High volume and cost efficiency have been and will continue to be the keys to survival and success in the competitive world of ophthalmic surgery. Many eye surgery centers are already humming along at a fast clip. Here are a dozen growth and efficiency secrets that some of the nation's busiest centers are anxious to share with you.

1. Work with aggressive surgeons.
At the Center for Sight in Sarasota, Fla., the 19 physicians are employees of the center. After surgical skills, the most important attribute of a surgeon is a strong understanding of marketing to a community. "We look for surgeons who are willing to be branded and put their face on a billboard," says James Dawes, MHA, CPME, COE, chief administrative officer. For the surgeon, it's all about selling yourself and your brand, says Mr. Dawes. Eye surgeons must be comfortable speaking to groups at senior centers, pancake breakfasts and other community events where prospective patients might be.

2. Get serious about marketing to referral sources.
Working closely with optometrists is an integral part of increasing cataract volume. "Work hard to be optometry-friendly," says Mr. Dawes. Surgeons from the Center for Sight meet with ODs, give continuing education and business presentations and offer support for optometrists' offices. The center also has a pair of full-time marketing professionals. One works like a pharmaceutical rep, meeting with ODs to tell them about the center and keep them supplied with educational and promotional material. The other rep is a referral concierge, working as a liaison between the eye center and the ODs' offices, making sure that everything is running smoothly.

3. Create a floating relief team.
At the Dulaney Eye Institute in Towson, Md., where about 7,600 cases will be performed this year in the center's 4 ORs, they have created a relief team. An RN and a tech run between the ORs doing whatever needs to be done, including helping with turnover and relieving OR team members for lunch or bathroom breaks. Having cross-trained relievers available helps keep the flow brisk in the ORs throughout the day, says Andrea M. Hyatt, CASC, administrator of the center.

4. Get more sterilizers.
Dulaney purchased 6 tabletop cassette autoclave sterilizers in addition to the 2 large gravity sterilizers that are set up in the substerile rooms between every 2 ORs. Having more than 1 sterilizer shortens turnaround time for reprocessing instruments and phaco handpieces. The center also has a certified OR technician dedicated to instrument reprocessing.

5. Escort patients directly to stretchers.
Once patients leave the waiting area, have pre-op nurses escort them directly to the stretcher, where they change into a gown, says Ms. Hyatt. At Dulaney, only retina patients remove all of their clothes. All other patients undress only from the waist up. Unless a patient has specific needs that would require a family member to be present in the pre-op phase, such as a language barrier or dementia, invite family members back to be with the patients only during the recovery phase. "It cuts down on the number of people in the pre-op area and lets the nurse focus on the patient, not the visitors," says Ms. Hyatt.

6. Mount monitors on stretchers.
When the monitor stays with the patient, there's no time wasted disconnecting and reconnecting the patient as he moves throughout the center. "It was an expensive investment, but one that has certainly paid off " says Ms. Hyatt. "That's been a huge time savings for staff."

7. Standardize throughout.
At Dulaney, each OR is laid out in the same manner and has a built-in wall of storage cabinets, the layout of which is duplicated in each OR. The 10 sets of cataract instruments have been standardized for all surgeons. Any additional instruments requested on a surgeon's preference card are stored in the substerile rooms in a basket labeled with the surgeon's name.

8. Evolve with technology.
When it looks like a new piece of equipment or technology can help improve the efficiency of your processes, get it, says Brad Houser, MBA, administrator at St. Luke's Cataract and Laser Institute in Tarpon Springs, Fla., which was founded by James P. Gills, MD, one of the first high-volume cataract surgeons in the country. About 5 years ago, the center bought new phaco machines with plans to use them for several years. Two years later, however, Mr. Houser and the surgeons decided to purchase the next evolution of the phaco machine because it showed promise. It was worth the added expense. Dr. Gills and the other surgeons said that the new machines saved them 30 to 60 seconds per case. When you multiply that time savings by the nearly 9,000 cases the center does each year, that's between 75 and 150 hours saved. This efficiency also improves patient outcomes because with less surgical time in the eye, there is less risk of complications such as cornea edema.

9. Don't diagnose and treat in the same day.
In a surgery center attached to an ophthalmology practice, it's tempting to set up a same-day system where the patient arrives for his first diagnostic visit and then proceeds directly to the surgery center for cataract surgery. Tempting, yes, but not always practical and very often a violation of Medicare rules.

A same-day system works well as long as each patient can be cleared for surgery that day or when there are no delays during the exams in the ophthalmologist's office. However, backups in the office or patients having to cancel surgery can gum up your OR schedule.

Medicare dictates that only under certain exceptions can surgery centers schedule and perform surgery on the same day. ASCs must notify patients verbally and in writing of their rights and the center's ownership before the day of surgery unless the procedure is scheduled the day it is to be performed and the referring physician indicates, in writing, that it is medically necessary for the patient to have the surgery on the same day. Medicare notes that cases occurring on the same day they're scheduled is expected to be rare, since ASCs typically perform elective procedures.

10. Be prepared to sell presbyopic IOLs.
Premium IOLs can make cataract cases more profitable, but they require educating the patient beforehand in order for him to choose the usually non-reimbursed lenses. At St. Luke's, the pre-surgical package includes information explaining presbyopic IOLs. When patients arrive at the office, a tech trained in presenting lens options meets with them before they meet with their surgeons, says Mr. Houser.

11. Use a pledget to dilate.
The traditional course of timed eye drops is labor intensive. Instead, create a solution of drops, and then administer them with a pledget sponge to save time. "It gives all the drugs simultaneously," says Lance S. Ferguson, MD, the founder of Commonwealth Eye Surgery in Lexington, Ky., where more than 4,100 cataract cases will be performed in 2 ORs this year. Here's how this dilation method is carried out: Place a pledget soaked in phenylephrine, cyclopentolate, tropicamide, a fluoroquinolone and an NSAID into the lower conjunctival sac of the eye. Push it down into the fornix and let it stay there for 15 to 20 minutes.

12. Use midazolam under the tongue.
The combination of topical anesthesia with tetracaine and sublingual midazolam for conscious sedation is an easy way to streamline anesthesia delivery for cataract surgery. "You save money and the patients prefer it," says Karen W. Chiles, RN, BSN, surgicenter director at Commonwealth Eye Surgery. Most patients would rather have drops of midazolam under the tongue than an IV insertion. Using sublingual midazolam saves the center the cost of syringes, catheters, tubing and saline bags. Most patients at Commonwealth Eye Surgery receive sublingual midazolam, but staff offer an IV to those that are anxious, says Ms. Chiles. The type of anesthesia that a patient will receive is determined during the pre-op work-up, about 2 weeks before the day of surgery. That way, patients who will need general anesthesia or specialized anesthesia care can be scheduled for a day when an anesthesia provider is available.

Keep trying things
Although it may seem that the nation's busiest centers have it all figured out, they don't. They're constantly experimenting, keeping the good ideas and ditching those that don't work so well.