Perioperative Success Starts with Giving Nurses a Voice at the Table

Success in the operating room is critical to the financial health of many healthcare organizations, with perioperative services contributing up to 75% of primary revenue streams. Effective perioperative care relies on skilled nurses who balance patient care while collaborating with other teams. In this episode of Value-Based Care Insights, Dan Marino sits down with Cindy Mahal, Chief Administrative Officer of Providence Saint Joseph Medical Center, to explore the challenges nurses face in achieving alignment and how to overcome them. We’ll uncover insights into key strategies administrators can implement to empower nurses, giving them a voice and enabling them to not only align but also lead.

LISTEN TO THE EPISODE:

 

Daniel Marino:

Welcome to value based care insights. I am your host, Daniel Marino. Over this past year, and probably for the last couple of years. Hospitals and health systems are still focused on improving their financial performance. And they're really doing it in a couple of ways. Right? I mean, you're focusing on trying to create more volume. Of course you're limited by the reimbursement that we get from payers, but we're also focused on reducing cost. And cost reduction through performance improvement or quality improvement has been a pretty significant initiative. Of course, driving financial performance for hospitals and health systems is really based on your Surgical services. Surgical services, perioperative services. Whether it's in the hospital or the Ambulatory Surgery Center accounts for anywhere between 55 to maybe 75% of overall revenue. It's considerable. So the focus on creating efficiencies in your OR through making sure that your on-time starts are occurring on time, turning around your rooms efficiently preparing patients, both pre-OP and post-OP. All of those items go into the efficiency and impact your revenue as well as impact your cost structure. And of course, the alignment between the hospital and the surgeons is really an important factor in making that happen. However, when you look at what it really takes to drive that performance. The nursing support is really the key in our opinion, in my opinion, to driving that success. And having strong alignment with the nurses that bridge the gap between what's required within the hospital and the health system and leadership, and with the surgeons is really what then drives the results. But it's a difficult role for nurses, and many nurses find themselves in a predicament where they have certain requirements of the hospital and leadership but patient care requirements for the surgeons. 

So here to talk about that is a Senior Level nursing executive. Someone I've known for quite some time. Cindy Mahal. She is the chief administrative officer for a large health system in California. Cindy has held numerous leadership roles, including nursing leadership and surgical services and in other areas of health system. She's also COO and in charge of the vision operations and strategy for a large system in California, Cindy, welcome to the program. 

 

Cindy Mahal:

Thanks, Dan. Thanks for having me. 

 

Daniel Marino:

So Cindy, as I mentioned oftentimes what we see, and I and I hear this a lot, either from the surgeons or from leadership, that the alignment of the surgeons with the vision of where the hospital wants to go around perioperative services or surgical services is critical. But really the key in making this work is, nurses and nurses are, they're challenged with this right? And I think for a whole host of reasons which I'd love to dive into. But why do you think that nursing oftentimes, as we think about making those changes? Why is there such a challenge for nurses. Why are they placed in this in this difficult role? 

 

Cindy Mahal:

Yeah. And I think from a nursing perspective, when you talk to the nurses at the at the bedside, believe they're balancing patient safety, which should be our priority with efficiency right? And they also want to find meaning in their work. They don't want to be this factory worker who's being pushed to go faster or focus on metrics. They want to focus on patient care. So it really puts them in a very difficult spot. They do know that, you know, surgery makes money. So you're part of that machine, and you have to accept that but you also want to be able to make sure you are focusing on your patient so. And we know surgery is an extreme sport, right? That is an extreme team sport where everyone has their role, and we all have to work together, and each of us have competing priorities. So I think nurses are put in a in a tough spot to get what we need for the patient, for the physicians and for the organization. 

 

Daniel Marino:

You know, we've been part of a number of perioperative improvement engagements and some of the consulting work that we've done. And governance is always a really an important part of that right. And what we see as part of that is that that's where leadership and the surgeons have to come together to create the common version of process or performance improvement. But then it's really led and directed by the nurses. What do you feel like? The nursing role should be in driving that change? How much influence should they have? Or do they have in working with the surgeons? 

 

Cindy Mahal:

Well, nurses have to be at the table, right? Because we're the ones getting the. I hate to say it getting the work done and seeing the big picture of what everybody needs. So you have to get their buy in. You have to be able to say, what are the barriers from your perspective, because the physician will tell you their barriers, you know. They'll say, Oh, it was a 40 min turnover when reality it was 25. You just weren't in the room for a significant portion. But, you know, talking to the nurses to find out what could we do to help them meet this target in a reasonable, right? I mean, you'll get things from well, we need 5 more of this, or give me a reasonable solution to kind of help you. So really bringing nurses to the table, explaining to him the value of why we're doing this right? We are very common sense people. We understand the whys behind thing, If it's explained to us in a proper manner that you know the or is your cash cow, and we need to keep things going in order to keep this organization going, and so be a part of that. Be a part of the success. And you know we'll highlight you. So I think that's really important. 

