The phacoemulsification machine is the cornerstone of an outpatient ophthalmology service. When it comes time to replace your facility's phaco system, it's understood that your physicians have a great amount of influence over which machine to purchase. But administrators also play a key role in making the right choice for their ORs. Here's how.

Get involved
For the physician, choosing a phaco machine "is a question of personal preference, of past experience, maybe of better technology," says Alex Stockdale, MBA, the administrator of Tennessee Valley Eye Surgery Center in Knoxville, chief financial officer of Johnson City Eye Surgery Center and CEO of Southeastern Retina Associates. "If you're not careful when the decision comes up, it's pretty easy for a sales rep, with his past relationship with the physician, to influence the decision, and not necessarily in the best interests of the physician or the facility."

Build a strong working relationship with your physicians well before you're in the market for new equipment, says Mr. Stockdale. "You can't be effective unless you know what your physicians do," he says. "Try to have a grasp on the surface of procedures, terminology, equipment, the handpieces, techniques: a general idea of how it all goes together.

"If your physicians know you're interested, they'll help you to understand," he adds. "I've seen administrators who didn't understand the clinical side make big tactical errors that cost them their jobs."

Once you have a handle on the basics of your cataract procedures and equipment, you also have to stay informed. "As an administrator, keeping up with new technology and which manufacturers have what can be overwhelming," says Gina Stancel, HCRM, CST, COA, the surgical administrator for Eye Centers of Florida in Fort Myers. She says vendor booths at such larger eye meetings as ASCRS and AAO are great places to see what's new and what's coming.

"Also, interaction with other ASCs can help a lot," she says, in getting a realistic sense of how that technology works in terms of operation and service when the OR clock is ticking.

Beth Hurley, RN, CRNO, COE, ophthalmic surgical center consultant and president of Innovative Surgical Resources in Phoenix, Ariz., recommends that you request your own individual meetings with manufacturers' representatives to raise your questions and concerns as opposed to meeting with the rep and physician together or leaving the communication entirely to the physician. "The rep should have a good understanding that the surgeon is not his only customer, and that the staff has significant input," she says.

Plus, after separate meetings, you and your physicians should compare notes on your issues of importance. "All this goes back to the relationship you have with your physician," says Ms. Hurley.

When to upgrade?
"The machines last a long time," says Mr. Stockdale. "But certainly over time the technology gets better, you see advances made in the handpieces. Maybe your older machine will get the job done, but if a new generation of phaco can be shown to have the potential for better outcomes, you might begin to consider replacing your machines before you physically have to."

New technology's luster isn't the only reason you might end up trying out new phaco systems, he says. So is the mounting expense of old technology. "I haven't seen machines wear out, per se, but they become more expensive to maintain than buying a new machine, and the new machines have the better technology."

Ms. Stancel agrees. "When your machines are not compatible with newer techniques, or are becoming a drain on maintenance, you need to start looking."

You may also find that a limited availability of technical service and product support for your older machine is making the decision to upgrade for you. "Manufacturers replace their old machines," says Mark Packer, MD, FACS, a clinical associate professor at Oregon Health and Science University and an ophthalmologist with Drs. Fine, Hoffman & Packer in Eugene, Ore. "They'll notify you of their plans to discontinue service on certain models and stop supplying the disposables for it after a certain time. It's not right away, but you'll want to change."

Trialing the technology
Most surgeons strongly prefer a specific manufacturer's equipment, says Mr. Stockdale, but an organized comparison of alternatives will catch their attention and manufacturers' reps will jump at the chance to demonstrate their products in your OR.

Testing out the candidates rests largely in your surgeons' hands, but you can help to create a controlled environment for the comparison to ensure as objective a process as possible from which they'll make their decision. Schedule the reps' visits so that as many surgeons as possible will be able to observe the demonstrations, says Mr. Stockdale, and arrange for the equipment to be available long enough for each physician to have a relatively equal time to try it out. "This lets the surgeon say, ???I tried all of these, and this is the one I prefer,'" he says.

"While physicians are sold on the technology," says Ms. Hurley, "administrators are sold on ???Is this the best thing for the patient? Is this the best quality we can deliver?'" For that reason, she says, any staff member who'll work with the phaco machine should have a hand, and a voice, in the trials.

"Surgeons talk about how well a machine works when it functions, not the practical aspects of its functioning," such as how easy it is to set up or turn over, how well the tubing works or how much time it takes to calibrate, says Dr. Packer. "That's something an administrator would see pretty quickly: Every time we use that machine, the case is five minutes longer than usual," he says.

Case costing
"Trialing can help you obtain the best price, because there's real competition," says Mr. Stockdale. "The sales reps have to sharpen their pencils and come across with the best deal they can." He recommends organizing a request-for-proposal process that seeks the best offer from each manufacturer "to take a little bit of the salesmanship out of it."

You'll be comparing the initial cost of the equipment as well as the variable costs of its components, such as tips and tubing and whether they're single-use or reusable, he says. But don't neglect an inquiry into the details of service contracts and warranties, as they'll help you estimate the continuing cost of maintaining your purchase.

Itemizing the first two of these costs can be a difficult process. "The way the phaco machines are sold is through the usage of related products," says Dr. Packer. "Part of your purchase price is applied to a set amount of accessories" — procedure packs, IOLs, pharmaceuticals or viscoelastics, for example — "from the company that makes the machine. Those associated products help to pay the machine off."

"They usually won't break it out, because they don't want you cherry-picking for the best prices on those things," says Ms. Hurley. "If they're not going to break out the costs, then the bottom line is cost per case. Ask them, ???If I perform 10 cases, what will this arrangement cost me?'"

"You have to look at your facility's usage of those accessories," says Dr. Packer, and communicate case volumes, case costs and brands used to your surgeons during the purchasing considerations, as it may put a machine's cost-efficiency into perspective. "At a surgery center with a dozen surgeons, the surgeons don't know what products the others are using. But the administrator has the data to say, ???Here's what this machine's going to cost us. We use more of these lenses, perhaps we should consider that machine.'"

Above all, remember that cost is always negotiable on equipment, especially if you're an eyes-only ASC or have a busy cataract practice and are buying more than one phaco machine, says Ms. Stancel. "Negotiate what will come with the machines. If they come with posterior handpieces that you won't use, trade those out for more phaco handpieces or irrigation/aspiration tips or vitrectors." And let the rep know how busy your surgeons are, she adds. "The volume of cases always makes a vendor attentive. That goes for every consumable eye product."

Achieving consensus
As far as the qualitative aspects of phaco machines are concerned, an administrator may not have a great amount of impact on the decision. Quantitatively, however, "you can give them the best data possible to make that choice," says Mr. Stockdale. "They can use that to judge whether a machine is worth the money, and whether the money is wisely spent."

"There's no perfect way to reach a consensus," he notes. But a surgical facility requires compromise. "Try to take emotion and past preferences out of the equation during the selection process, and keep discussions focused toward the end result," namely, an efficient and successful practice.