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         Clinical intelligence for supply chain leadership

 
 
 

INSIDE THE CURRENT ISSUE

April 2015

Operating Room

Outpatient Connection

A new council has been formed to rid the world's operating environments of surgical plume

Surgical smoke plume is a hazardous byproduct of operative procedures known to contain harmful gases, minute particles, and microorganisms. Inhalation of this plume by clinicians and patients has been well documented as a hazard to their health and well-being.

Internationally, many standards and mandates exist to protect medical staff and patients from exposure to these plumes. However, in many countries including the United States, adherence to these standards remains at unacceptable levels. The need for further studies, lack of education, and dissemination of the educational information that already exists are some of the causes for the lack of full compliance.

A new non-profit council has recently formed with a mission to finally rid the world's operating environments of surgical smoke plume once and for all. With the participation of key clinical stakeholders, clinician based organizations, industry partners, and standard setting bodies, this new consensus body is known as the International Council on Surgical Plume (ICSP). The charter of this Council is to provide education, aid in the creation of new clinical studies, drive regulatory reform, and advocate enforcement of existing mandates related to surgical plume throughout the world.

With the formation of the ICSP, surgical stakeholders can join in one voice to advocate for clearer mandates, better dissemination of existing studies, construct meaningful new studies that resonate with those not yet advocating for plume management, and review of new and existing clinical information for scientific credibility.

Individual clinicians, clinical organizations, educators, safety advocates, standard setting bodies, and other surgical team members are encouraged to join in this effort to rid surgical environments of the hazards associated with plume inhalation. To learn more about the ICSP and how you can help, please visit www.plumecouncil.com.

Hospitals participating in ACS NSQIP improve outcomes

The majority of hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) improve surgical outcomes over time, and improvement continues with each year that hospitals participate in the program, according to a new study.

ACS NSQIP is a nationally validated, risk-adjusted, outcomes-based program designed to measure and improve the quality of surgical care in participating hospitals. The program employs prospective, peer-controlled, validated clinical data collection to quantify 30-day surgical outcomes and allows comparisons of outcomes among all participating hospitals. The estimates likely underestimate the actual benefits of the program, according to the study. Visit the American College of Surgeons at https://www.facs.org/
media/press-releases/2015/
annals0227 for the study.

 
 
 

Street vs. suite smarts seek balance in OR planning

by Valerie J. Dimond

In early February, Florida Hospital Carrollwood, a 120-bed facility serving the greater Orlando region, broke ground on a major improvement project that will include 12 new state-of-the-art operating rooms (ORs) outfitted with a variety of up-to-the-minute technology. It's a strategic move that more and more hospitals believe is necessary for remaining competitive and attracting top talent - i.e., the surgeons performing some of today's most cutting edge and minimally-invasive procedures.

Florida Hospital Carrollwood Breaking Ground Ceremony

Integrating an OR with advanced technology - to make it "smart"– typically involves bringing together three important components: automation, telemedicine and a direct interface with a facility's information system. According to market research, 23 percent of ORs in the U.S. had video and other high-tech features in 2013. By 2019, that figure is expected to reach 31 percent.1

"Our true niche is surgery. With our recent Joint Commission certifications in spine surgery, bariatric surgery, and total knee replacement, as well as our goals for certifications in hip and shoulder - we would like to ensure we have the best space and technology to perform these procedures," said Shane Cox, Chief Financial Officer at Carrollwood. He says they now use a Mazor Renaissance Robot for spine surgery with plans to install a daVinci robot. "We want to expand upon the already stellar surgery program we currently have, in order to continue advancing our care and attracting the region's best surgeons," said Cox, noting the addition of nine new surgeons over the last several months.

Assessing needs

Carla Loher, Carrollwood's Database Coordinator and Manager, Central Sterile, said after carefully considering the technologies and services from two of the industry's top suppliers, they decided to go with the Stryker Complete Integration System.

"All technology will be integrated within the system, and will feed data, photos, video, etc. directly into the EMR, and into patient medical records. This will serve to positively impact efficiency and flow and allow physicians to directly access all information from a patient's recent surgery, which can then be shared with the patient in his/her post-op visit," explained Loher. "Additionally, the system has an In Light Camera that will allow us to broadcast surgeries to teaching facilities, as well as to our own boardroom for physician forums and also includes an automated time out procedure, which improves patient safety. It allows us to effortlessly access In-Light documentation that can be sent directly to a patient's chart. This integration in our new OR spaces will also allow us to be much more efficient - storage of data, safety, records - all in one place. It is a ‘one stop shop.'"

