TOOL TIME While controlling costs is key to efficient retina surgery, current technology can speed the process.

Adding retina surgery to your case mix can make sense for many reasons. The procedures will expand your ophthalmic business. Your surgeons will benefit from your flexible schedule and consistent staffing. And patients will appreciate the convenience and comfort you provide. But all of these advantages depend on whether the retina surgeries you host can be done efficiently. We asked administrators whose ORs see a high volume of retina surgeries for their best advice on keeping these cases moving. Here's what they told us.

Are you ready for retina?
First of all, bringing retina services on line at your facility means more than just buying your surgeons a vitrectomy machine and a tray of specialized instruments. Alex Stockdale, MBA, administrator for Knoxville, Tenn.-based ophthalmology practice Campbell, Cunningham, Taylor & Haun, suggests you ask these 4 questions:

• Does it complement our facility? It should go without saying that eye-only centers or multi-specialty centers with significant ophthalmic offerings are best suited, from a clinical and business standpoint, to take on outpatient retina.

• Do we have the time available? Retina can be time-consuming as well as financially costly. Don't displace your longtime revenue generators — busy cataract surgeons or other short, high-volume cases — from the schedule to chase new prospects.

• Do we know efficient surgeons we can work with? More than anything else, retina services — and particularly, retina services done efficiently — rely on surgeons who are both technically skilled and economically efficient. More on this later.

• Do we have the patient population? "You can make money at retina with sufficient volume," says Mr. Stockdale. "It's about 100 cases a year to break even."

There is, administrators admit, a go-big-or-go-home aspect to retina surgery. "If you're going to do retina, you have to commit to retina," says Vonnie Thomas, RN, coordinator for ophthalmology at the Andrews Institute Ambulatory Surgery Center in Gulf Breeze, Fla. If the answer to each of the above questions is "yes," it may be a lucrative possibility.

Recruit the right talent
While retina surgery techniques are one particular set of skills, outpatient surgery efficiency in the OR is an entirely different mindset. You'll need to recruit specialists who have mastered both to keep your cases on time and under budget.

"It's really important for the surgeon to be efficient," says Lou Sheffler, MPS, chief operating officer for Somerset, N.J.-based American Surgisite Centers, which manages 12 eye ASCs.

With regard to retina, efficiency means completing cases in 30 to 45 minutes, thanks to the use of small-gauge techniques. It means an awareness that you're in a cost-sensitive environment and controlling your use of supplies, OR time and staff accordingly. "The trick of running retina in a surgery center is vetting the surgeons you bring on board," says Mr. Sheffler. "This saves you the pain of finding your surgeons are sinking you with costs and time."

So how can you recruit the most efficient surgeons? You've got a few options. "Retina docs get their business from cataract docs," he says. "Canvass your cataract docs for suggestions. Who do they refer retina cases to? Who do they respect to get good results?"

You could contact professional organizations, such as the American Academy of Ophthalmology, American Society of Retina Specialists or Outpatient Ophthalmic Surgery Society, to find out which MD members are nearby your facility.

But perhaps you might also consider asking your local Alcon and Bausch & Lomb reps about the surgeons they're visiting. "The information's out there, and you can get it," says Mr. Sheffler. "It may not be in-depth, but if a new doctor arrives in the area, maybe the rep can offer some insight along the lines of, he's very busy, he does a lot of cases."

"Retina is a small world," says Mr. Stockdale, and vetting surgeons as possible recruits can net useful information, but you still must see them in person, in action, either in your ORs or at a hospital. "The most important thing is, are people going to feel comfortable working with this surgeon? Is he a team player?" he asks. Even a surgeon who is superhumanly efficient will soon cause problems if he is miserable to work with. "It comes down to, administrators, anesthesia providers and staff should spend some time with any surgeon you're considering."

The eye in team
A highly efficient surgeon's productivity might be hampered, though, if he's not supported by a well-trained staff. "Efficiency is about being ready and having things ready for the doctor," says Mr. Sheffler. "A circulator, a scrub nurse and a tech charting, operating machinery, introducing new instruments, knowing what's needed in the event of unplanned situations. Step-by-step doesn't just automatically happen: It's a trained ballet."

For staff, the necessary knowledge for a case might not be directly transferable from what they're used to. "Retina surgery is very different from cataract surgery," he says. "They're both eye surgery, but you might as well be operating on a different part of the body. There's radically different anatomy, machinery and setup involved. With cataracts, it's easy to tell what's going on through the video monitor. But retina's in the back, you can't always follow it from the video.

"Obviously, if a surgical staffer has never done a retina procedure with a surgeon, she's not going to know exactly what he wants, and that time gap can be awkward and slow" from setup through closing, says Mr. Sheffler.

