You manage your employees, your case costs and your procedure times, and you're not careless. Your facility turns a profit. Why compare it to other facilities? The accrediting agencies require you to, for one thing. But also, patients deserve to be treated, and staff members deserve to work, where people are striving for excellence. Competition breeds excellence, and numbers don't lie. Benchmarking is essential.

Identifying the need
Our three-OR center has never had bad results - our patient satisfaction rate has regularly ranked in the 96th percentile, according to one national surveyor - but we can always do better. In 2003, we decided to look into the complaints about waiting times we'd always heard from our cataract patients. The number of questions they'd ask during post-op phone calls also deserved study.

Our patients weren't the only ones raising issues. Sometimes they wouldn't be ready for surgery at the same time our surgeons were. Plus, our surgical volume had more than doubled, from 100 cases to 250 cases a month, and we were just adding orthopedic and general surgery procedures to our previously ophthalmic-only center, so patient flow was less than ideal. We weren't as organized as we could have been, and it was going to get worse. This was obviously an opportunity for us to organize our workflow, for the patients' benefit as well as our own.

Fortunately, we'd been keeping good records. After each patient's surgery, we input the case history - demographics, procedure details, times - into a computer database, periodically sending that data to benchmarking consultants for a report of our averages and comparisons with other facilities. Referring to our benchmarking data created our impetus for change. If other folks are completing cataract procedures in that amount of time, we said, why can't we?

Benchmarking options
There's no point in collecting data if you're not going to do anything with it. In the best-case scenario, benchmarking's spotlight on where you're outside the average should spark quality improvement measures. We're looking at five or 10 factors at any given time, from chart processes to whether our patients are filling the prescriptions we give them.

You've got several options if you're seeking to benchmark your facility and its procedures. You can institute an internal benchmarking process, collecting and analyzing your statistics yourself from month to month or from quarter to quarter. Your state and national professional associations also offer external benchmarking data or services to their members, oftentimes at no charge.

While there are advantages to those options, we've hired a consulting group to crunch our numbers and a national surveying firm to take the temperature of our patients' experiences, so to speak. We don't always have the resources to conduct internal benchmarking efforts, and professional associations aren't single-mindedly dedicated to the art and science of data collection and statistical analysis the way that benchmarking companies are.

Our outside consultants not only deliver the numbers, but make suggestions for improvement based on what the numbers show them and the patients tell them. Their weekly reports offer timely feedback and their Internet applications provide immediate access. In my mind, there's no comparison. Plus, my competition uses them, so you're really comparing apples to apples.

Rethinking the process
Our surgeons weren't the problem. At the time we examined our processes, the cataract surgery itself took an average of 14 minutes, five minutes less than the benchmarking report's multi-center average. (We've since reduced our time to 11 minutes, three minutes better than the overall average.)

Reviewing the steps of the cataract procedure, one big number stood out. Our discharge time was 36 minutes, which was awful in comparison with the average of 25 minutes. We are, of course, in the business of patient care, but in the ambulatory surgery field it's undeniable that you're also in the business of time. We had to get that number down.

We flowcharted the cataract patient process, consulting the benchmarking data at every step as we looked for ways to redesign our methods and better economize on time. To make benchmarking work for you, the bottom line is people. You'll need your people working together to study the data and communicate the aims of the project. You'll need your people to look at their work critically and ask themselves and others, "How are we doing this? How can we do this better?"

Of all the changes we considered and adopted to streamline the process, three major efforts stand out.

• Prepping. First, we've doubled the number of patients we're prepping at one time from three to six. Now we always have a patient ready for surgery, and we've practically eliminated the waiting room wait between admission and pre-op - which could last an hour during the worst of our delays.
• Scheduling. Second, we've coordinated our OR schedule to better handle each procedure's needs. We've always had cataract procedures going on in two ORs simultaneously, but when we thought about it, moving the microscope 20 times a day - from the right side to the left and back again - didn't make a lot of sense. So we'll schedule one room for right eye procedures and one room for left. Then the microscope stays in one place and saves us the time of repositioning it when we bring in the next patient.
• Discharge. Third, we give the patient their post-op instructions in pre-op. Think about it: he's just come out of surgery and is woozy from anesthesia. He might not be giving his undivided attention to the directions the recovery nurse is explaining. It's no wonder we've had to answer so many questions during our post-op calls.

On the other hand, during pre-op there's 10 or 15 minutes after you've administered the patient's eyedrops when you're simply waiting for their eyes to dilate. We decided to use this time, not lose it. We put the patient's eyedrops in as soon as the consent's signed, then explain their discharge instructions and bag of post-op supplies. We even encourage the patient's escort to join him in the room, so more than one person hears the directions. As a result, we're using time efficiently while also keeping the patient occupied and attended. Plus, we've reduced our average recovery-to-discharge time below 25 minutes. We've even seen it as low as 19 minutes.

Holding our gains
Before we started our benchmarking and improvement project for cataract procedures, one patient might have taken us, from admission to discharge, about four hours. I'll admit, we didn't have that many patients then; but once the volume started picking up, we realized that keeping an eye on our time was going to become very important. Now, when we're perfect, we can go start to finish in maybe two hours.

It took us the better part of a year to carry out this project and incorporate these changes. It took participation and cooperation among our surgeons and staff. Some ideas worked, some didn't and some we're still refining. We never increased the size of our staff to change our workflow, something I thought for sure we'd have to do. And that we're holding our gains, both in time and patient response. After our changes took effect, surveys showed our patient satisfaction rose to the 99th percentile nationally.

We do 450 cataract cases a month now. Certainly you can't control delays, and in terms of individual patient cases, you're always going to have statistical outliers. But there's always a good chance you can organize your work better by comparing your data against others'. We found that the more organized we were, the more patients liked us, which was critical. Because the ambulatory surgery field may be a business of time, but it's undeniable that we're also in the business of patient care.