Carol Philipson, Vice President, Outpatient and Support Services at Carrollwood said during the planning stages, they made a point to bring as many stakeholders and front line users to the table early on - from equipment planners, to architects, IT, nursing staff and physicians.

"During design development we established user groups during the design process - each group assessed a separate piece of the project, yet all was done in conjunction together in order to ensure the process was smooth and moved along quickly," Philipson said. They also created a practice OR so user groups could evaluate design and flow. "The mock room allowed every piece of the design to be scrutinized by the parties who would be experiencing the final design in action - physicians, nurses, OR techs, etc. The room did present a significant financial investment, but it was absolutely essential to the design process."

Worth the investment

Building a smart OR is a significant investment. Automation packages can run from $20,000 to $50,000 per room, not counting additional costs to upgrade existing equipment with remote capabilities, such as lights and tables. Integrating telemedicine technology so that surgeons can teach and consult remotely with others in real time can cost $30,000 to $400,000 and creating on-demand access to a hospital's information system - to obtain PACS images, lab reports and electronic medical records - can go as high as $500,000. These figures may seem daunting at first glance but studies consistently show high-tech ORs have a significant and positive impact on clinical outcomes and efficiencies. They make surgeries more precise and can reduce certain types of "never events" by 50 percent. 2 If outcomes like these translate to to higher throughput and fewer unscheduled and overtime events, for a high-volume, mid- to large-size hospital, the investment is worth considering.

Cox said Carrollwood expects a return on its investment in about 8 years. For other facilities that may be considering a smart OR build, Loher says plan ahead … and when word gets out about what you're up to, expect a lot of noise. "When vendors find out you're doing a build, they come out of the woodwork," she said. "Rely on what works and what has worked in the past, and on your staff and physicians. Hold the vendors accountable."

Vetting the vendors

Healthcare Purchasing News asked some of the industry's leading high-tech OR suppliers about what it takes to build a smart OR today, why they are increasingly important, and what a smart surgical suite might look like in the near future.

HPN: How do you determine what makes a surgical suite smart - what can these newer, high-tech ORs deliver that traditional ones cannot?

Devon Bream, MPH, FACHE, Vice President, Global Medical Sales & Marketing, Black Diamond Video: Smart surgical suites have been evolving over the past decade. Originally, a suite that had technology which assisted the surgeon would be classified as "smart." Now smart surgical suites assist the entire surgical team, workflow of the hospital and ultimately provide better patient care. Today's smart surgical suite utilizes the investment the hospital has put into their Electronic Health Record (EHR) system, leverages data from a real time location system (RTLS), utilizes smart pre-sets from OR integration, provides infrastructure for emerging video signal types like 4K Ultra High Definition (4K UHD), and allows telemedicine capabilities. These new suites deliver the ability for clinical teams to maximize the utilization of all the devices required to perform today's complex procedures.  

 

Black Diamond Video's integrated hybrid suite

Lauren Stamper, Portfolio Manager, ORIS, Stryker Communications: Several advancements not found in traditional ORs that are essential to providing optimal patient care are quick access to mission critical data from various hospital information systems (HIS), surgical video enhancements designed to increase accuracy and efficiency during a procedure and support for 4k imaging modalities common in hybrid ORs. They also increase efficiency with room and device setup automation based on procedure/surgeon, integrate real-time videoconferencing and streaming for consultation or education purposes, and offer EMR connectivity - seamlessly linking surgical images taken during procedure to the patient's record for future reference.

Jason Deeken, Senior Director, Marketing Surgical Solutions Integration, STERIS Corporation: When we think of smart surgical suites, we usually start with OR Integration Systems (ORI). Once simply a mechanism to manage video signals, these systems are now becoming the brains behind any smart OR. A smart surgical suite is one that puts timely, relevant information at the surgeon's fingertips -information that, despite coming from disparate sources can be tied together seamlessly during a call and shared among different areas of the hospital inside and outside of the OR. This affords greater efficiencies and lead to better patient outcomes. Smart surgical suites are also scalable to future needs and innovations, helping hospitals protect their investment.

