In my job as a consultant to surgical facilities and medical practices, I'm rarely called in to evaluate an inefficient surgery center. Most facilities have efficiency and cost-cutting mastered. They've gone through the obvious steps of case costing, cross training, reducing labor and keeping their fixed and supply costs down. Efficiency is rarely the problem with cataract surgery. Improving profitability is the challenge. How do you pull more money out of an extremely lean operation? If you think you know everything about improving efficiency and profitability in cataract surgery, get ready to be surprised by these 5 common myths.

Myth #1: You can never be too efficient
Cross training and reducing staff to the bare minimum is a quick way to improve the bottom line. It reduces your labor costs and helps you create a highly skilled staff that can do a wide range of tasks as they're needed. But there's a cost to running such a tight operation. Some tasks may be done by employees who are too expensive for the assigned responsibilities. If the executive director is handling payroll or your clinical director is working cases every day, you've cut too much when it comes to staffing.

There's a difference between efficiency and effectiveness. If your operation is highly efficient but maxed out, it will be hard to add more cases and maintain that efficiency. In order to increase volume, you need to have the capacity to add cases. This means you may need to plan on growing and to staff accordingly. Long-term efficiency requires that key managers and physicians have time to develop and implement a strategic growth plan for the center, not just deal with daily operations.

Myth #2: The more surgeons, the better
Recruiting more surgeons who'll bring cases to your center and fill in the gaps in your schedule seems like the most direct means of increasing volume. Unfortunately, that's not always true. Adding more surgeons adds more variables and sometimes confusion. It's much more difficult to juggle the schedules of 15 surgeons, compared to just 5 surgeons.

We all know that some blocks in the schedule are more desirable than others, and some surgeons will simply go elsewhere if they're given the less desirable blocks. This leaves you with holes in your schedule that are difficult to fill and staff standing around with nothing to do for long periods of the day. More surgeons also means more vacations — and time blocks to fill — as well as the chance that newly recruited surgeons may be less productive, may not fill their blocks or may cause delays because of tardiness or unrealistic scheduling.

Before you bring in more surgeons, try working with the ones that you have in order to increase your case volume. It may be easier, and more profitable, to work on adding a case per day per existing surgeon than to bring in a new surgeon. To do this, the surgeon and staff will have to work together to become even more efficient so that the added case doesn't create a bottleneck that delays all the day's cases.

If the surgeon's block time is filled for several weeks because the practice has grown and patients have to wait for 5 or 6 weeks to schedule surgery, you may not be able to increase the surgeon's block time permanently in a way that fits his schedule. However, you can schedule an extra session or 2 per month to take the pressure off the schedule. Also, ask your surgeons if they're not bringing some procedures to the center due to equipment issues or the center's lack of enrollment in certain health plans. Evaluate those procedures to determine if you can profitably add them to your case mix.

Myth #3: Labor is the major constraint to profitability
Everyone knows that reductions in labor costs usually translate directly into improvements on the bottom line. Labor usually rivals surgical supply costs as the largest line item in a facility's budget, so it's an easy target for cuts. But staffing isn't as expensive as you think it is, if you staff wisely. Each task in the center should be done by someone at the appropriate skill level and pay scale. If you look at your staff, you may have assigned a task to someone who is overqualified, which means that you're paying too much to have that task done. For example, having a registered nurse doing sterile processing or patient transport may mean that you're a team member short.

In some cases, hiring someone with the appropriate skills and salary level can improve your profitability in the long run, even though you're increasing your labor costs. For example, if you hire a tech to help with room turnover and the added efficiency lets you do 1 or 2 more cases per day or complete the daily schedule an hour earlier, then the added labor cost is worth it. The additional revenue or labor cost savings on those cases will easily pay the salary of the new staff member.

Myth #4: It's more efficient for 1 surgeon to work 2 ORs simultaneously
Many cataract surgeons like to go back and forth between 2 ORs so that they're not waiting during room turnover. I've found that unless the surgeon can do at least 5 cataract cases an hour, or 18 to 20 cases a day, using 2 rooms doesn't make economic sense. The surgeon might not be waiting, but paid staff and anesthesia providers are. It's difficult to staff a room for less than 5 hours a day because you either have people with little or nothing to do for part of the day, or you have to send them home early, which makes them unhappy because they're not making the money that they'd anticipated. The 2-OR technique works only for the fastest high-volume surgeons. Otherwise, you're bound to lose money.

Myth #5: Expand and you'll become more profitable
Whether you recruit more surgeons or convince your existing surgeons to schedule more cases during their blocks, you're going to reach a point where opening another OR seems like a good idea. Before you do it, wait. Consider this decision very carefully. Adding another OR — even if it's already shelled out in your center — adds a whole slew of new expenses such as labor, equipment, an anesthesia provider and sometimes renovation costs.

Figure out how much it costs per day to run the new OR and weigh it against how many additional cases you can realistically schedule in that room. The costs directly associated with these additional cases — labor, supplies, renovation and equipment expenses — are your marginal costs. When figuring out whether it's worth it to open the additional room, look at the marginal cost rather than the average cost, which would include your fixed costs. Your rent, utilities, insurance and other fixed costs will be the same regardless of whether you open the additional room.

After doing the calculations, you might learn that you have to spend $450 per case to bring in $1,000 per case, making a profit of $550 per case. Compared to your existing room, where you spend $325 per case to bring in $1,000 per case and make a profit of $675 per case, this new room may not be worth the cost and effort until you're sure of creating a substantial increase in case volume.

If you feel you have to build another OR, consider the impact on the facility as a whole. The additional room may also require additional space in other areas, including sterile processing, pre-op, recovery, storage and reception area seating. Space or cost constraints may preclude adding an OR as a strategy.

Another way to look at it would be to consider how much money you'll save if you don't do the extra cases. This may seem like a strange way of framing the issue, but often it's best to consider every angle before you set out. The best path may be the most obvious.

The hidden costs of growth
As these myths show, increasing volume is the most effective way to improve profitability in an already efficient center. But doing this has its challenges. You need physicians to bring more cases and need the OR space and labor to handle the increased volume. Growth comes with costs that cut into your profitability.