Is it possible for ophthalmic surgery to remain a profitable specialty in today's tenuous economic times? It is, but only if you aggressively cut costs and revamp certain processes, say the eyecare leaders to whom we spoke.

Techniques such as pre-dilating patients, efficient instrument reprocessing, cross-training and, in some cases, outsourcing can help squeeze out a better bottom line. Last month, Outpatient Surgery Magazine reached out to administrators and managers in ophthalmic surgical facilities to learn about how they have improved the profitability of eye surgery cases. Here are practical suggestions from your peers on how to reach and maintain a comfortable profit margin with your eye cases.

1. Fine-tune your procedure packs
You might be surprised what you discover when you examine the contents of your procedure packs. Heather A. Huffman, RN, CNOR, administrative director of the Surgical Eye Center of Morgantown in West Virginia, was able to delete some of the smaller items that her surgeons weren't consistently using. For example, she decreased the number of disposable towels from five to two and deleted the package of surgical spears, since not all docs were using them. "If we do a procedure that requires more supplies, then we open those supplies individually," she says. Not all of her docs routinely suture the incision for cataracts. "With others," she says, "we wait to see if they need it first before we just open it."

During a review of her packs, Pam Canfield, RN, MPA, executive director of the Eye Center of Columbus in Ohio, found that many surgeons either changed what they used or stopped using items, and that those items had not been removed from their "pull" lists. Ms. Canfield kept the vendors involved in the review process. "We talked with our vendors to review all of our packs and implant costs," she says. "We've had some success in reducing the costs of our packs."

As a general rule, you'll save on ophthalmic supplies when you use procedure packs. "Once our 10 primary surgeons reached a consensus on the basic contents, our vendors were able to offer better pricing related to our volume," says Donna Cairone, MHSA, BSN, CNOR, RNFA, director of nursing at the Eye Surgery Center of Chester County in Exton, Pa.

2. Have patients arrive pre-dilated
Ask the referring physicians to prescribe dilating drops to be taken at home the morning of surgery. Having patients arrive at the surgical facility already dilated can save time and money. As an added bonus, you'll save on supplies because the patient is paying for the drops and the supplies to administer them. More importantly, you'll decrease your labor costs. Pre-dilating reduces the amount of time that a patient stays in the surgery center by about 30 minutes, which translates to fewer nurse labor hours needed to care for the patient.

Other surgery centers use a compounded eyedrop solution or slurry before surgery. This can also reduce labor hours since it reduces the number of drops patients are given before cataract surgery.

3. Use a diamond knife
When you look for things to eliminate from your packs, consider reusable blades. You might save money and generate less waste. "We took out disposable blades and are currently using a reusable diamond knife," says Nikki Ross, AAS, materials manager at Marysville Surgical Center in Marysville, Ohio. Although expensive ($500 to $3,000), diamond blades make clean incisions and they last much longer than metal blades, as long as you treat them right. Make sure that everyone who handles the knives, especially the person cleaning and sterilizing them, understands the delicate nature of the blade. Chipped blades can be re-sharpened, but it will cost you as much as $1,000.

4. Case cost and benchmark
At Portland Adventist Medical Center in Portland, Ore., hospital managers keep surgeons informed of all products and their own case costs per procedure, says Jennifer Jeffries-Bilic, RNFA, CLNC, CST, charge nurse for day surgery. Managers we talked to say that figuring how much each case costs and comparing your numbers with those of your peers will give you a good idea of how you're doing and where you need to concentrate.

Ms. Huffman says the results of her recent case-cost analysis were a real eye-opener for her eye surgeons. "I think each doc was truly amazed when he saw his individual costs per case as it compared to other docs," she says. "They've taken ownership to see what they can do to lower their own costs."

Her center's average supply cost per case for non-complex cataract surgery — including the IOL and diamond knife repairs — is about $215, she says. Ms. Huffman put a special spin on the case-costing data by breaking it down even further to show each surgeon's percentage of total volume compared to his percentage of total cost. "This was very interesting," she says.

She says one of the toughest areas for her to address has been the cost and types of IOLs used. "Each doc has very specific clinical views on what they believe is the best for each patient," she says. "We've negotiated some very competitive pricing, but since the docs have seen the pricing of IOLs in black and white, they have at least made an effort to look at all types of lenses and associated costs. The end result is that they have been willing to try some of the less expensive lenses, but this is definitely a work in progress."

One of Ms. Huffman's biggest cost savings is with viscoelastic. "We did a trial of different vendors, and most of the docs have switched to a different type that is more cost-effective. Plus, those who were using two different kinds per case are now just using one," she says.