Jay D. Miller, President & CEO, IMRIS: A surgical suite becomes smart when technology is integrated which extends the skills of the surgeon with the intent of improving patient outcomes, particularly for procedures considered not possible or challenging in traditional ORs. IMRIS intraoperative solutions transport state-of-the-art, high-quality MR or CT scanners to the patient using ceiling-mounted rails. This gives a surgeon access to images and other data during surgery. These images are typically only available within the radiology department - which improves the clinician's precision in performing the operation, reduces patient risks and leads to better outcomes.

Christy Gaudet, Director, OR1 Marketing, KARL STORZ: Devices characterized as "smart" generally can anticipate what you will need before you do. These devices can also prepare for your next move, and guide you with options that can also streamline workflow. A true "smart surgical suite" is an OR that incorporates software programmed to anticipate and guide surgical workflow, functions as a hub for information exchange and management, has access to EHR data that can help support the competency of the clinical end-user, and incorporates analytics to drive workflow and enhance efficiency.

Are smart surgical suites still an emerging trend or are they becoming more common-or perhaps even necessary-in the surgical environment today? 

Bream: Smart surgical suites are a standard of care for all new OR construction and are driving OR remodel projects. Workflow in today's OR is more critical than ever with reimbursements being tied to performance and outcomes. Smart surgical suites are a key component to improving the total hospital workflow challenges. Ensuring the right patient, the right surgical team, the right equipment, and the right medical information is present would be nearly impossible to coordinate without smart surgical suites.

Stamper: The trend for integrating surgical suites has been steadily increasing over the past several years in both new builds as well as renovation projects. As technology continues to evolve with a heavy emphasis on EMR connectivity, the need for this type of operating environment is critical. Due to increasing levels and access to patient-pertinent data, integrated surgical suites will continue to grow and will eventually become the standard of care.

Deeken: Smart surgical suites with some level of OR integration have definitely moved into the mainstream because of the workflow benefits they bring, and the increasing prevalence of minimally invasive procedures. The more sophisticated features, such as environmental elements and video conferencing, are still an emerging trend, however.

Miller: They are becoming more and more common today as this is leading to the standard of care for hospitals. In our business which is focused on the neurosurgical market, we aren't seeing just the research hospitals investing in these solutions but any hospital looking to take their neuroscience program to the next level. The concept has become necessary as clinical teams explore new procedures, especially less invasive approaches that can be less traumatic for the patient and lead to better outcomes and recovery. We have over 50 customers with nearly 90 operating rooms used by roughly 150 neurosurgeons, and these numbers are growing every day. To date, over 17,000 procedures have been performed in IMRIS operating rooms.

IMRIS VISIUS Surgical Theatre

Gaudet: Smart surgical suites are still an emerging trend and are even more important than they were a decade ago. The OR must become a "model department" for improved clinical care, while also helping to contain costs. The principal way to contain costs in the OR is to become more efficient.  And, the most promising solution for becoming more efficient is to leverage data and the processing power of software used in a "smart surgical suite."

What are the most important considerations to keep in mind when planning a smart OR?

Bream: An assumption must be made that better technologies will continue to enhance the OR work space year after year. Therefore, when planning a smart OR today, it is imperative that the clinical teams plan for, and invest in, the correct type of infrastructure to handle today's needs as well as tomorrows. For example, today's video technology that surgeons and interventionists use is high definition (HD). The evolution of video signal types will bring the need for OR integration and infrastructure to accommodate 4K UHD in the very near future. Planning for these essential needs is critical.

Stamper: Good planning is key, and there are a number of special considerations to take into account for both new builds and renovation projects. One of the most important elements to a successful integrated OR is the room design which is something that Stryker specializes in with over 20 years of experience. Creating a flexible working environment that optimizes floor space can aid in workflow efficiencies for the surgical staff. Equipment commonly associated with a smart integrated surgical suite includes ceiling-mounted booms, surgical lights and a video integration platform that facilitates video capture, routing, conferencing, controls and EMR connectivity. These technologies are scalable, are not specialty-specific, and bring tangible benefits to all types of procedures.

Deeken: Flexibility and scalability are among the most important considerations when planning a smart OR. Having a scalable bandwidth, such as what fiber optics provides, can help a hospital plan for the future without having to over-buy up front. Hospitals need to prepare to have richer interactions with their IT structure to accommodate future demand in Internet-connected devices and equipment, electronic health records integration, image-management capabilities, and more.