 

Daniel Marino:

You know. Sometimes I think surgeons could be a little difficult to work with. Right?  

 

Cindy Mahal:

Sometimes. 

 

Daniel Marino:

Just sometimes. And do you see situations where for those challenging surgeons, the nurses kind of put in the middle of this, right? How do you, how do you deal with that? That difficult surgeon, that surgeon, who, you know, wants to do it their way? They may have a number of reasons for that. So either their practice style or maybe they're extremely, you know, they have just a real busy practice. What wouldn't nurses do? They're like stuck in the middle. 

 

Cindy Mahal:

And I think you know those are the best ones to start projects with. Because if they're a success, then you've got them, and others will say, Hey, if so, and so can do it, and I know he has his, his or her routines. Then it must be something I need to get on board with. So, 1st of all, working with that surgeon to seek to understand.  Why won't you participate with me? Help me understand, because this is going to benefit you as well, and your patients. So really trying to get the buy in and bringing that group together and seeing what the win is for each of them. But I do like, you know, tackling that difficult surgeon and saying, you're gonna do this with me, and we're gonna be successful. And you're gonna see a benefit in the end, and I need your partnership, right? Pleading to them for that, because they do want to, partner they all have. We all have the same goals. We may articulate them differently. But I think you know, seeking their partnership, working with them, explaining to them what the nurses are doing, and why. Because sometimes they may not understand that, or their state requirements, why the nurse must do this, or must ask these questions, or take time with the patient. 

 

Daniel Marino:

Well, and maybe to your point. Maybe the surgeons don't really recognize all that right. I mean, really busy. And they're focused on again, taking care of the patient and performing the procedure, and probably getting in and getting out as quick as they can. Or you know, I mean, there could be other influences there. But I think you know, when I think about performance improvement, and I think about that level of support, you know, there's a there's, there's a couple of really important elements that come into play that drive that success. I think one is the operational support that if nurses are leading this, and they should or be a, you know, significant contributor, having that right level of operational support is so critical. But then, having the cultural change report the support as well, too. What role should administration play in supporting maybe the nurses, or the process in ensuring that that right level of both operational and culture support is occurring? 

 

Cindy Mahal:

Yeah. And you know again, as leaders, we have to lead by example. And I think that is key. And from an administrative perspective, again seeking to understand. Why can't we get to this target? And what can I do to help the nurses get to this target? I think that is something that's really important and not treating people as if they're not wanting to do the right thing right, giving them the benefit of the doubt to say, you know, we all have pride in the work we do, so why wouldn't I want to be, you know, the most efficient and the highest quality OR around. Of course we want. So people do want that, and for administrative to be supportive. And if we do have barriers helping us break it down right? Helping them break down why we have this barrier and letting them know, giving them the kudos when they do have some small wins. I think that's really important rounding in those areas. If we know we're kicking off a on time, start project from an administrative perspective, be around, be visible, show your support. So that way the nurses and the physicians all know that you've got administrative support for this as well. I think that's really important. 

 

Daniel Marino:

Well, and that's such a good point. I think administration has to be visible right? They have to be visible, and at least be able to show that support. Because I you know, as we've talked about. And I've heard this from many nursing leaders. They sort of feel like they're on an island sometimes on their own, and you can't just do it on their own right. This has to be a team based approach. And there's it's difficult. It's difficult whether you're managing the culture, change the operational change, you know. I mean, there could be a whole host of reasons that are influencing it. 

If you're just tuning in. I'm Daniel Marino, and you're listening to value-based care insights. I am here today with Cindy Mahal. She is a chief operating officer of a large health system, a seasoned nurse executive, and we are talking about the nursing support or enhancing the nursing support that is required as organizations go through improvements in surgical services. Cindy, I wanna I wanna get back to kind of the role of the nursing leader if you will. You know when you, when you think about surgical services, and you think about the services that are occurring either in the ASC, Or in the hospital OR, you know you'll have the director of nursing who's in who's in the OR and then, you know, you'll have the or nurses that are included in in there. How should that team work together come together to support any type of perioperative improvement process? 

 

Cindy Mahal:

Well, they have to be a team, and they have to be able to be empowered to take chances, take risk right? And really put themselves out there. And then, as an executive leader like myself, I have to be there to give them opportunities to, to shine, to excel, to build their confidence because it is a tough. A tough, OR is a tough environment to work with. You've got a lot of competing priorities, a lot of big personalities. So as a nursing leader, it's my job to support them and create a psychologically safe environment where they can come to me with different things as well as empower them to make mistakes. Hopefully they don't but feel confident enough where, if they do make a mistake. They're going to be supported. So, we have to grow our own leaders because leadership is tough. People don't really want to take on that 24, 7 responsibilities. You never know what's coming at you. 

