Rick Dana Barlow    Ken Perez     Brian Adcock   Teresa McCommon

If budget-minded hospitals want to use the highest quality products in order to deliver the highest quality patient care then clinicians and materials managers had better put their heads together and find a way to team up.

That was the subject of a panel discussion, "How Purchasing Managers and Nurses Collaborate on Effective Buying Strategies," which was sponsored by Healthcare Purchasing News here at the annual meeting of the American Association of Critical-Care Nurses (AACN). HPN has had the opportunity to work with the NTI/AACN group for the third year in a row hosting supply chain panel discussions.

We’ll focus on the first of these discussions in this issue and print the results of the second panel discussion in August.

For the May 19 session, HPN Senior Editor Rick Dana Barlow moderated a trio of panelists, which included Ken Perez, vice president of marketing at Omnicell Inc. (Mountain View, CA); Brian Adcock, regional vice president at Medline Industries (Jacksonville, FL); and Teresa McCommon, R.N., BSN, corporate director of materials management at Orlando Regional Healthcare System, where she is responsible for supplies and logistics. The six-hospital system’s combined annual supply budget exceeds $200 million….

Barlow began the session with a brief explanation of the panel’s direction. "Notice in the title we used ‘effective’ and not ‘efficient.’ What we’re talking about today is effective buying strategies, and how these two groups can effectively work together for a common good. An efficient system, which may involve someone telling you what to do, can be described as an adversarial relationship.

"Today, despite all the talk of partnerships in the industry, we still have a lot of adversarial relationships: vendors vs. vendors; vendors vs. GPO; GPOs vs. hospitals; even within the provider community, you have surgical hospitals vs. hospitals; ambulatory surgery centers vs. hospitals. Not surprisingly, there are even adversarial relationships among internal departments within a hospital: operations vs. finance; OR vs. materials management; lab vs. materials management; nursing vs. materials management.

"To make any relationship work you have to assume certain roles, and work towards the benefit of the other party. It’s very important in this day and age, when we’re focused on cost containment, for nurses and materials management professionals to work together."

In succession, all three panelists offered some opening remarks about their ideas for effective buying strategies.

"The shared common goal that we all have in healthcare is delivering effective patient care, Perez said. "All vendors, whether they be providers of healthcare information technology, capital equipment, surgical supplies, pharmaceuticals, distributors, and the healthcare providers, share a common interest: delivering effective patient care. When we talk about effective patient care, it’s not only efficient, but it’s accurate and safe. Also, it ultimately results in improved clinical and financial outcomes."

Perez also pointed out the importance of improving the working environment of nurses. "There is a continued nursing shortage in the U.S. obviously. But in addition to that, there is increased demand for nurses to do more with less and fewer resources. There’s an incredible need to improve the working environment to empower nurses to do their job more effectively and more efficiently."

He discussed nurse preference, saying, "Nurses should be involved early in the process of evaluating the products, equipment and tools that are going to be implemented. They tend to be forced to accept products and solutions after the decision has already been made. It’s important to get feedback from nursing early on about products and equipment."

Finally, he illustrated the role of healthcare information technology vendors in the supply chain process. "We have a responsibility to support and cater to and tailor our products to nurse preference. We have to enable nurses to do their job better, to develop solutions that are user friendly, intuitive, and actually support the nursing work flow. Another responsibility of healthcare IT vendors, is to provide data that allows purchasing managers and nurses to look at actual consumption and inventory levels over time on an aggregate, broad basis, rather than anecdotal."

Adcock commented on the professional disconnects he sees throughout the hospital. "There’s one huge misconception that I see in hospital after hospital: clinicians feel that purchasing, or materials management, is just looking for the cheapest price and the lowest cost product; they don’t care about patient care.

"On the other hand, purchasing feels like nurses don’t know anything about making purchasing decisions. They may know about products, but if given free reign to buy, they’d buy every new widget that came along," he noted.

"But as a vendor, what we want to convey is that that’s not necessarily true. I think nowadays purchasing departments are very much involved in not only saving money, but also bringing quality products to hospitals. I think that they know and understand clinicians’ goals a lot better than they did in the past. On the other hand, I think that clinicians are cost-conscious. I think they do know that there are Medicaid cuts, etc. They do have savings in mind and are looking for best values.

"Clinicians getting involved in the process can save more money than just the price of the product, based on nursing time and a lot of soft costs that they bring to the table that materials managers don’t necessarily see," he added. "The bottom line is purchasing and clinicians need each other."

As a nurse-turned-materials manager, McCommon offered a unique perspective on the issue. "I’m very fortunate in that in my organization there’s been a belief that we needed to involve nurses in the purchasing decisions that were being made on a day-to-day basis. They brought a critical care nurse onto the team at that time. The position has evolved now to where I have a team that has two other nurses on it. One has a critical care background and one has a surgical background with years of experience between them."

