Benchmarking is a great way to quickly analyze data, track your surgical facility's progress and identify opportunities for improvement. But there are so many benchmarks to measure in surgery and only so many hours in the day, so how do you know which numbers matter most? We asked a panel of industry observers for their views on the most important business and clinical measurements as well as for a recommendation of the numbers to aim for.

Days in AR: 33 to 35
"AR days are a big deal," says Ann Geier, RN, MS, CNOR, CASC, vice president of operations for Ambulatory Surgical Centers of America in Mount Pleasant, S.C. "That's an indication of how many days before you're getting paid, if you're getting paid."

As recently as 5 years ago, the industry average for accounts receivable hovered around 47 to 53 days, she says, but "electronic billing has made a huge difference." Now, however, "I'd say 33 days or fewer because I know it's achievable," with 28 or 29 days even better.

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As with any benchmark, there are variations. John J. Goehle, MBA, CASC, CPA, the chief operating officer of Ambulatory Healthcare Strategies in Rochester, N.Y., says he's seen an average of 45 days, with orthopedic practices at 59 and some single-specialty facilities at 36.

"In today's electronic billing environment, we should expect to be below 40 days, perhaps around 35 days," he says. "The benchmark data reflects a national average and would reflect a range of organizations." Out-of-network facilities, for instance, would see more days in AR than the average, while those who rely heavily on Medicare or in-network contracts would see fewer. "An organization should use the benchmark to determine when it's time to start analyzing their receivable situation," he says.

One possible upshot of that analysis may be bulking up your business staff, notes Ms. Geier, who credits ASCOA co-founder Tom Bombardier with this solution. "You may think you have too many people in your business office," she says, "but if your AR days are climbing, hiring a staffer to do nothing but collect will pay for herself 10 times over."

Current AR: 50% or more
The amount of current accounts receivable money (that is, under 30 days) indicates how well your business office operates, and it should be high. Ms. Geier notes that the industry average is about 50%, but that the average among ASCOA's facilities is 68%. "We are very aggressive in collections," she says.

"Administrators need to know what is in the current bucket," she says. "What they shouldn't see is a large amount in the 61- to 90-day range or older. They'll have a lot of trouble collecting that."

Says Mr. Goehle, "Higher percentages (of older AR) would indicate that either old receivables are not being collected, or no one is working and cleaning up older receivables." According to his research, the national average of AR balances aged over 121 days is 12.39%.

As with days in AR, out-of-network billing or a schedule heavy with workers' comp cases will increase collection times. As for the other side of the ledger, accounts payable, "We want everything current, within 30 days," says Ms. Geier. "When bills come in, we pay them."

Supply costs: 19% to 20%
As a percentage of collections, supply costs average at 19%, say Ms. Geier and Mr. Goehle, but not without caveats. First, says Mr. Goehle, breaking down case costs by specialty will deliver widely varying results. While GI's supplies average 7% of net revenues, ophthalmology's total to 34%.

Second, breaking down case costs by specialty will also provide differing collections for comparison. "Historically, the best practices for this measure (which includes implants) has been 20%," says Mr. Goehle. "Perhaps it is time to revisit whether 20% is still a 'best practice,' [since] costs have been declining as a percentage of net revenue since the major changes in reimbursement have occurred over the last 4 to 5 years.

"With this particular ratio," he says, "it is best to follow the percentages by specialty."

Overall, though, "you shouldn't be spending more than 22% of collections" on supplies, says Ms. Geier, who recommends weekly or monthly case costing reports incorporating 100% of cases, not just a random sample, as a key step in controlling costs. If you don't know you're overspending until long after the fact, she says, it's difficult to make changes to the process.

Staffing costs: 20% to 22%
As a percentage of net collections, staff salaries and wages should roughly equate to that of supply costs. The industry-wide average is 21%, and Mr. Goehle says this figure doesn't swing widely from specialty to specialty, with orthopedics seeing 17% and single-specialty centers 22%.

"This average provides guidance on how efficient your organization is with regard to staffing," he says. "Best practices for this ratio have traditionally been about 20%. Organizations that are in highly managed care markets might find it difficult to get down to the average, whereas organizations in markets with higher reimbursement will often be below 20%.

"Use this statistic as a guide and, more importantly, track it over time to see how it changes within your organization," he adds. "Take steps to reduce staffing costs when they remain higher than your average for extended periods of time."

Toward that end, Ms. Geier recommends the use of per diem employees and sending staff home when your surgical schedule's completed for the day. Also, compress that schedule. "The worst thing you can have is 2 cases scheduled for 7:30 a.m., and the next at 1 p.m.," she says. "Then you're paying your staff to stand idle."

Man-hours per case: 6 to 8 (depending)

Another staffing statistic that many management companies track as a key indicator is clinical man-hours per procedure. This figure, which offers a different view on employee cost efficiency, is calculated by totaling up all the hours your clinical staff (circulator, scrub tech, pre-op and PACU nurses, perhaps your materials manager) has worked during a set period of time, then dividing that sum by the number of cases performed during that time.