Miller: Hospitals studying adopting intraoperative imaging should fully involve cross-functional teams of surgeons, perioperative nurses, administrators, architects/program managers and others. This team will review space considerations along with types of surgical procedures for which they hope to utilize this new equipment once installed and clinical work they are considering in the future. In the case of 3D visualization with navigation provided through intraoperative imaging, they may want to account for other adjunctive therapies they hope to adopt to improve patient outcomes, such as laser ablation and deep brain stimulation utilizing robotics.

Gaudet: All smart surgical suites have an integration system as their foundation. The array of "smart" features that are built into that foundation can be customized to reflect the needs of the institution. When planning which features need to be "bolted on" to the integration system's foundation, it's important to understand the current state of the OR. You should openly "acknowledge" that existing state (both the positives and the negatives), and then rank the areas in need of improvement. 

How do these technologies and products reduce medical errors, decrease risk to patients, improve surgical efficiency, cut costs and provide other benefits?

Bream: Smart surgical suites ensure the correct patient, correct patient data, correct equipment, and correct clinical team are present in the OR. Utilizing the EHR data provides automatic queries and eliminates the need for manual typing by the clinical team. Smart alerts notify clinicians where they need to be. Equipment tracking helps find mobile equipment efficiently. Remote access to image archives allows clinicians to quickly and easily share with patients and family members pictures, videos and data from the clinical case. All of these examples ultimately provide a safer, more efficient, pleasurable healthcare experience. Black Diamond Video is focused on disruptive hardware technologies, as well as work flow of the clinical experience. The BDV Clarity software enhances the workflow by allowing surgeons to view into their OR from smart phones, archive patient images for easy access anytime and anywhere, seamless telemedicine consults can occur with pathologists and clinical experts, interface with any EHR system to ensure accurate data exchanges, simultaneously record multiple modalities for Trauma care improvement, and improve uptime by providing 24/7 secure VPN remote support for up to 92 percent of all service needs. 

Stamper: These technologies provide numerous clinical benefits that impact both the patient and the surgical staff. For example, video enhancement technologies - like Stryker's Clarity - provide a surgeon the clearest visual of the internal body which can result in better patient care. Additionally, Stryker has married its efficiency-driving products with complementary services. The Stryker iSuite (comprised of booms, lights, and video integration) was designed to aid in workflow gains and provide a better level of patient care. When outfitting a suite, an experienced project management team learns your goals, assists in room design optimization, and helps you plan for the future as well. Once installed and live, we offer an assessment service in which your surgical services line is observed for strengths and areas for improvement. The data collected (which can range from inventory management to SPD flow to room utilization to staff communication) is presented back to your key stakeholders with suggestions for change to optimize your surgical services line. Beyond that, Stryker can create and implement the plans for change if desired. In a recent case study, we worked with a customer to identify $8 million in additional revenue opportunities, improve on-time first case starts by 32 percent, and find cost savings of $440k per year in supplies.3

STERIS S.A.F.E. Situational
Awareness for Everyone Display

Deeken: Improving efficiency and patient safety are the drivers behind recent innovations that have brought streamlined and automated patient information into the OR. Now, OR staffs don't need to manually copy critical information onto a white board. They have real-time access to labs, allergies and more kinds of accurate data from disparate hospital sources that can help improve efficiency and patient safety. Improving patient safety was the driver behind the development of our Situational Awareness for Everyone Display (S.A.F.E.). It provides one trusted source for the most current data updates of the patient and operation; specifically key information from diverse IT systems - Laboratory, Radiology, Medical Records, Allergies and more. RealView Software optimizes perioperative workflow in real time, alerting staff about potential bottlenecks while providing instant notifications to physicians and staff to keep surgical schedules moving and on time. One hospital study documented more than 14,000 additional surgical cases added in the five years after deployment of the Realview software. Case volumes improved, on average, 29.4 percent per year. Relieving patient anxiety before a surgical procedure is the objective of our SignatureSuite technology, part of the Harmony iQ Integration System. Studies show that improving the patient experience by reducing anxiety, improving their comfort and distracting them from the pending procedure may allay patients' fears and improve their overall experience and willingness to recommend the hospital to others. Another study suggests such steps can even positively affect recovery.4 Our SignatureSuite system enables a hospital to deliver soothing and familiar audiovisual content tableside to enhance patients' experiences, and distract them from the anxieties of the pending surgical procedure. Content can be pre-selected from a content library that includes oceans and beaches, waterfalls, rivers, forests, etc. The system can also simultaneously adjust room lighting to deliver a more spa-like effect.