 

Daniel Marino:

As you mentioned, you have to. You have to have the more what I would call maybe the junior nurses really engaged in the process right? I mean, if they're if they're part of the improvement process, the perioperative process, if they're being held to the same standard, if they're part of the outcomes that are being measured. Then, you know, again, they feel like they're contributing to it. It's a growth area for some of these junior nurses. But I also feel like some of these folks that are, you know, that are actually in the OR doing the work. I mean, they've got the answers right. They know some of the things that that could either are creating bottlenecks or challenges in in the OR. Engaging them is just so critical. So in your experience when you've done, when you put forth a lot of perioperative improvement initiatives. Talk a little bit about the type of teams that you've created that has focused on engaging the nurses. So in in such a role that you know you're hearing from them, and they're part of the process. 

 

Cindy Mahal:

Yeah. And I think part of that again, we talked about being visible, you know, being rounding, being available, watching what they're doing, watching their struggles, but also giving the nurses opportunities to be able to highlight their knowledge base and building them up. So simple example, if we're working with a supply chain meeting, and they're talking about orthopedics, you know, having that orthopedic team leader on the line and letting her be there to explain the whys behind certain choices, or showing, giving her the ability to shine, to be quite honest amongst her peers. So that way you can build their confidence, and they can take on different things. Having some of the team leaders also take on certain projects. Right? I think that gives them an opportunity to be able to learn different skills, expose them to different leaders in the organization as well, so they can grow and see which leadership styles and tips they like but I think, really giving them opportunities. And when I pick my team, you know, I pick people who 1st of all are hungry to learn right? I will teach you whatever you want to know. And people who want to grow, that's great. There's yeah. You you see it. You know the people who are looking at you, engaging and asking questions, and then sometimes I'll pick a naysayer, just because I want to say, Yeah, if I can turn this one around, then you know, others will follow right? Just to give them that exposure. 

 

Daniel Marino:

Yeah, I like, I like that philosophy, though getting the you know, the staff, the nurses involved that are hungry, right? That want to learn. Because, boy, they can, you know, that's a great way of changing the culture. So when you, when you think about perioperative services, when we've worked with a number of organizations. We looked at a couple, you know, you look at a couple of really key statistics. Right? You look at block utilization. 1st case on time start. That's a big one, right? Because if you don't start on time for that 1st case that you know, you sort of have a trickle down effect throughout the day. That's hard to pick up and then turnaround time of the rooms. So when you create those, let's say, overarching macro statistics that are affecting the overall performance of perioperative services. Do have you in the past parsed out specific KPIs for your nursing team that says, Look, in order to achieve, let's say, the turnaround time that we need of these rooms as a nursing team we need to do this. Have you gotten to that level, or do they? Are they held responsible to those larger Macro key performance indicators? 

 

Cindy Mahal:

A little bit of both. We've tried when we had the key performance measures for turnover, because that was one that I really focused on, because that's a that can be a lot of downtime and a big physician to satisfy her. Really, working with the teams on the support they needed, and having those nurses involved in that. What is it? What is it going to take? What can we do to do that? We did that for a couple of years where that was part of their performance. Review. Right did they meet that. But It had to be. It had to be tangible again, just like, you know, when I have a goal that I know there's no way, I'm going to meet that right? So how much energy do you really give to it? So really making that, you know, having the goal and then potential a little bit of a stretch goal to see what we can do to give the team a little something to rally around. We've also tried other metrics where we and I've gotten this from my other OR AORN leaders when we meet annually to talk about different team concepts where you could incentivize teams and have goals for specific teams, physicians, and nurses. Your, you know, your non licensed practitioners in the in the OR as well. How can we all work together to get this turnover to where we needed to be as well as the on time start, and then creating some sort of financial incentive. It's not huge. It's not like we're throwing millions of dollars. But at least it's something. 

 

Daniel Marino:

Yeah, that kind of behavior, right? Rewards the work that you're putting in, plus it gives you an opportunity to celebrate the successes. Yeah. So I I agree with you. 

 

Cindy Mahal:

Right. You're building a team, and everybody wants to be part of something. And with your part of this team, and you're really kicking it out. You can see it when you walk down that hallway, you know which teams are doing it and which teams are not right? They're together. Okay, I'm going to get the patient. Okay, you go get this. You know, you get that. Okay, anesthesia. Are you ready? Yeah, I'll meet you there. So you see, when it's when it's humming. 