Adding the hours from sick days, vacation days and other non-productive time into the original sum can show you the total hour expenses per case. At a multi-specialty facility that handles longer cases, clinical man-hours per case may average from 6 to 8, says Ms. Geier, though centers specializing in eye surgery, GI and pain management may see lower numbers such as 3 to 5.

Of the center's employees, you're only counting clinical staff hours, since your business office personnel are a fixed cost who aren't dismissed with changes in the surgical schedule, says Ms. Geier. As man-hours per procedure can fluctuate over the short term due to scheduling, case volume, the punctuality of your physicians and anesthesia providers, the availability of per diems in your area and other factors, it's advisable to track this average over a longer time, such as a quarter.

Room turnover time: 7 to 10 minutes
OR times for surgical procedures vary depending on the types of cases performed, variables that resist across-the-board comparisons, and the techniques of the surgeons performing them, which are difficult to standardize. For instance, according to recent studies from the Accreditation Association for Ambulatory Health Care's Institute for Quality Improvement:

• cataract extractions with lens insertions ranged from 6 to 35 minutes (with a median of 13 minutes);
• colonoscopies ranged from 8 to 37 minutes from scope in to scope out (median 17 minutes);
• knee arthroscopies with meniscectomies ranged from 17 to 74 minutes from incision to dressing on (median 27 minutes); and
• pain management injections in the lower back ranged from 3 to 19 minutes (median 8 minutes).

The variability of OR times makes between-case room turnovers a critical area for schedule efficiency, says Ms. Geier, whose company has timed an average of 7 minutes for short cases and 10 minutes for longer ones. "Those times are not always achievable," she says, "but they're the averages."

A 10-minute turnover time is indeed a reasonable goal. Forty percent of the 710 facility managers we polled last month turn rooms over in 10 minutes; 21% do so in 15 minutes, 20% in 20 minutes, 9% in 25 minutes and 10% in 30 minutes.

Infection rate: close to zero
In terms of clinical practices, the differing types of surgical procedures, preparations, levels of invasiveness and physician technique make it difficult to establish an apples-to-apples multi-specialty benchmark, admits Naomi Kuznets, PhD, senior director and general manager of the AAAHC Institute in Skokie, Ill. The incidence rate of surgical site infections, however, does provide a universal standard of comparison: it should be as close to zero as possible.

Overall, the ideal rate is very low, about 0.1%, says Jennifer Green, vice president of network development at Surgical Outcomes Information Exchange in Richmond, Va. Some specialties, such as gynecological, urological and orthopedic surgery tend to be slightly higher, but an SSI rate shouldn't be above 0.5%.

Determining this rate is a job in itself. Whether a patient suffers a superficial wound infection a week or 10 days after surgery, or a deep infection within a joint emerges months later, they'll be out of your care by the time the complication presents.

"How are you tracking patients and post-op infections?" asks Ms. Green. "What type of follow-up do you have in place? Do you have a way to know if a patient is admitted with an infection within 6 months? Is there a mechanism to identify the patient as one of yours? Will your surgeons tell you?"

As each facility is unique, there is no absolutely foolproof way to track post-op infections, she admits, but patient and physician reporting as well as open communication between healthcare facilities in your area are key. "You've got to go as far as you can go," she says.

On the other end of the perioperative process, and the other end of the percentage scale, your pre-op staff should be administering antibiotics to surgical patients within 1 hour of incision 100% of the time. This major infection prevention effort (mandated by the Joint Commission and Surgical Care Improvement Project) ensures that the drug is adequately present in surgical site tissue during and immediately after the case. It should be noted that vancomycin and fluoroquinolones are to be delivered within 2 hours, with the patient closely observed for adverse reactions.

Medical errors: zero
They're called "never events" for a reason, and if there's one inviolable rule of patient care, it is "do no harm." "You don't want your patient to leave you worse than they came in," says Ms. Kuznets. Your incidences of medication errors; deaths or disabilities from patient falls; retained objects; or wrong-site, -patient or -procedure surgeries might be at zero. "If you're not at zero on those, striving for zero is important," says Ms. Kuznets. "If you are, doing everything you can to remain at zero is important."

Remember, though, that "just because you haven't had a wrong-site surgery doesn't mean you can't have one," she says. Precautions such as the Joint Commission's Universal Protocol must be followed without fail. There are, however, clinical contingencies that in many cases shouldn't be zero. A hospital transfer rate of zero is not as reassuring as it may initially seem, says Ms. Kuznets. "That means you may have sent the patient home just to go to the hospital later," she notes. "With emerging cardiac issues, to name an example, you do want to send that patient to the hospital."

Post-op pain is another such area. "Never expect to see zero pain," says Ms. Green. "But you should be able to gauge changes. If the patient can't tell their provider if their pain has been dealt with, or whether it's gotten worse, that's a cause for concern."

The big picture
Simply tabulating statistics, printing them out, comparing them to national averages and keeping them in a binder to show accreditors is a waste of effort, says Ms. Green. Instead, you should be consistently putting those numbers before surgeons and staff and emphasizing why they're important. "Document what you can do and what you have done to improve, and show that to your accreditors," she says. "If we have to measure, let us do it in a way that is going to help us."

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