Miller: Minimally invasive procedures inside smart ORs allow surgeons to do certain procedures better than before and in some cases treat conditions that were untreatable previously. In many cases, these tools improve surgical precision by providing visual guidance or navigation that leads to better recovery time and long-term outcomes. Intraoperative imaging may reduce costs by lowering rates of second surgeries and recovery for patients. In more than 40 percent of the surgeries done in IMRIS ORs, surgeons modify the procedure based on examining the intraoperative MR, and the surgeons do so because they believe these modifications lead to better patient outcomes. Our leading product is intraoperative MRI provided in the VISIUS Surgical Theatre. Those hospitals who invest in our technology will ultimately save on procedures and neurosurgeons have confidence that they've provided the best possible care. In more than 40 percent of brain tumor cases, surgeons modified the procedure or removed more tumor based on information provided by the imaging. This reduces the cost of having additional surgeries. More and more studies are showing the value of intraoperative imaging for other neurosurgical conditions and procedures. Looking down the road we are developing a MR-compatible surgical robotic system that will be an extension of the surgeon with increased precision and visualization, especially in treating tumors, brain lesions and epilepsy.

Gaudet: KARL STORZ was the first to market last year with a TurnOver Management System, or TOMS. The system is a panoramic visual reminder that tracks TurnOver Time on all surgical displays. TurnOver time is a key metric in improving surgical efficiency. Visual reminders have been determined to generally reinforce "focus" and "goals." For example, digital speed limit signs help remind drivers how far under or over the posted speed limit they are driving. These signs visually reinforce a goal, (i.e., driving at the legal speed limit).  In the OR, the TOMS reinforces a "Time Goal" for the surgical staff; while leveraging the hospital's investment in its integration system. This is a "bolt on" type of feature for the integration system, and helps establish a "smart" environment by overlaying visual data (in this instance, time).

Creating a seamless smart suite means bringing many different devices and equipment together. Can you talk a little bit about what needs to happen, common challenges, solutions, dos and don'ts?

Bream: To bring devices together, that were originally designed to perform dedicated and independent functions, requires a robust OR integration solution which is vendor-neutral. Vendors typically build "vertical" platforms that only work with their own proprietary devices. This is counterintuitive for a smart suite where the goal is to have all of the equipment work harmoniously. Additionally, the core of the smart suite, which is the OR integration, needs to accommodate legacy equipment as well as future devices. No hospital can afford to upgrade or replace every device they have acquired, regardless of the age, when new equipment is purchased. This legacy equipment must be able to work with the new equipment and the OR integration needs to facilitate this requirement.   

Stamper: It is very common for equipment from multiple vendors to be present in the same integrated suite, especially in highly specialized rooms such as hybrid ORs. These rooms can come together seamlessly when customer expectations are well explained and when the vendors are able to collaborate and plan early in the project management process. DO over-communicate how you expect the room to function. DON'T wait to share technical details about the other solutions in the room with each vendor. 

Deeken: Our strategy is based on an open architecture, focusing on a best-in-breed versus a one-size-fits-all approach. The challenges of making different systems talk to one another appears to be lessening, which enables a hospital to pick the optimal solutions for them. It's to a hospital's advantage to work with a consultative partner that is experienced with the entire perioperative environment, and is thinking holistically about the physical structure, medical devices and flow of information.

Gaudet: By definition, smart surgical suites require an integration system. Today's integration systems easily interface with various makes and models of devices. A common problem that customers encounter is overdesign and underutilization. Planning teams need to respond to this challenge by focusing on the following questions: What do I need this room to do at a basic level - at an advanced level? Do all of my ORs need to perform the same functions? What workflow and other improvements do I want to drive in the OR? What policies need to be in place to drive these improvements? A common pitfall is a lack of utilization enforcement through policy (i.e., the change management part of the purchase is commonly missing).

KARL STORZ OR1 integrated operating room

How does one make the argument for such a big investment?

