The health care industry is in a state of change. The days of the traditional fee-for-service reimbursement system are numbered. There is the belief that providers of health care will be more accountable for both the cost and quality of health care.<sup>8 Laszewski R. Conditions for consensus Health Management Quarterly 1993 ;  15 : 2-7

Cliccare qui per andare alla sezione Riferimenti</sup> The primary focus of health care change will be to provide quality care at the lowest possible cost. Managed care and capitation are the modes of providing care in the future. The new environment of capitation or a fixed rate for each covered life has turned revenue centers into cost centers in the new environment.

In a cost-conscious, competitive environment the operating room will be a major focus of change. One estimate is that 30.1% of all health care outlays are related to surgical expenditures.<sup>13 Munoz E., Tortella B., Jaker M. Surgical resource consumption in an academic health consortium Surgery 1994 ;  115 : 411-416

Cliccare qui per andare alla sezione Riferimenti</sup> In past years many attempts at cost control and increasing efficiency have been met with resistance by nursing and medical staffs. Because operating rooms are large revenue producers, they have been historically viewed as closed systems.<sup>3 Furlow L. Behind closed doors: What the nurse executive should know about surgical services J Nurs Adm 1994 ;  24 : 25-28  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> The motivation for change has not existed until recently with the arrival of capitation and limited reimbursement, the key parameters of a managed care environment.

With the onset of managed care, health care providers have fewer resources and greater demands for cost-effective, quality surgical care. As hospitals revision their future, they must begin to revision what needs to occur in the operating room to incorporate this vital, specialized link into an integrated, customer-focused, service-line continuum.<sup>2 Boston C. Breaking down the walls without tearing down the house J Nurs Adm 1994 ;  24 : 5-6

Cliccare qui per andare alla sezione Riferimenti</sup> Among the changes necessary are new performance criteria, new patient care delivery models, and restructuring of facility processes, creating a health care system that accomplishes the most with the fewest resources.<sup>11 Moss M. Perioperative nursing in the managed care era Nursing Economics 1995 ;  13 : 54-57

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The restructuring necessary to direct this change involves system thinking. Peter Senge,<sup>20 Senge P.   The Fifth Discipline: The Art and Practice of the Learning Organization New York: Doubleday (1994). 

Cliccare qui per andare alla sezione Riferimenti</sup> author of The Fifth Discipline: The Art and Practice of the Learning Organization, describes business reorganization as a growing capacity to create more information than anyone can absorb, foster more interdependencies than anyone can manage, and accelerate change faster than anyone's ability to keep pace. The fifth discipline identified in his title is systems thinking, a conceptual framework to make the full patterns of complex interrelated actions clearer and help people see how to change them. Inherent in systems thinking is the recognition of patterns of behavior, repeating themes, and the problems that recur regardless of the setting.<sup>22 Tonges M., Madden M. “Running the vicious cycle backward” and other systems solutions to nursing problems J Nurs Adm 1993 ;  23 : 39-44  [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Such is the nature of “sacred cows” of the operating room. Traditionally held beliefs must be abandoned in order to create efficiency and the cost control necessary for survival in the competitive new environment of managed care.

Arthur Andersen's<sup>1 Arthur Andersen Consultants   Best Practices: Putting Insight Into Practice Dallas: Arthur Andersen (1992). 

Cliccare qui per andare alla sezione Riferimenti</sup> “best practices” state that a major factor during managed care negotiations is price. One dilemma in managing costs is the concern that too much emphasis on cost control and cost reduction will affect quality. Quality does not have to suffer. Traditional business views cost and quality as “two sides of the same coin.”<sup>4 Iaccoca L.   Iaccoca: An Autobiography New York: Bantam Books (1984). 

Cliccare qui per andare alla sezione Riferimenti</sup> Senge suggests that both quality and cost control can improve together over time. The result is a service that attracts patients, physicians, and managed care partners and an environment that attracts and retains professional nurses.

Surgical costs are related to operating room utilization, inventory volume, supplies used, and the costs of equipment. Facility design also affects efficiency and the ability to reduce costs. All these issues must be evaluated and monitored to ensure quality care at the lowest cost.