In an experienced surgeon's hands, shoulder arthroscopies can be speedy and profitable procedures for your facility. But your surgeons aren't the only link in the patient flow chain. From a surgeon's point of view, an OR's personnel, equipment and schedule are also critical factors that, managed correctly, can boost the overall efficiency of an arthroscopy caseload. Here's how.

Team spirit
If you're going to perform efficient arthroscopies, you need a core of dedicated, experienced individuals on the case to provide continuity in support and patient care.

Personnel issues can be politically sensitive, especially in smaller facilities, and I certainly don't mean to suggest that not every employee who works in your ORs is qualified to staff arthroscopies. Consider, though, that shoulder procedures are technically demanding, a specialty unto itself. It's uncommon to see an orthopedic surgeon with equal experience in shoulders, knees and other joints. Plus, your facility very likely takes seriously its responsibility to ensure that its surgeons are trained and capable.

Imagine, then, the advantages to be gained if a surgeon performs a series of shoulder arthoscopies with team members who not only have a solid understanding of the procedure, but whom the surgeon works with on a regular basis.

A surgical team assembled with experience and continuity in mind - as opposed to the rotating slate of support staff that one might encounter in a large, multi-specialty operating theater - can pay off in pre- and post-op efficiency, case time management and quick room turnovers.

For example: Given the importance of precisely controlled anesthesia to ambulatory surgery and patient recovery, an anesthesiologist who has a good working relationship with the team will instill the surgeon with confidence in his support, while changing faces at the anesthesiologist's end of the table may forfeit any consistency in anesthesia administered.

Or: A circulating nurse with sufficient experience in arthroscopy and familiarity with the surgeon's work habits is a safeguard against the random assignments of nursing shifts and their associated barriers to full involvement in a case - as when the dreaded three o'clock mark arrives in the OR. You can't have your people punching a clock.

Working with a consistent staff also promotes a culture where individuals can work together efficiently. In hospitals, especially larger ones, individuals can end up working in their own silos, focusing mostly on their own spheres of influence. Nursing's only interested in nursing, for instance, and anesthesia's concern is what anesthesia does. Unless you walk through the daily events of your facility, you may not see this. But team members who work together regularly may be more able to break down these walls and communicate as a team.

Enough equipment
Perhaps nothing contributes more to efficiency in shoulder arthroscopy procedures than adequate capital investment in a facility's equipment. Whether it's scopes, electronic tools such as shavers and suctions or trays of instruments, you'll want to have enough equipment to be able to handle a day of cases without waiting for it to return from reprocessing and with backups available in the event an item should fail.

I do 10 shoulder arthroscopies in a day, walking back and forth between two ORs, and there's a full set of equipment waiting in each room when I get there. At our ASC, we've worked it out so there's enough equipment to cycle through the cleaning process while also continuously serving cases in the OR.

To a surgeon, one major barrier may be whether administrators are willing to accommodate this extra equipment planning into their budgets. Purchasing can be frustrating. But if they endorse efficiency, the ability for surgeons to perform a series of procedures without stopping should convince them.

When considering purchases, administrators and their materials managers should keep in mind that many physicians have built closer relationships with vendors than their facilities have - or, alternatively, vendors remain keenly interested in physicians' needs - and, as a result, physicians can often leverage better discounts on equipment and instruments. Facilities need to understand that that bargaining power exists.

The game is partially hardball: We tell them that we're only purchasing from one vendor at this facility, so they can either be in or out, and see if they'll meet our price.

But it also requires a unified front from the physicians. Who gets to choose the preferred vendor? You have to come to an agreement. We formed an executive committee to decide the issue. Of course, surgeons who have equity interests in the facility had more influence in the eventual decision than visiting surgeons who play a smaller role in its operations. The committee's decision probably can't make everyone happy, but perhaps everyone can be equally unhappy.

When surgeon preferences meet economic impact, the options are carefully priced out, but when the purchase is capital equipment, service is also an issue. Which vendor has been most responsive? Which has been at your facility when you needed repairs or replacements? That can seal the deal.

Scheduling strategy
A review of the case lineup by the surgeon, anesthesiologist and circulating nurse before the day of surgery can help a surgical team to schedule how a series of shoulder cases might be most efficiently ordered, depending on the number of ORs and the equipment they'll have available to them.

Scheduling same-side shoulders consecutively in one room to minimize the repositioning of equipment and cut down on room turnover time is one basic solution that will also reduce staff fatigue.

The type of anesthesia expected to be used in each case is another way to stack the procedures. Patients undergoing general anesthesia are in the OR early to allow for their longer recovery times, while those treated with local anesthesia and peripheral nerve blocks can be taken later in the day.

You can also group cases by level of difficulty in order to maximize OR utilization. In short, don't schedule a quick and easy procedure next to a more difficult and time-consuming one, as it may not leave enough time for a room turnover or for a complete instrument reprocessing cycle, in addition to leaving an OR standing empty for a long period of time.

If, as I'd recommended above, the surgeon is working with the same anesthesiologist, circulating nurse and scrub tech each time, he may be confident enough that his staff members are familiar with his preferences and priorities in scheduling procedures that the dialogue that builds a day's strategy doesn't even have to involve the surgeon. We can rely on our team.