For best results, train staff members specifically for retina surgery and assign that dedicated team to all retina cases, he says. If you have diligent, ambitious OR personnel eager to learn something new, schedule them some one-on-one time with the surgeon, who can explain what he's doing in a retina case. Visiting the hospital to watch the surgeon do cases there is another good way to get started. Additionally, manufacturers' reps can often teach in-service classes on the equipment used in the procedures.

Alternatively, you could bridge the gap between retina surgeon and OR staff with ready assistance. The Cleveland Eye & Laser Surgery Center employs physician assistants to serve its surgeons. "Having an experienced person you work with all the time helps to facilitate surgery," says Warren Laurita, administrator of the Fairview Park, Ohio, facility. These surgical assistants set up vitrectomy and laser equipment, position and prep patients, and handle other tasks within the scope of the licensing limitations of a PA. "Our surgeons do the majority of their cases here, but they do some in other surgery centers," says Mr. Laurita. "For the cases they do elsewhere, they bring their surgery assistants, so they're working with the same people wherever they go, and don't have to rely on other staff."

RIGHT-HAND MAN David G. Miller, MD, performs surgery at the Cleveland Eye & Laser Surgery Center with surgical assistant George Michael Carson, PA.

Managing patients and schedules
Retina surgery, says Mr. Stockdale, is "conditionally profitable." While efficiently performed simpler procedures can be a good fit for outpatient surgery facilities, more complicated cases can (through OR time and supply and staffing costs) absorb the facility reimbursement offered. That's why patient selection and selective scheduling are key to efficiency.

"It's always a bit of a balancing act," says Mr. Stockdale. It's not the soundest strategy for a surgery center to load up its schedule with complicated, hospital-worthy cases that risk losing it money. Conversely, however, the facility that rejects enough of these cases risks alienating its surgeons.

What is required is routine open discussions on case selection, to ensure that administrators, surgeons and anesthesia providers might voice their concerns and reach an agreement on patient conditions and case costs. At the Andrews Institute ASC, once the surgeon chooses the case, the pre-assessment nurse has the latitude to red-flag the patient if, for instance, the patient has a high body-mass index, is oxygen-dependent, has a respiration O2 level below 90%, has suffered a recent cardiac event or a long history of reflux. In the event that such cautions are raised, the surgeon and anesthesiologist decide whether the case should be performed there.

When a retina case is scheduled, especially one that's more complex in nature, it's advisable for it to be scheduled for the morning, says Mr. Stockdale. Contingencies such as retinal detachments, endophthalmitis, lens issues and other unexpected add-ons can lengthen a case, and they can easily push recovery and discharge past the end of the day if they're encountered during the afternoon.

If you can afford to reserve 2 ORs for 1 surgeon, scheduling a mix of simpler and more complex retina cases in both and letting him "flip" between them (as many cataract surgeons do) can boost efficiency by virtually eliminating the impact of room turnover time, says Terri Gatton, RN, CNOR, CASC, administrator at the Andrews Institute ASC.

While there's 1 retina surgeon at work, there are 2 anesthetists, 2 vitrectomy machines and 2 sets of OR staff, 1 in each room. "When we reach a certain point in the case, toward the end, we call out of the room to the anesthesia provider, who starts the next block," says Belinda James, RN, BSN, clinical director at Andrews. "There's always a patient ready to go." What's more, she says, the patients are on convertible stretcher-table-chairs, so they're able to go from admission to discharge without the heavy lifting of patient transfer.

Economy and efficiency
Once surgery gets underway, the efficiency ball is largely in the surgeon's court, says Mr. Sheffler, although it must be noted that technology advances in the latest equipment not only attract surgeons to your ORs, but also speed them up while they're there. Vitrectomy machines that are easier for your staff to set up and cutters that operate faster and aspirate better can, in skilled hands, potentially reduce the amount of time it takes to complete a procedure.

Room turnover and setup revolve in part around the reprocessing of instruments. Purchasing multiple trays of instruments, enough to supply the number of cases that can be performed during a reprocessing cycle, can make sure that case delays due to instrument shortages are not an issue. Not everything's reusable, though. While older retina instruments tend to be, says Mr. Sheffler, more and more newer ones are single-use, in order to ensure that the surgeon has the sharpest, best-operating tool in his hand for each case. This stands to speed turnover, since there's no worries about reprocessing, but it does affect the supply budget.

The cost-conscious mindset that your outpatient retina surgeon must adopt will ideally prevent them from unnecessarily asking for higher-end disposable supplies. If they determine a need for them, however, your staff can hold the bottom line by not opening them until they are requested, says Ms. James. "We can easily open them at the field."

Whether the subject is equipment, instruments or supplies, standardization is not only an economical and organized solution, but an efficient one as well. "The more you have people demanding many particular kinds of drugs, the more variety of supplies to pull, the more disruptive a process it is for your staff," says Mr. Laurita. "Getting everybody to work the same eliminates the cost of duplicative equipment and supplies, and creates a known routine for staff." While standardization depends heavily on the flexibility of your surgeons, the consolidation can result in negotiating power.