If you haven't participated in a benchmarking study, you can purchase results from a handful of organizations, including the AAAHC Institute for Quality Improvement, the Ambulatory Surgery Center Association, the Outpatient Ophthalmic Surgery Society or Surgical Outcomes Information Exchange. Better yet, consider participating in one of these organizations' benchmarking studies. The very act of participating will make you aware of how you do things in your center. When you get the results from the study organizer, they'll be in a format that will let you easily compare yourself to national and regional standards.

5. Set out only what you need
Survey your physicians to see which instruments they use most often. At Wayne Memorial Hospital in Goldsboro, N.C., that led to more trays with fewer instruments on them. Consulting with physicians, Teresa Corbett, RN, CNOR, the administrative director for surgical services, was able to remove about 30 specialized forceps, scissors, needle holders, twist fixes and irrigating tips that were rarely used. These instruments are still available in a special tray that is only opened when needed, she says. At the same time, the hospital budgeted for more trays of the dozen instruments most often used in phaco procedures, which reduced the need for flash sterilization.

Also, keep an eye on which instruments are unused at the end of a procedure. Removing the least-used instruments can save time processing instruments between cases. It can also extend the life of the rarely-used instruments, which will suffer less wear and tear from processing and sterilization.

6. Keep patients dressed
Reducing the amount of clothing that a patient has to remove before a procedure can save time both in the pre-op and post-op areas. Some centers keep patients fully dressed, while others have patients remove only their shirts for better EKG access. This often depends on the anesthesia provider's preference. At Mt. Carmel St. Ann's Hospital in Westerville, Ohio, patients remove only their upper-body clothing. "We allow them to leave on shoes and socks," says Constance Saltus, BSN, MBA, director of surgery at the hospital.

7. Switch to standard balanced salt solution
Encourage your physicians to consider using standard balanced salt solution. Many ophthalmologists have found no significant difference in patient outcomes using regular balanced salt solution vs. name brand solution for every case. Making the switch to standard balanced salt solution for every case can save as much as $40 per patient, managers told us.

8. Automate rinsing for tubing and instruments
Using a syringe to rinse tubing, handpieces and cannulas is slow and can be inconsistent, depending on the tech's experience and ability. For several years, the Howerton Eye and Laser Surgery Center in Austin, Texas, has used an automated rinse system. The small pump with a foot pedal helps standardize the rinsing process for lumen instruments and tubing. Besides water, the device also has an air cycle to blow the fluid from the instruments. "It's really made the service tech's life easier," says Ernest Howerton, MD, owner of the center.

9. Streamline your handoffs
Turnover time can mean the difference between profit and loss for a surgical facility. Once the patient leaves the OR, have the staff turn the room over as rapidly as possible. Have the next patient sitting in the hall right outside the OR door. "The circulator can push the finished patient out, lock the brake and immediately wheel the next patient in," says Shirley Ramey, RN, nurse manager at the Ambulatory Surgery Center of Burley in Burley, Idaho. In Ms. Ramey's center, supplies and instruments for the following case are opened in the sterile room right off the OR and wheeled in as the next patient is moved into the OR. "Our turnover times are about three minutes," says Ms. Ramey.

10. Designate a float person
Assigning someone to be traffic cop and concierge can reduce bottlenecks. Hands-on clinical directors make great floaters because they're familiar with the responsibilities of all positions. Otherwise, choose someone who has varied experiences and can be efficient. A surgery center in Denver has a float person who helps with turnovers, lends a hand with admissions and dismissals and can change beds after discharge. Another floater is available to bring in instruments for the next case as the circulator, surgeon and anesthesia provider are performing their timeout and prepping the eye.

11. Consider outsourcing
Some surgery centers have found that outsourcing services, employees and equipment can have a significant impact on their bottom line. As a result of the economic downturn, it may be difficult to obtain a line of credit when expensive equipment such as a phaco machine needs to be replaced. In these situations, leased equipment can be a short-term option. Also, several organizations outsource employees for surgery centers. These companies handle payroll, benefits and other human resources issues, letting the facility's administrative staff focus on other aspects of profitability.

Don't stop trying
Keeping an ophthalmic surgical service profitable requires a fluid strategy. Physicians, administrators, clinical directors and staff must all have buy-in. You'll need to continuously fine-tune and analyze all processes with a critical eye in order to root out waste. But you can't do it alone. Improving profitability depends on the cooperation of the entire team on a daily basis.