family when they visit the doctor’s office.
  • I created a Standard Operating Procedure/Protocol for pre-admission testing and for day of surgery. This protocol will be used to notify the ASC staff on guidelines to be followed when preparing patients for surgical procedures.
  • A patient/family update protocol and update for was also developed. These forms provide guidelines to be followed by all ASC and OR staff on how to communicate with patient/family using AIDET (Acknowledge, Introduce, Duration, Explanation, & Thank You) guidelines.
  • The ASC nurses and clinical care extenders will use the AIDET guidelines to talk to the family, answer any of their questions, make frequent visits to the OR to receive updates and then share them immediately with family members in the waiting lobby.
  • The updates received from the OR should be documented in nursing notes.
  • Families in the waiting lobby are to be updated every 2 hours (or less) through the Family Update Form.
  • If the patient/family has presented a complaint against the care at the hospital, the nursing staff should listen carefully and take accurate notes on the back of the Family Update Form.
  • ASC nursing staff should use the Principles of Service Recovery (4As): let the patient/family know you accept their concern; acknowledge mistake without making excuses; make a sincere apology for not meeting service expectation; and make amends by communicating your resolution. If necessary, initiate a chain of command (with relevant RN leaders) to address the matter.
  • In order to improve patient/family response to concerns, the relevant RN manager will be informed about the complaint so that Service Recovery can be implemented immediately. The Service Recovery should be adopted when patients/families report an incident that produces dissatisfaction.

We are in the process of implementing our new plan. Nonetheless, our objective is to raise our Press Ganey scores by a starting point of 82.3.

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Barenfanger, J., Sautter, R. & Lang, D. (2004). Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol, 121, 801 803.

Burke, C., Salas, E. & Wilson-Donnelly, K. (2004). How to turn a team of experts into an expert medical team: Guidance from the aviation and military communities. Qual Saf Health Care, 13, 96-104.

Chaboyer, W. (2009). Whiteboards: one tool to improve patient flow. Medical Journal of Australia, 190(11), 137-140.

Farber, J. (2010). Measuring and Improving Ambulatory Surgery Patients’ Satisfaction. AORN Journal, 92(3), 313-321.

Haig, K., Sutton, S. & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf, 32,167-175.

Mohr, J., Batalden, P. & Barach, P. (2004). Integrating patient safety into the clinical microsystems. Qual Saf Health Care, 13, 34-38.

Salas E., Wilson, K. & Murphy, C. (2007). What crew resource management training will not do for patient safety: Unless…. J Patient Saf, 3, 62-64.

Schein, E. (1996). Kurt Lewin’s Change Theory in the Field and in the Classroom: Notes Toward a Model of Managed Learning. Reflections, 1(1), 59-74.

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Sutcliffe, K., Lewton, E. & Rosenthal, M. (2004). Communication failures: An insidious contributor to medical mishaps. Acad Med, 79, 186-194.

Weick, K. & Quinn, R. (1999). Organizational Change and Development. Annu. Rev. Psychol. 50, 361-86.


Table 1: PG Question Analysis Quarterly Report, July 1, 2010-September 31, 2010.

Section question Mean Score Large PG database rank#
Information on delays 78.5 18
Response to complaints 88.7 15
waiting-time in x-ray 82.6 16

#- Benchmark rank as a national comparison of hospitals with>100 beds in the PG database.

Driving forces and restraining forces (Lewin’s theory of change).
Figure 1: Driving forces and restraining forces (Lewin’s theory of change).

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