Describing her motivation for joining what some fellow clinicians called the "people in the basement," she said, "The whole reason that I’m doing what I’m doing is I think it’s important for nurses to be involved in all aspects of healthcare. I’ve been involved on the physician side, I’ve been involved at the bedside, and now I’m involved in the business side. You can’t sit back as a nurse and expect things to happen if you’re not willing to get involved and you’re not willing to be educated on the process. I decided that the best way for me – after managing critical care units for years and making a career shift – to be able to continue to help my peer group, to continue to help the physicians and clinicians, was to be someplace where I could make a difference, I could get their voices heard and I could integrate them into the decision making processes that go on in the organization."

McCommon reiterated a point made by Perez regarding economics and outcomes. "We have a philosophy in our organization that it is about both. It’s about having an organization that’s fiscally responsible, that will be viable, that will be able to hold the margins that we need to develop the infrastructures to give the latest technology to the clinicians. I know what I need to take care of my patients. But I also know what it takes to run a corporation of that size. Many hospitals are operating in the red, so we have to look at it from both sides: economics and outcomes. That’s how we named our value analysis committee. It’s the medical economics outcome committee, and it’s made up of vice presidents, physicians from every subspecialty within our organization, clinicians, materials management, finance people, managed care contracting individuals, and we sit down and look at the big picture and we share that information with the clinicians and ask them to get involved in the process."

McCommon also spoke about the expensive price tags that inevitably are attached to the latest and greatest technologies coming down the pipe; along with the high-dollar cost of healthcare labor. "The biggest dollar amount spent in healthcare right now is on employee resources," she said. "We want to be sure there are nurses available at the bedside, that there are physicians who are credentialed to provide those services. So we need to be responsible with what we’re buying and what we’re bringing in. It does take contracting. It does take some tough negotiation. It does take sometimes to say, I’ll give here so that I can have here – in order to save my organization $5 to $10 million a year, which is what I’m charged with doing."

For McCommon, education is at the heart of effective supply chain management.

"My goal is to educate nurses, to educate physicians. My goal is to get out there and to have a voice and to get people involved. Data is powerful, and I think it’s going to take all of us coming together for us to be viable in the future."

Barlow then asked panelists to share practical tips for materials managers to keep patient satisfaction in mind, and for nurses to focus on the fiscal health of the facility.

"From the materials side, each one of us is ultimately responsible for the customer satisfaction scores by the patient because we’re the ones who feed the hospital, who provide what is needed by the clinician at the bedside," McCommon said. "So when the patient is scoring that nursing unit that they’re being discharged from, they’re scoring all of us, and if we don’t do our job on the materials management side and [clinicians] don’t have the supplies that they need, [frustration] ultimately trickles down. The patient perceives that. The patient may even experience it, based on not having those supplies there."

She challenged nurses to critically analyze processes and question their effectiveness, and then "communicate that back in a responsible manner to the individuals who can make a difference."

McCommon also stressed the need for nurses to provide product feedback to materials managers. "How can we make decisions on contracting on what’s the best product? Safety is driven by the clinician. If we don’t get that feedback back from the clinical side, it’s difficult to make decisions and provide you with what you need."

Perez reiterated the nurse’s importance – and prominence – among patients. "People perceive the quality of healthcare primarily based on their interaction with the nurse. According to ASHP [the American Society of Health-System Pharmacists], 99.7% of all medications are administered by nurses. What people think about when it comes to the face of healthcare, their experience, is the nurse. As those customer satisfaction surveys roll up it is a reflection not only on nursing but on the entire institution, physicians, pharmacists, as well as materials management."

Nurses in the audience shared stories of frustration from occasionally not having critical supplies in stock. Several noted how R.N.s were part of their facility’s management team and how that benefited their situation; others highlighted the lack of knowledge on both sides regarding each other’s departmental work processes.

Adcock then asked the audience for a show of hands as to how many facilities had a nurse on the materials management team. The response: just a few.

"While it would be great to have a Teresa at your facility, the reality is 80% + of the hospitals out there don’t," he said. "So in order to get that involvement you’re going to have to step up to a certain degree."

Barlow cited one example of a materials manager who went the extra mile to go on rounds with clinicians, and asked McCommon if that was something she personally took the initiative to do.

"I go to all six campuses and walk around," she replied. "I know a lot of faces. They know who I am. They know what I do. They give me feedback on that. There’s a comfort level that’s building because of that relationship, that two-way communication that is going on.

"I knew the disconnect was there when I went into my first position," she continued. "I said I’ve got to start bridging this gap. When I had an open position and I was recruiting for an R.N. I had more internal applicants that were nurses than I could ever have imagined. I was shocked and I was pleased. It was a phenomenal thing."

Barlow then asked all three panelists for a list of do’s and don’t’s.

"When it comes to purchasing, as a clinician what you don’t want to do is use the old ploy of, ‘Dr. Fix-All wants it, needs it, so that’s what we’re going to have,’" Adcock said.

