The COVID-19 pandemic has had a huge impact on ASCs’ operations, and when the crisis wanes and operations begin to get back to normal, centers will be looking to make up for lost time and revenue. Operating as efficiently as possible, while still serving patients’ needs, will be paramount to success.
“The key to efficiency is to never cut a corner,” says Michael Patterson, DO. “Because if you cut a corner and slip, you fall down. You might have been winning the race, but now you're dead last. You've got to be consistently consistent.”
Dr. Patterson, a partner in Eye Centers of Tennessee and the Cataract & Laser Center in Crossville, TN, says he’s “all about efficiency” in the surgery center, and with good reason.
“In ophthalmology, we're at a point when budgets keep getting cut, and revenue is dropping,” he says. “With the recent 15% decrease in Medicare reimbursement for cataract surgery, something’s got to give. Can we perform our same premier-standard, perfect cataract surgery and save money? Yes. But only if we’re willing to move out of our comfort zone.”
In this article, Dr. Patterson and members of his nursing staff—as well as independent consultant and founder of ASC Compliance, LLC, Elethia Dean, RN, BSN, MBA, PhD—share lean operating principles to help you reduce waste and save time and money in your ASC.
COVID-19 UPDATES
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And, for the latest pandemic coverage, including news that affects healthcare businesses as well as a collection of resources, visit ophthalmologymanagement.com .
Shake Up the Status Quo
“One of the problems I’m seeing is that some surgeons are staying with the status quo,” says Dr. Patterson. He notes that while it makes sense to operate within your comfort zone to maintain the quality of your outcomes, when outside forces intervene it may be time to examine other options. He suggests the following.
1 Reevaluate the tools of your trade.
“We want to make sure we're performing the same premium cataract surgery for fewer dollars, and that goes to our packs, our phaco machines, and every single piece of equipment we're buying,” he says. “For instance, ophthalmic viscosurgical devices (OVDs) can cost anywhere from $15 to $100 per tube. Surgeons who are using the $100 OVD should look into less-expensive options. If 2,000 cataract surgeries are performed in your center annually, and you can save just $50 per case, that's $100,000 saved in one year's time.”
Dr. Patterson encourages surgeons to look at their IOLs with the same critical eye.
“Find a company that will give you the best price break if you expect to be using many of their lenses,” he says. “While prices of standard IOLs vary by manufacturer, there are always lenses with better pricing that see just as well.”
2 Avoid long-term contracts.
In today’s economic environment, Dr. Patterson recommends avoiding 1- and 2-year contracts with vendors so that you can react quickly to changes in the market.
“If you are bound to a 2-year contract, what do you do when reimbursement is reduced during the first year? Can you get out of a contract for a particular lens if a new and improved—and less expensive—lens hits the market? You need to constantly be renegotiating your contracts,” he says.
3 Stay alert for any changes in reimbursement.
Reimbursements are the financial lifeblood of ASCs, and Dr. Patterson emphasizes closely monitoring those reimbursement numbers—particularly when new devices are involved.
“A relatively recent advancement in glaucoma management is microinvasive glaucoma surgery (MIGS) with various types of devices,” he says. “If you’re not paying attention, you won’t realize that the cost of a MIGS device could have increased by $300 while reimbursement decreased by $200, and you’re losing money.”
Dr. Patterson encourages surgeons to explore other options in products, equipment, and techniques to uncover new methods to improve efficiency.
“Make sure you're not doing something just because you're comfortable with it,” he says. “Shop around. This is a business for the companies you’re dealing with. They want to make money, but you have your own business to run, and you have a fiduciary responsibility to provide the best quality product and make money for your staff.”
Improve OR Turnover Time
In addition to her consulting business, Dr. Dean is the director of nursing for an ophthalmic ASC and helps manage several surgery centers in other medical specialties. She says that turnover time represents the biggest potential for waste in an ASC, regardless of the specialty, and slow turnovers are often related to inappropriate staffing. She recommends dividing labor by skillset for top efficiency.
“Maximize your nursing staff and use ancillary staff wherever possible,” she says. “For example, you may prefer that your nurse move patients to and from the OR, but nursing skills are not required to clean the OR, open packs, and set up the room for the next patient. Your ancillary staff can take care of those tasks, while your nurse is caring for patients.”
Dr. Dean points out that how you configure your staff—the ratio between nurses and non-licensed employees—depends on your needs and preferences. Larger surgery centers with three or four ORs may find it’s most efficient to have two ancillary staff members, one turning over the ORs and a second cleaning beds and restocking the pre-op/post-op areas.
Another area where nursing skill may not be required is escorting patients to vehicles. “Some procedures, particularly in ophthalmology, do not require the administration of I.V. sedation,” Dr. Dean says. “Typically, a patient who has not been sedated can be escorted out of the surgery center by ancillary staff. It’s an assessment to consider where in your facility ancillary staff would be appropriate and where nursing staff would be a better option.”
Dr. Dean also offers a time-saving pearl: Be aware of the kill time of the solution you use to disinfect your OR. Kill times can range from 1 minute to 10 minutes or more, and therefore the product you use can add minutes to your turnover time.
“If the kill time of the product you use is 10 minutes, for every sixth case you just lost 60 minutes—or the equivalent of 3 or 4 uncomplicated cataract surgeries,” she explains. “That's a significant loss of revenue.”
