Welcome to the new Outpatient Surgery website! Check out our login FAQs.
How Does Your Cataract Service Compare?
Check out these national benchmarks and ways to improve the areas where you're lacking.
Daniel Cook
Publish Date: October 27, 2008   |  Tags:   Ophthalmology

We wanted to know how you keep your cataract services running smoothly and economically. We also wanted to provide you with national benchmarks in a few performance categories so you can compare your ability to attract surgeons, control supply costs and streamline patient flow against some of the nation's best performing facilities. The Outpatient Ophthalmic Surgery Society recently concluded its baseline benchmarking survey of 62 ophthalmic surgery center facilities. Here are just a few of their findings and some tips on how you can improve those areas in your facility.

- 2,000 to 4,000 sq. ft. facilities = 5.93 minutes
- 4,500 to 6,500 sq. ft. facilities = 6.6 minutes
- 7,000 sq. ft. facilities = 5.85 minutes

1. Turnover Time Donna White, RN, the director of nursing for Madison Street Surgery Center in Denver, Colo., says her staff turns rooms over in five minutes. How? "We wear rollerblades," she says, tongue planted firmly in cheek. It might just seem like her staff has some wheeled help as they whirl around the center in a synchronized blur of activity.

On the day of surgery a floating nurse dedicates herself to nothing but transporting instrument sets to and from sterile processing, and escorting patients from pre-op to the OR to the PACU. In fact, since most patients remain in recovery for just 30 minutes, many of the PACU slots in Ms. White's facility remain empty. One recovery bay is located just outside the OR doors.

That's where Ms. White's staff place patients who are next in line for surgery. The area is a patient on-deck circle, if you will. As soon as one case ends, the OR nurse walks just a few feet to pull the next patient into surgery. Ms. White also assigns an extra nurse "runner" to each day's staffing schedule to help turn over the facility's two ORs.

"When you have a fast surgeon, your staff must support his pace," says Ms. White. Look at your case volume. If you're cranking through more than 20 cases in a day, a dedicated floater might be worth the payroll hit. "Most people want to cut clinical staffing expenses but that's the key ingredient to remaining efficient in a high-volume center."

Linda Pavletich, RN, BSN, CASC, LHRM, the administrator of St. John's Surgery Center in Fort Myers, Fla., agrees. "Have a well-trained staff and adequate staffing levels to perform all jobs necessary," she says. "If you need more instrument trays for better turnover times or cross-training of other staff members to assist, so be it."

Jay Sveen, CRNA, clinical director and COO of Lincoln Surgical Hospital in Lincoln, Neb., performs retrobulbar blocks on patients in the pre-op holding area, meaning surgeons never have to leave the OR. He has two or three patients blocked and ready for surgery at any given time. His facility also dedicates an extra nurse and surgical tech to each room to serve as staff gophers. The aim is to have all OR personnel remain in the room between cases to speed room turnovers. Mr. Sveen also gives a nod to the latest generation of phaco machines. He says the newest equipment is designed for easy setup by a single tech, freeing the room's OR nurse to prep the patient, set the surgical scope and organize needed supplies.

Robin Williamson, RN, clinical director of Stony Point Surgery Center in Richmond, Va., runs a multi-specialty facility with seven ORs. She employs two extra circulating nurses to exchange soiled instrument sets with clean ones while the facility's CRNA moves the finished patient into PACU and collects the next patient from the pre-op area. To speed turnover times, the clinical team doesn't mop the OR floor unless BSS happened to spill off the surgical drape during the procedure.

83.9 percent of respondents have patients wear their street clothes.

The remaining respondents have their patients change clothes.

2. Street Clothes or Gowns?
Some facilities still have patients change into gowns before surgery. Many would say that's an efficiency killer. Cataract surgery can be done safely if patients remain in street clothes. Ask your patients to wear a button-front top. That will allow your staff easy access for the placement of EKG monitoring equipment.