"One major do for nursing is to document, McCommon noted. "You don’t know how frustrating it is from a materials management standpoint when we get a recall, when we have to try to figure out where something went, especially if it’s an implantable. The don’t is: don’t let just anything walk through the door. There are huge instances with a lot of dollars associated with them where certain devices were utilized on patients that were not FDA-approved that the physician brought in. The responsibility of you as a clinician at the bedside is to say, ‘wait a minute, I’ve never seen that before.’ And you may have Dr. X, Y or Z, who’s not real happy with you, challenging you on that. But I don’t know a critical care nurse in the world who’s not willing to challenge somebody when it’s the right thing for their patient. Recognize that the implications of him wanting it are far more reaching than just his yelling if he doesn’t get it."

Said Perez: "For nurses, don’t circumvent systems that materials management has put in place to try to capture usage and monitor consumption. It may be time consuming, it may be challenging. But stick with the program, use the systems, and give your feedback about the usability of those systems afterward. It only irritates materials management when the system that’s put in place, whether it be scanning or some other system, is not being used because then the data disappears and they’re not able to make a rational decision."

A materials manager in the audience relayed how a nurse saw that a physician was using a modified device. The nurse brought the issue to the risk manager who asked materials management to research use of the modification. She found that it was acceptable. "The burden is off of the nurse’s shoulders, and we felt like we did our due diligence of researching it, and we were able to arrive at a good outcome," the materials manager said.

Another audience member, a risk manager, explained how oftentimes products are changed at a moment’s notice, and often for products of lesser quality. "This product is then actually costing the organization more money. Nobody really measures the nurse’s time. Nursing is one of the largest salaries in the hospital. But no one measures nurses’ time as to cost of running around looking for items. Not only that, but what about the impact to the patient and the patient’s safety? I guess sometimes that’s why a lot of nurses leave the profession, because they become frustrated of running up against brick walls. I would like to see more looking at nursing time when we evaluate a product. Yes, this product can do this, but this is how much it will save you in nursing time and actually put a cost value on that vs. just saying that we saved the nurses’ time. This is how much we saved."

McCommon countered: "It’s important to remember that sometimes you need to spend more to have better outcomes. You can document shorter lengths of stay, better revenue streams, because you were willing to invest on the front end. If you go out and get a [bandage] and it doesn’t stick and you use six [bandages] instead of one, what have you saved by doing that?"

McCommon asked nurses to bear in mind that the picture of healthcare today often means that product availability can be dependent on backorders, or group purchasing organization (GPO) contracts. "One of the processes that we put in place that I think has been very beneficial, especially to deal with the backorder situations, is to identify what is an appropriate substitute that could be used. We have key clinicians across the system that we use as resources to put that in front of. For example, there’s an identified clinician in neo/ICU, there’s one in critical care, med/surg, wound management. When we get hit with something like that, it’s not materials making the decision. It’s ‘let me get in what I can, put it in front of that end user and say, what will work for you while we’re buying some time to get what you’re used to?’"

Perez remarked on the issue of soft savings and the tendency for materials management to prioritize hard dollar savings. He explained the need to look at metrics such as length of stay and patient satisfaction surveys. And he talked about the role of the chief nursing officer as a "watchdog" to retain nurses. "CEOs are very concerned about labor issues, particularly nursing. It keeps them up at night."

Barlow then used Perez’s last line as a segue to the audience: "What keeps you up at night?"

One nurse replied, "When nurses want to say something…we’re very emotional people, we care about our patients. We’re not into the money and the other issues. We have to find a way for emotions to be said in a way that money matters…to be representative. If you’re not presenting it the right way – that we’re going to save so many dollars, etc. – you’re not going to get what you want. So we have to find someone in the hospital that can get the emotions out and present it in a way that the upper echelon will understand."

Said McCommon, "Healthcare is a business. Nurses are part of that business structure. But we didn’t go to school to learn that. It’s the responsibility to start educating nurses so that they do look at that and they do understand that." She agreed with the nurse, "this is an emotional business that we’re in. We’re dealing with people’s lives and we’re passionate about that. But you’ve got to figure out a way to articulate that, and take the emotion out of it, and make decisions that are based on good medical outcomes."

But that nurse interjected, "Nobody’s explaining it to each other…the money factor for us, and then they don’t understand that we care about the patients. We have to hit a happy medium."

Adcock shared this advice: "Nurses, if you find a product, you’ve got to go to materials and have supporting documents. Make the vendors come up with the clinical data, and provide you with studies. You’ve got to be involved, or someone representing you has got to be involved or it’s not going anywhere."

Perez summed up the session with a comment on the growing responsibilities of nursing in materials management. "Nursing is being asked to play a leadership role in evaluating products, technologies and tools to help in the area of patient safety. It can’t be led by materials management; it can’t be led by pharmacy, because ultimately the tools are being used at the bedside by nurses." HPN