 

Daniel Marino:

Yeah. And you're building that excite. You're building that excitement. And I agree with you. And I think an important point that you brought up, which I think is really critical. You know. Again, I've done numerous performance improvement engagements, and I always believe that if you can't measure it, you can't manage it, and you need to have goals right? So I think for perioperative services. If you have a team goal and you have indicators that are being measured, and then you have, say, surgical goals as well as how you're measuring. But then nursing goals and indicators of how you're measuring. Then, all of a sudden all of those pieces. You know that behavior, that the work, the performance, improvement. You're tying that to some type of an end goal, right so to kind of like that shining star. And then not only does it allow you to ensure that you're moving at the right pace and achieving what you want to achieve. But you're able to celebrate the wins, which, frankly, I think doesn't happen enough in a lot of the work. 

 

Cindy Mahal:

I agree, or we celebrate quickly, and then we move on right? And I think we I don't know. That's because we're just in a such a fast-paced environment and high intensity. So we forget. 

 

Daniel Marino:

We do. Yeah. And I'll tell you. You know it's good to sit back once in a while, and just, you know, celebrate the wins, because, you know, there's it's a hard business that we're in. And, as you said, it's stressful, and especially for the nurses. I give a lot of credit to the nurses who are placed in these difficult roles because it is, it is stressful, no doubt about it. So you know, for any of our listeners, for folks that are tuning in. And you know, as I said in my opening comments. Many organizations, you know, and I would almost go so far as to say, maybe all hospitals and health systems have some opportunity, one way or another, to improve perioperative services. And again nursing is so critical towards achieving that goal and making that happen. Any piece of advice come to mind where organizations should start, or how they should better align their nursing team to accomplish some of those goals? 

 

Cindy Mahal:

Well, I think they have to have them at the table right? I think I've been from the bottom to the top, so I know what it's like to be in that boardroom where someone is setting that goal for you. And you're like, wait, wait, you know. Hold on right now we've got 25 nurses and orientation, and we've got this and that. And you know this is not the time to do that. So really, making sure that you have nursing at the table to understand what's going on there and in the culture to help them. But listening to the voice of the nurses, what can we do? Where's our? Where's our biggest problem? What can we do to get a couple quick wins right. I think you want to at least kick off a project, not taking on the biggest monster in the room, but at least taking on a few little things. That can really help you. Having a retreat. I've done that before when I kicked off big projects, you know. Let's have a retreat. Get all the key stakeholders there, and let's hash it out in an environment that is not in the workplace where we can talk about it, and people feel comfortable. 

 

Daniel Marino:

I love that idea. I love that idea. 

 

Cindy Mahal:

That has helped. 

 

Daniel Marino:

Yeah. It gives you a great opportunity, then, to brainstorm, to feel comfortable, you know, in in a safe place where you know, you can talk about not only where we want to go, but identify the barriers which oftentimes the challenges and barriers. Many folks know it, but they're afraid to verbalize it, and I think if you're in a safe space in a retreat, great place to do it. 

 

Cindy Mahal:

Yeah. Yeah. And then I always throw in a little bit of leadership development as well. You know, we'll talk about crucial conversations, or we'll talk about how to create a culture of psychological safety. So it helps them. So they walk away with a little tool for their toolbox as well. 

 

Daniel Marino:

Yeah, and then the other one that I would add to that. And you mentioned it earlier is making sure we have the administrative support there, because I often do feel like, you know, in talking with many of the nurses nursing leaders, if they're facing a difficult challenge, you know, they have to turn to somebody right? There has to be levels of support there because it is a difficult role, and sometimes they're faced with some, some real tough challenges, whether it's issues of patient safety or understanding. You know how to begin to build the right culture of change. All of those things that administrative support is really key. 

 

Cindy Mahal:

Yeah. And I've been lucky because I've had even our system COO come to our retreats when we've had them, or the Presidents have been there to show support. So I think that's key. 

 

Daniel Marino:

Yeah, that's great. Well, Cindy, this is fantastic. And I appreciate you sharing some, your, your insight. This has been really, really valuable. If any of our listeners are interested in connecting with you. You know I'm assuming you're on Linkedin. 

 

Cindy Mahal:

Yes, I'm on Linkedin. It's MAHAL. Cindy. So please reach out to me. Love to chit, chat, and help wherever I can. 

 

Daniel Marino:

Good, good, well, and a special congratulations to you in your new role. I know it's, you know, kind of a big move for you to relocate. But I know you're gonna do great. And you've got a lot of great expertise and experience under your belt, which I'm sure you're gonna draw from in in your role as you move forward. 

 

Cindy Mahal:

Thanks. Dan. 

 

Daniel Marino:

Thanks, Cindy. I really appreciate it. And to you our listeners. Thank you so much for tuning in until the next insight. I am Daniel Marino, bringing you 30 min of value to your day. Take care! 

 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners