INSIDE THE NUMBERS
Readers Reveal Efficiency Facts

ALWAYS READY Thirty-one percent of facility managers have 5 or more instrument sets per OR.

SOURCE: Outpatient Surgery Magazine
Reader Survey, December 2012, n=128

FRONTLINE FEEDBACK
What Makes Eye Centers Tick?

EYE CHART Ensuring the right implants are always available will avoid unneeded delays.

We surveyed managers and administrators at leading eye facilities for their best tips on improving cataract efficiency. Here's what some of them had to say.

• Room turnovers. Billi Benson, BSN, administrator of the Columbus (Neb.) Surgery Center, employs 3 scrub techs to speed room turnovers: one to assist the surgeon during the current case, one to clean instruments used during the previous case and one to set up supplies for the following case, during which she'll assist the surgeon. They run that cycle all day, rotating through roles and turning over rooms together. (Ms. Benson also stacks right and left eyes in the surgical schedule so her staff doesn't have to flip equipment from one side of the room to the other between cases.)

Ensure every member of your clinical team has specific roles during room turnovers. For example, at the end of each case at the Physicians' Eye Surgery Center in Charleston, S.C., the circulator administers post-op eye drops, removes the surgical drape and moves the patient to recovery; the scrub tech cleans instruments and takes them to the reprocessing area; and a dedicated turnover nurse cleans up the trash, wipes down the room's surfaces and begins opening supplies for the next case.

• Implant inventory. Jackie Dayton, RN, nursing supervisor at the Surgery Center of Ophthalmology Consultants in Fort Wayne, Ind., keeps an inventory of 6 to 8 lenses per diopter, from +6.0 to +30.0. She works a week ahead on the surgical schedule to ensure they have the needed implants on site, which means she pays standard shipping costs instead of incurring overnight costs when getting lenses delivered to the facility.

• Instrument sets. Have enough instruments to match your case volume and the speed of your surgeons, says Sarah Hilligoss, RN, BSN, clinical director of the Prairie Surgery Center in Springfield, Ill. "Our surgeons complete cases in 5 to 10 minutes," she explains. "We have at least 7 cataract trays so we're never waiting" around for sets to come back from reprocessing.

Carol DeFillippo, MPS, RN, CNOR, outsources her hospital's cataract cases to a company that brings in enough equipment, staff and instruments to support 2 cataract rooms running at full speed. The director of operative and perioperative services at Wilson (N.C.) Medical Center says the outsourcing firm — which saved her facility from pouring hundreds of thousands of dollars into a cataract service line — says the company provides 8 instrument sets for the 24 cases the hospital hosts between 7:30 a.m. and 4 p.m. Ms. DeFillippo emphasizes that's enough to reprocess instruments between cases so no item undergoes immediate-use sterilization simply for efficiency's sake.

• Stretcher chairs. "Transporting patients on a single surface from pre-op to post-op on a day filled with 15 procedures can save you 30 minutes," says Scott Wilson, materials biomedical manager at the Center for Surgery in Encinitas, Calif. Many survey respondents agree that stretcher chairs help keep a cataract schedule on track because time isn't wasted transferring patients from one surface to another, and they're already positioned properly and adequately warmed as they're wheeled into the OR.

One facility manager mounts mobile vital signs monitors to stretcher chairs. The same monitor rides with patients throughout all phases of care, so staff don't have to disconnect patients from and reconnect them to stationary monitors in pre-op, the OR and PACU.

• Attitude. Do you think many hands make for light work? Not so, says Lisa Fields, administrator of the Eye Surgery Center of Augusta in Georgia, who likes to keep her surgical team lean and mean. "Overstaffing gives everyone a carefree, time-to-spare attitude," she says. "Adequate staffing puts everyone in a busy position so the flow of the day is smoother."

Would recruiting surgeons who operate faster improve cataract efficiency? Maybe, but many respondents say most surgeons operate at comparable speeds. For most facility leaders, greater efficiency is a mindset. "I think it's a matter of the entire team, including the surgeons, working together to provide quality care in a timely manner," says Mary Radke, RN, BSN, manager of the Dakota Surgery and Laser Center in Bismarck, N.D. She believes surgeons willing to lend a hand between cases are far more valuable than docs who pride themselves on operating quickly.

Case in point: The physicians at Perimeter Surgery Center in Cookeville, Tenn., are actively involved in turning over rooms, according to Ginny Tayes, the facility's director. While the scrub nurses and circulators work to get rooms ready for the next case, the docs take dirty instrument trays to the autoclave, bring back clean sets, spike BSS bottles and help scrub nurses open wrapped supplies on the back table when time permits.

— Daniel Cook

FALSE ALARM
Cataract Anesthesia Denials Cause Stir

Nurse anesthetists sounded the alarms last month when CRNAs began receiving denials from Medicare intermediary Noridian on claims for anesthesia care delivered during cataract surgery (CPT 00142) that didn't include documentation of medical necessity.

Several CRNAs we spoke to contacted Noridian's medical director, Bernice Hecker, MD, MHA, FACC, who assured them the new medical necessity requirement was a mistake. "She apologized for the error, and said they would be taking a closer look at their processes to figure out how it happened, and how to avoid similar errors in the future," says Jay Horowitz, CRNA, owner of Quality Anesthesia Corporation in Sarasota, Fla.

Dr. Hecker says a scheduled edit update was associated with the problem. "We took urgent action to terminate the edit when providers alerted us to the potential of inappropriate denials," she explains. At the time of publication, Noridian planned on beginning payment adjustments to claims on Jan. 8, and expected the process to take about 10 days to complete.

The hubbub might have been much ado about nothing, but perhaps not without good reason. Wary anesthetists were aware Noridian stopped reimbursing CRNAs for pain management procedures in 2011, only to have CMS reverse the policy change a year later.

There's still a lesson to be learned in Noridian's oversight, says Dan Simonson, CRNA, MHPA, chief anesthetist and managing partner at the Spokane (Wash.) Eye Surgery Center. He claims the company's lower-level support staff told concerned providers that the policy change was planned, and that they'd have to accept it. "How did this mistake get through their system, and why were the support personnel so sure it was correct?" he asks.

That shows the importance of maintaining good relationships with the carrier medical directors at your largest insurers, says Mr. Simonson. "You don't have to be satisfied with the response from low-level employees on matters of this importance," he adds. "Medical directors of insurance companies are usually the 'court of last response' on denials, but because they are providers themselves, they're often far more knowledgeable and reasonable than the company's administrative staff."

— Daniel Cook

INSTAPOLL:
When did you last flash-sterilize an instrument?

Source: Outpatient Surgery Magazine InstaPoll
(www.outpatientsurgery.net), InstaPoll, October 2012, n=371