STAY TUNED
Addressing Attitudes Toward Waste in the OR
Developed in partnership with ASCRS and AAO, and including participation of the Canadian Ophthalmic Society, OOSS has conducted a record-setting survey to help shape strategies to address surgical waste, efficiency, and cost.
Physicians, nurses, and administrators engaged in an attitudinal survey of OR Waste Management. Insight and findings will be shared by OOSS over the next 6 months.
Surgeons, Lead by Example
“The surgeon drives efficiency in the OR,” Dr. Patterson says. “To do that well, they have to understand what’s happening around them, everything from the processes that ensure the correct IOL is in the room to placement of the drape. We have to set expectations and be involved to the nth degree but without micromanaging. In short, help your staff.”
And Dr. Patterson’s nursing staff appreciates his involvement in OR set up and turnover. “He performs various tasks that make the room turnover and set up much more efficient,” says Marcia Conley, RN, director of nursing. “That’s something he brought to the table, and it has made his day and his turnover much more efficient.”
“Dr. Patterson does as much as possible on his own in the OR,” adds Cammie Henry, RN. “He opens packs, sets up the back table, and prepares his instruments. He's not standing back, waiting for the scrub technician to do everything for him.”
Dr. Patterson explains: “I gown and glove myself, and I set up my own back table so that my staff can take care of the tasks that make them more efficient. I help turn over the room for every case. Some surgeons like to take a mental break between cases. If you need to do that, I suggest you consider scheduling a 15-minute break every day instead of taking breaks between cases, because when you do that, your staff can't get into an efficient rhythm.”
Henry says from her perspective, Dr. Patterson’s contribution is tangible. “There’s no lag time,” she says. “By the time I’ve moved one patient out of the OR to the post-anesthesia care unit, I can move the next patient back to the OR. There's no downtime in between. By the time I get back there, they're ready to start the next case.”
Conley estimates that by pitching in in the OR, Dr. Patterson saves about 1 to 2 minutes per case. “At the end of the day, when we’re doing 30-plus cataract cases, that’s a lot of time saved,” she says.
Dr. Patterson cites a maxim he learned from his father, Larry Patterson, MD, as the basis for his demeanor in the OR: Speed does not lead to efficiency, but efficiency can lead to speed.
Avoid Unnecessary Steps in the OR
Acknowledging the need to follow ASC regulations, Dr. Patterson advises: “Do what's necessary, but don't continue to do tasks that aren’t required. Here's a good example: When you're finishing a case and your back table is done being used, someone—for us, it’s our circulator or surgical coordinator—should break down the table and start cleaning it immediately. That way, once the patient is moved out of the room, you're ready to start the next case.”
He also recommends reviewing your timeout protocols.
“The timeout needs to be efficient and to the point, otherwise you're going to forget what you're doing,” he says. “In our OR, the surgeon, the circulating nurse, the surgical coordinator, the anesthesia provider, and the scrub technician are all looking at the lens to make sure it's correct. We also have the specifications written on the schedule, at the end of the bed, and on the wall.”
Conley says, “We’ve always been efficient in our surgery center. In fact, we've had surgeons and staff from other facilities come in to observe us for efficiency training. Dr. Patterson is taking our efficiency to the next level with his hands-on approach in the OR.”
Be the Minimalist: Reduce Waste
Dr. Patterson’s ASC takes a minimalistic approach in order to reduce waste. “We use all diamond blades and reusable phaco and I/A tips,” he says. “I also reuse Bovie tips for my oculoplastics cases. Our standard cataract tray contains only essential instruments. If we need an extra instrument, we have them peel-packed on the side, but we don't have eight trays of eight sets of instruments. We don't need that many. They’re expensive and wasteful.”
Two blades are on each tray, and three different trays are used throughout the day. This allows time between cases for the scrub tech to clean the blades appropriately along with the other instruments before they’re taken to the decontamination/sterilization room.
Both surgeons use the same streamlined custom pack, which helps reduce waste and saves time. (For more on custom packs, see page 14.)
“This aids our efficiency, because we’re not trying to figure out this doctor's pack versus that doctor's pack, this glove versus that glove,” Conley says. “Because our pack is so lean, we realize a cost savings on the front end. Rather than include extra items in our pack ‘just in case,’ we have backups for everything on our table. For example, we found we don't need two towels for every case, so we include only one towel in our pack. On the odd occasion when we need an extra towel, we open up another one from our back table. This is much more cost-efficient for us.”
Enhance the Patient’s Experience
Not only does an ASC that optimizes its efficiency measures save time and money, it also creates a favorable environment for patients.
“Let's look at turnover time. Patient satisfaction increases as the time spent waiting for a procedure decreases” Dr. Dean explains. “No one, including patients, wants to feel like they're wasting their time. So the more efficient any organization is, whether it’s a surgery center or a grocery store, the more valued the customers feel.
“A valued customer will always give you return business. If a patient has to wait 4 hours before seeing a physician, chances are she’s not going to want to go back to see that physician because of all that wasted time. And it won’t be long before that one unhappy patient tells a hundred more people.”
Tap Into Valued Resources
To improve efficiency, time frames, and turnover in the OR, Dr. Patterson suggests that surgeons and staff visit surgery centers that are known to be efficient to learn from them.
He also advises getting involved with the Outpatient Ophthalmic Surgery Society (OOSS) and OOSS University (university.ooss.org ) to tap into the expertise represented in those organizations.
“Talk to the board members, talk to the people who have actually run high-volume surgery centers, and then evaluate your current protocols,” he says. “It does take time and dedication, but the rewards are worthwhile.” ■