Bream: Hospitals need to properly research and understand the various options available. The high growth of the smart suite technology has encouraged disruptive technology developers, like Black Diamond Video, to provide more functionality at market driven prices. Five years ago the OR integration for a standard smart suite averaged around $150,000 per room.  By designing cost out, Black Diamond Video can offer more functionality for the same smart suite under $100,000 per room. Additionally, leveraging the EHR system the hospital has installed provides further ROI on the EHR investment. Total cost of ownership is also driven down by designing products which can handle future requirements versus replacing those very five years. Finally, providing remote service is far more economical than having sales representatives and service technicians stationed in every hospital OR. These are the innovative and disruptive solutions which Black Diamond Video is bringing to the market.

Stamper: The equipment required to outfit an integrated surgical suite is scalable as is the pricing. Stryker understands that an ASC (ambulatory surgery center) has very different requirements than a teaching institution, and product and price reflect that. Many hospitals start off with the basics and add-on each year as new technology is introduced and their needs evolve. I encourage customers to read an MD Buyline sponsored "Buyer's Brief" written by HFMA last year that provides un-biased justification for investing in integrated OR equipment1 .

Deeken: The needs of the surgeons, staff and hospital often vary widely depending on dimensions like service line specialization, teaching and research, and the role and size of the hospital within the community. We do not recommend one solution for all applications, but instead believe it's important to partner with someone who can help evaluate and address a hospital's needs and challenges. ORs are also one of the most important profit centers for any hospital and therefore small improvements in efficiency can make a significant impact.

Miller: Although a significant investment, having these systems will allow them to perform surgery better than before and provides a combined direct and indirect ROI, particularly by reducing additional surgeries for patients. Expanding neurosurgical programs also are economic and reputation drivers for the hospital and community. Institutions have commented that having these capabilities has drawn patients from outside their regions and prevented local patients from going elsewhere. These same hospitals say adding this technology aids in its ability to recruit top surgeons and other specialists.

What do you see happening inside the OR, say five years from now? 

Bream: As procedures become more complex, smart suites will require more equipment to work together. As procedures continue to evolve that require multiple specialists to collaborate, technology will enhance this collaboration. Pricing pressures and patient privacy will continue to change the classic model of having sales representatives in every procedure to support surgical cases. When you combine these three healthcare influencers, the OR in five years will look and feel very different. The OR in five years will be a multi specialty "work shop" that requires disparate devices to work harmoniously and be supported and serviced virtually by the remote presence of device manufacturers.

Stamper: Shared communication standards between various types of equipment (medical devices and HIS systems) for more robust integrations, minimized human interaction with the technology and more focus on the patient, more video enhancement technologies to help guide MIS procedures, and a ubiquitous EMR solution that allows all healthcare providers access to a single record for any given patient.  

Stryker iSuite

Deeken: In the near future we're going to see a greater role for software and data/information sharing between devices and electronic medical records. We'll also continue to see enhancements to sustainability and green considerations in the OR. Finally, the demand for communication among the OR, supporting staff and other key groups outside the room will increase.

Miller: For many specialties, the future inside the OR involves not just a range of imaging options but also robotics for surgical procedures that are increasingly minimally invasive and, therefore, less expensive. History tells us that this should lead to improved long-term outcomes and patient recovery. IMRIS is currently developing an MR-compatible surgical robotic system for neurosurgical applications that will improve the clinician's precision and patient outcomes for certain procedures such as brain tumors.

Gaudet: In five years, the smart surgical suite will have fine-tuned these features so that they can already be in motion and, in some instances, already be deployed by the start of a procedure. Such advanced systems will: automatically recognize which surgeon is operating, and pre-set the room to that surgeon's preferences; automatically pull in supporting clinical data for that surgical procedure; enable immediate access to "On Demand" expert help and mentoring for all aspects of the surgical procedure; track the movements of each care provider and provide analytics that can support workflow improvements; cue care providers in performing successive clinical steps; and incorporate telementoring and telemedicine solutions to support improved clinical competency and delivery of care.

References:

1. iData Research, U.S. and European Video, High-Tech and Integrated Operating Room Market Outlook to 2019: Led by STERIS, STRYKER and Karl Storz, July, 16, 2014.

2. Healthcare Financial Management Association, Buyer’s Brief: Integrated Operating rooms, November 2013.

3. Stryker Performance Solutions, Case Study, Siouxland Surgery Center, Surgical Services Optimization, 2014.

4. R.S. Ulrich, View through a window may influence recovery from surgery, Science, 1984 Apr 27; 224 (4647); p 420-1).