Ms. White has reached a happy medium, requiring her patients to remove only their shirts. "It's quicker than if they were to completely change," she says, "but also makes things easier on our staff."

- 2,000 to 4,000 sq. ft. facilities = 104.31 minutes'
- 4,500 to 6,500 sq. ft. facilities = 104.76 minutes
- 7,000 sq. ft. facilities = 94.75 minutes

3. From Check-in to Checkout
Make pre-op registration quick and easy, starting with the pre-op phone call. Cover the obvious - make sure patients bring proper forms of identification and consent forms - but consider adding a standard question to assess the patient's need for power of attorney. Cataract patients are typically elderly and Ms. White began to see many patients present with mild confusion or Alzheimer's disease, making pre-op directives difficult to communicate and causing delays when staff had to get power of attorney documents signed on the day of surgery.

Her staff now covers the power of attorney topic during a standard pre-op phone call. Instead of scrambling to get a form signed when a confused patient arrives at her center, Ms. White now has the required document in hand. She suggests you do the same to avoid unforeseen and avoidable delays in the registration process.

- In/out of OR
  2,000 to 4,000 sq. ft. facilities = 21.28 minutes
  4,500 to 6,500 sq. ft. facilities = 23 minutes
  7,000 sq. ft. facilities = 28.7 minutes

- Anesthesia start/finish
  2,000 to 4,000 sq. ft. facilities = 26.8 minutes
  4,500 to 6,500 sq. ft. facilities = 25.95 minutes
  7,000 sq. ft. facilities = 25.1 minutes

- Surgery time (defined as incision to removal of drape)
  2,000 to 4,000 sq. ft. facilities = 17.8 minutes
  4,500 to 6,500 sq. ft. facilities = 14.62 minutes
  7,000 sq. ft. facilities = 14.35 minutes

4. Procedure Time
To a woman (and man), everyone we talked to believes that the running of an efficient center is the best way to make surgeons happy. The ultimate goal, after all, is to have patients prepped, positioned and ready for the surgeon as soon as he enters the OR. You want your surgeons concentrating on surgery and nothing else. Above all, surgeons appreciate a well-run center that can almost guarantee on-time case starts from the day's first procedure to the last. Well, they also appreciate lunch. Ms. White buys her surgeons a noontime meal every day, ordering Thai, Chinese or salad plates: whatever it takes to sate her surgeons' appetites.

Your patients' satisfaction is just as important as your surgeons' happiness. The two are in fact intertwined, says Ms. White. Most of her cataract volume comes from a single ophthalmology practice. If patients are happy with her center, they associate that satisfaction with their surgeon, who will pay that gratitude forward to you and your staff. Make your patients happy and everyone wins.

Her surgeons seem to understand that give-and-take relationship between the patients, surgeons and center. They meet with patients in the recovery area and give each a small green plant in a small clay pot. Ms. White's staff snaps a Polaroid of the surgeon, patient and plant, and slides the picture into a simple thank-you note. Each potted gift costs just $1.50, but they make a lasting impression on patients, who once complained to Ms. White about never seeing their surgeons after their sedation wore off.

The sights and sounds of a surgery center are commonplace to you and your staff but can be a source of great anxiety to patients. Use pre-op phone calls to not only ensure that patients bring the proper paperwork and empty stomach to your center, but also to allay their fears of the unknown. Set realistic expectations. Ms. Pavletich has her staff assure patients that they will receive individualized care even though they'll likely be greeted by a crowded waiting room - the trademark of a successful surgery center. She also tells patients that the necessary efficiency of her staff is a well-oiled machine and not the "assembly line" one patient called it while leaving her center.

And don't forget about the family member or friend who waits for their loved one to emerge from surgery. Ms. Pavletich leaves cookies and coffee in her waiting room next to a sign that politely reminds surgery patients about their pre-procedure eating rules. The note does, however, promise that patients will be rewarded with a treat in the recovery area. That treat, it turns out, is a fresh muffin.

