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6 Ways That Hospitals Can Recapture Cataracts
Advice on how to compete with alternative-site surgery centers.
Yasmine Iqbal
Publish Date: October 10, 2007   |  Tags:   Ophthalmology

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.

Ensure efficiency
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.

10 Winning Ophthalmology Strategies For Hospitals And Surgery Centers Alike

Whether you're in a hospital or freestanding facility, here are 10 small and not-so-small things you can do to make your outpatient ophthalmic surgery services flourish.

1. Dedicate yourself to eyecare. An administrator who makes the success of the ophthalmology service a crusade is mission-critical. "The responsibility rests on my shoulders," says Linda Phillips, RN, the administrator for Castleman Surgery Center in Southgate, Mich., a single-specialty eye center. "I have to be able to see the big picture and always be thinking about what I can do next to bring about further improvement." When Castleman needed to raise its volume and add a second OR, Ms. Phillips set out to recruit additional surgeons, offering them shares in the surgery center.

2. Commit the facility to quality. Many surgery centers submit to quality assurance (QA) studies in a perfunctory manner as part of the credentialing process, says Gina Stancel, HCRM, CST, COA. That, she says, simply isn't good enough. An ongoing QA program is the only way to identify weaknesses and improve, says Ms. Stancel, the surgical administrator at the Eye Centers of Florida in Ft. Myers, Fla., which handles 6,000 cases per year. "We have ongoing studies to monitor all facets of our operation from patient satisfaction through visitor satisfaction," she says. Surgeons are encouraged to visit the center to watch surgery, and their reactions are recorded and analyzed. "We learn a lot about what we could be doing better by listening to these surgeons and hearing about practices that they've implemented, and I think they learn from us. When they come back for a return visit and bring some of their staff, we know we're doing something right," says Ms. Stancel.

3. Be a model of efficiency. The efficient use of resources can make or break your eye services. Castleman's newly added second OR means there's always a room ready for a surgeon. This has lead to increased volume and decreased costs. "The surgeon can go back and forth between rooms and never have to wait for set-up," says Ms. Phillips. This, she explains, lends itself to further efficiencies in staffing costs. "I don't have to have a second staff in that second OR. All we need is one extra technician to open up the table. The technician from pre-op rolls the patient into the OR, and then the scrub technician and surgeon walk in and everything is ready for them," she explains. Since opening the second OR, Ms. Phillips says overhead has decreased by about 10 percent.

4. Grow your cases, control your costs. The two key determinants for financial success of an ophthalmic ASC - or any outpatient surgery setting for that matter - are an adequate case volume and a cost- and time-sparing mentality, says ophthalmology practice management consultant John Pinto of J. Pinto & Associates, Inc. "With anything under 50 cataract cases per month, it's increasingly difficult to cash flow an ophthalmic ASC," he says. "By the same token, you can do all the cases in the county and still lose money if you don't contain costs in all areas: facility, capital equipment, supplies and staffing," he says. Above almost everything else, Mr. Pinto points out, an ASC will be a more successful business if the affiliated physicians are thrifty with their time. "It's impossible to reach standard profit margins if you can only perform one or two cataract cases an hour. Three and four cases per hour are now the gold standard, and the most efficient practices periodically exceed this tempo," he says.

5. Appreciate your staff. There's a clear advantage to showing staff appreciation - less time wasted hiring and training new employees. There's a less obvious benefit, as well - patient safety and satisfaction. Sheryl Mortweet, RN, center director of the Shepherd Eye Center in Las Vegas has been running the center for 15 years, and most of her staff has been there for at least a decade. "When we notice that someone is going the extra mile, we show our appreciation by giving her movie tickets or some other tangible acknowledgement," she says. It doesn't cost nearly as much to show nurses and technicians that they're valued as it does to replace a disgruntled employee. "These people know each other and they know what they're supposed to do. That longevity benefits the ASC in innumerable ways," says Ms. Mortweet.

6. Bask in your autonomy. Administrators who are empowered to make a surgery center be all it can be consistently take those facilities to new levels of success. "It's very important for the physician to give the administrator the freedom to do the job," says Ms. Stancel. The basis for this, she says, is respect and communication. "If the physician hired the administrator, he or she probably respects that person's judgment, and respects what the role of administrator entails. If the administrator communicates when her authority is being undermined, you can maintain an effective relationship," she says. Surgeons will gladly relinquish business and personnel matters to administrators so they can keep busy doing surgery.

7. Satisfy patients. Patient satisfaction rates high on the list of goals toward which the most successful ophthalmology ASCs aim. For instance, Ms. Phillips sends out monthly postage-paid patient-satisfaction surveys that ask if the patient's wait time was too long; if they were comfortable during their stay; if they were treated courteously; if the recovery room instructions were clear; if there were any unexpected experiences; and if they would use the service again or recommend it to others. She averages about a 25 percent return rate, with 95 percent of the returns being positive.

8. Know what's new. Ms. Stancel says her efforts to keep abreast of developments within both health care and practice management have taken her surgery center to the top of its class. "It's crucial to stay ahead of the information curve with respect to knowledge of equipment, trends and changes in coding, among other things," says Ms. Stancel. Ivan Jacobs, MD, an ophthalmologist at the Eye Care & Surgery Center of New Jersey, agrees. Besides going paperless with computerized electronic medical records, Dr. Jacobs and staff have streamlined their operation by using an integrated database of patient information to create operative charts that they e-mail to the surgical center. "The information only needs to be input one time. This lets our one secretary handle our annual volume of 1,700 cataracts, 300 Nd:YAGs and 300 various other ophthalmic plastic and reconstructive procedures," says Dr. Jacobs.

9. Control costs. Containing supply and equipment costs is key. Ms. Stancel deals with as few suppliers as possible, but never limits herself to one. "If a better price comes along, I want to have the option of taking advantage of that," she says. Tom Mitros, MD, on the other hand, deals strictly with one supplier for equipment and disposables, and says that strategy works out perfectly for the Surgery Center of Salem County, in Salem, N.J. "We have a deal that is very competitive. It's never been worth our while to switch out of our contract," says Dr. Mitros, an anesthesiologist and the administrator of the center. Christina A. Kennelley, practice administrator of the Shepherd Eye Center in Las Vegas, relies on the bargaining power of AmSurg, a partial owner of the surgery center. "AmSurg is a publicly held company that has partnered with more than 100 surgery centers - most of which are ophthalmology or GI centers. With that kind of buying power, we can count on them negotiating pretty favorable costs for us," she says.

10. Be prepared. Dr. Mitros says preparation equals safety and success. "The more prepared you are and the fewer distractions or delays there are on the day of surgery, the more efficient the unit runs," says Dr. Mitros. "It's not only about quick turnover time. If the patient goes home with the wrong IOL, it really doesn't matter how quickly the procedure was performed," he says.

Ms. Nataloni ([email protected]), a freelance writer specializing in ophthalmology, lives in Sewell, N.J.