Cataract surgeries seem to be tailor-made for ambulatory surgery centers - patients are generally healthy, the procedures usually take only minutes to complete and recovery time is usually less than a half-hour. But that doesn't mean that hospitals should cede these cases to alternative surgery sites. We asked experts who've helped build successful cataract surgery programs for advice on how to increase volume, ensure efficiency and maintain profitability in the hospital setting.
Keep cataracts separate
Hospitals that do a high volume of cataracts generally keep them separate from the rest of their outpatient cases. One such facility is Swedish Medical Center in Seattle, which has an eye surgery center in a medical office building adjacent to the hospital; they host about 2,000 cataracts a year. At Methodist Hospital, in Houston, cataracts are done in a hospital-based ASC that is physically connected to the hospital; within the ASC, a suite of ORs are used only for ophthalmic cases, including about 1,200 cataracts a year. If you can't designate rooms for these cases, you may want to limit cataract procedures to specific days.
As freestanding centers know, keeping cataracts separate is important for many reasons:
- it ensures that surgeons aren't bumped for more emergent cases;
- it keeps the staff focused and helps expedite patient flow; and
- it ensures that these patients aren't lumped in with patients much more ill than they are.
Provide a core group of experienced staff
"It's really important to have staff that know the procedure," says Robert Arleo, MD, an Ithaca, N.Y.-based ophthalmologist. "Nurses need to anticipate what the surgeon needs, know the nuances of the equipment and be able to troubleshoot it, if necessary." When Dr. Arleo operated at a hospital (he now operates in a hospital-owned surgery center), he assembled a core group of nurses and, with the help of knowledgeable sales representatives, trained them in the particulars of the procedure and the equipment.
Gloria Jimenea, clinical supervisor at Methodist Hospital, also has highly experienced nurses - some of them have been doing ophthalmic procedures for 30 years - but she also makes a special effort to pinpoint and train new nurses who express an interest in ophthalmology.
Dr. Arleo notes that it's important that nurses are familiar not only with cataract procedures in general, but also with individual surgeons' needs. When he does procedures, for example, he wants patients positioned and prepped, but he prefers to load his own implants and drape the patient himself. "Different surgeons have different comfort levels with delegation," he says.
Offer the right equipment
"While you don't necessarily have to have the newest technology," says Kelly Malone, the director of ambulatory surgery programs at Swedish Medical Center, "it does need to be the right technology." At his hospital, he takes pains to involve surgeons in the equipment selection process. "When we're in the market for a new phaco machine, for example, we try multiple models and have a lot of group discussions with surgeons before we decide."
Pay attention when surgeons express a strong desire for trying a new piece of equipment. "Hospitals need to be flexible and think long-term instead of trying to force a certain piece of equipment down a surgeon's throat," says Dr. Arleo. "It pays to get surgeons something they're comfortable with."
If you have the means, offering equipment with the newest bells and whistles will certainly help attract surgeons to your facility. Ms. Jimenea says two of the reasons surgeons prefer Methodist Hospital are the ceiling-mounted microscopes and state-of-the-art phaco machines. The hospital doesn't offer block time and competes with another nearby hospital and freestanding surgery center, but cataract volume is steadily increasing nonetheless.
Stealing another page from ASCs, hospitals with high-volume cataract programs take steps to ensure that their pre-op, operative and post-op processes are highly efficient. Our experts offered these tips:
- Offer a one-stop shop where patients can register, have their labwork completed and have their pre-op workups done before they go into surgery.
- Don't require patients to disrobe completely; in most cases, they can stay in their street clothes and don caps and shoe covers.
- Eliminate patient transfers by keeping patients on stretcher chairs, which they can stay on from pre-op to post-op.
- Ensure proper patient positioning by marking the floor of the ophthalmic ORs so the staff knows exactly where to place the stretchers.
- Eliminate a surgeon's downtime between cases by setting up two rooms back-to-back, so he can move immediately from one room to the next. If you don't have two rooms, make sure you have enough staff on hand to help turn over the room quickly.
Treat patients as valued customers
One of the reasons ophthalmologists prefer doing cataracts in alternative-site facilities is the way their patients are treated by the perioperative staff. "It's really important to remember that these patients aren't sick," says Dr. Arleo. "They need to be taken care of like they're walking into Macy's." It's critical that everyone from the front-office staff to the recovery nurses has a customer-focused attitude, and it helps if you have enough staff on hand to provide patients with extra TLC, he says.
Stephen Lane, MD, who performs cataracts at two hospitals and is president of the American Society of Cataract and Refractive Surgery, agrees. "Patients shouldn't feel like they're in the hospital for major surgery," he says. Little things - such as offering a warm blanket, allowing families to stay with patients for as long as possible, providing relaxing music in the OR and offering a post-op snack - mean a lot to these patients, as well as their surgeons.
The staff at United Health Services Hospitals in Johnson City, N.Y., has instituted "service recovery tools" to placate patients when things don't go as well as planned, according to Gail Thalacker, the director of surgical services. For example, if a patient's surgery is delayed, the staff is trained to provide them with extra attention and use key phrases, such as "I'm listening" or "I have the time for you" to make a connection with him. They can also offer consolation gifts, such as gift certificates to a local restaurant, to help mollify ruffled feelings.
If you don't want to invest in staff and equipment, you can contract with a cataract outsource company that'll provide the capital equipment, supplies and certified surgical technicians who turn over the room and troubleshoot the equipment. These services offer volume purchasing power, marketing assistance and access to new technology. In exchange for a capitated per-procedure cost ($400 to $500 per case), you can perform cataract cases without any capital investment or risk.
Worth fighting for
Whether you adopt all these strategies or just a few, there's no reason for hospital-based facilities to give up on cataracts. "Many hospitals send the message to surgeons that they can't make money from cataract surgeries," says Dr. Arleo. But this simply isn't true. "If you have the ORs, equipment and staff and can do these cases efficiently, these cases can be a cash cow," he says.