Ms. Williamson, like most of you, collects patient satisfaction surveys. Collecting them is one thing, but learning lessons that will improve your services is quite another. She discovered that her staff did well in informing pre-op patients if the start of their case was delayed. However, family members were left to wait and wonder. Her staff now relays surgical delays to those in the waiting room and allows patients' escorts to join them in the pre-op area if the delay is significant.

For Mr. Sveen's patients, there is such a thing as a free lunch. He benefits from working in a surgical hospital with the means to employ a full-time RN who serves as liaison between patients' families and surgeons. Still, even with a full-time soother of nerves on staff, delays happen and feathers get ruffled. When patients and their families are upset about sitting in Mr. Sveen's hospital for longer than the typical hour and a half, he'll comp them lunch in the hospital's caf' or slip them a gift certificate to a local restaurant. He says freshening the bad taste in any of the 5,000 mouths they host each year is good business and well worth a few lunches on the house.

To help control supply expenses, Ms. Williamson uses an itemized spreadsheet that lists each doc's per-case expenses without revealing their identity. She implores surgeons to consider a less expensive brand of viscoelastic if their purchases fall on the high end of the $25 to $85 range that her facility spends on the supply.

Renegotiate your vendor contracts every six to nine months in a constant search for the best deals possible, says Mr. Sveen. His large surgical hospital also runs satellite facilities throughout Nebraska. He cuts down on lens expenses by purchasing in bulk for the entire network. Ms. Pavletich also recommends you parlay a large caseload into IOL savings. Her facility hosts about 450 cases each month, generated from nine surgeons. She bulk-buys lenses falling in the frequently used 18 diopters to 25 diopters range.

Mr. Sveen empowers his nurses and techs to make suggestions that lead to supply savings. His staff's bonuses are in fact tied to the facility's annual revenue, just one reason the facility recently worked to rebuild the surgeons' custom packs. The techs and nurses also recognized a waste of viscoelastic stock and re-organized the cataract packs into two versions, based on the two types of viscoelastic used by the facility's surgeons. Finally, Mr. Sveen's staff constantly offers less expensive blades for surgeons to trial. However, he cautions against settling for lesser quality for the sake of a healthier bottom line. "Instead of using a single, more expensive blade we had surgeons opening multiple packages of the blades we trialed because they weren't sharp enough," he says.

Alex Stockdale, MBA, administrator of the Knoxville Eye Surgery Center and CFO of Johnson City Eye Surgery Center, both in Tennessee, used benchmarks to spark a supply-saving dialogue with his surgeons. When reviewing benchmarks, consider that the responding facilities are often the class of their size and type, the best organized and best staffed, with the resources and time to respond to a survey, he says. Also keep in mind that some surgeons may balk at the input or comparisons. "Surgeons want data," he explains. "But sometimes they don't want to be scrutinized."

He says benchmarks can be a valuable tool - even a reality check - if you know how the figures are derived and how they compare to your center's performance. Mr. Stockdale suggests that you first consider the benchmark survey's sample size. He says a cohort of 600 is ideal but unrealistic, adding that a sampling of 50 facilities or higher is an adequate slice to consider. The size of the facilities being measured and the procedures they perform are also important considerations. You want to ensure that you're comparing apples to apples and not to oranges.

Just The First Step

The benchmarks appearing in this article are taken from the Outpatient Ophthalmic Surgery Society's baseline survey of 62 ophthalmic ASCs. For interpretive value, the organization grouped many of the benchmark measures by size of facility. In 2008, the organization will launch its full benchmarking program that will be open to all OOSS members. The organization hopes to target key benchmarks that will help identify the best clinical and business practices leading to high net profits without sacrificing quality patient care.

For more information on OOSS's benchmarking program, visit "Measures for Success" at writeOutLink("www.ooss.org",1).

- Daniel Cook