Secrets of High-Volume Cataract Facilities

Jay Horowitz, CRNA, who provides anesthesia services for ophthalmologist Hunter Newsom, MD, is in awe of the surgeon's efficiency. "It's not just speed that makes him so unusual — the top 10% of cataract surgeons can all operate quickly," he says. "What I think sets Dr. Newsom apart is his almost supernatural ability to repeat the procedure identically with each patient."

Mr. Horowitz says keeping up with Dr. Newsom requires a system of logistics, ergonomics, focused discussions and explanations with patients, and coordination with staff. A lot of it has developed into "scripts,' according to Mr. Horowitz, "I introduce myself to the patient the same way," he explains. "I ask patients questions the same way. I explain what's going to happen during surgery the same way. Doing so allows for additional time to explore any unusual answers or give explanations. Most of the staff have developed their own scripts, from the admitting staff to the pre-op nurses to the OR staff. While it sounds the same all day, it is not rote."

You'd be hard-pressed to find quicker in-and-out turnarounds in surgery than you will at high-volume cataract facilities. While these straightforward procedures aren't usually difficult for your clinical staff to perform, making sure the machine is well-oiled and keeps cranking as efficiently as possible every day is challenging. We spoke to those on the frontlines and assembled these helpful hints that might help — when you have a quiet moment to contemplate them, of course.

Orchestrating a successful day of cataract surgeries requires precise adherence to scheduling. "A key factor for performing high-volume cataract surgery is to be prepared and don't delay your OR start time," says Susan J. Sawyer, RN, administrator at Tampa (Fla.) Surgery Center. ?"My top surgeon can perform a four- to five-minute cataract extraction with intraocular lens implantation. It's the team's job to keep the train moving."

With her center performing eight to 10 cases per hour, she stresses that it's important not only that everyone knows their specific roles and tasks, but that they stay focused throughout the day.

Smart scheduling also helps, according to Ms. Sawyer. She suggests performing expected easier cases first and putting complicated cases at the end of the day, where they won't jam up the schedule if they take longer to complete.

"Having staff who can recognize and step in to deal with the little differences that can clog the system is invaluable."
— Jay Horowitz, CRNA

Newsom Eye in Tampa, Fla., often does nine cataract procedures per hour, but with the huge variety of specialty lenses that require viewing topography and marking, and minimally invasive glaucoma procedures, the team generally plans for eight per hour. "On the rare day where we perform straightforward procedures with standard lenses, we could easily do 10 or 11 per hour," says Mr. Horowitz. "We try to start Dr. Newsom out with the more basic cases and add complexity after he warms up."

This is an even more urgent matter in the midst of the COVID-19 pandemic. "Don't be afraid to overstaff during peak performance times," says Ms. Sawyer. ?"PRNs work four to six hours a few days a week in my facility, and when they're here it's always crunch time. It's so important due to call offs now more than ever. Many of my nurses are being requested for mandatory overtime at local hospitals due to the healthcare worker shortages and possible exposure and quarantining.

Being properly staffed is not only important to keep the day moving, but it's also beneficial to the employees who are working that day. "Working short-staffed ?is not only a patient safety issue, but it creates burnout," says Ms. Sawyer. "You will lose great people, and having to hire and retrain is not very cost-effective."

A jack-of-all-trades, all-hands-on-deck mentality separates great eye centers from merely good ones. Especially now, when staffing is even more challenging due to the pandemic and the economy, the ability for one employee to perform multiple tasks is a huge benefit to a busy cataract facility.

"It's invaluable to have employees cross-trained so that when there's an individual out, there is always someone else who can step in," says Dana Cowart, COT, administrator at Newsom Surgery Center of Sebring (Fla.). ?"There's not a day that goes by that we don't have to make some type of adjustment to our staffing schedule."

Mr. Horowitz works with staff who are cross-trained to work in pre-op, the OR and post-op. The result, he says, is that each person knows the importance of each function and understands each role they may be assigned on any given day. "Having staff who can recognize and step in to deal with the little differences each day that can clog the system is invaluable," he says.

Mr. Horowitz points out cross-trained staff are versatile enough to manage issues related to high blood pressure, discrepancies in paperwork, lens choices, tough IV starts and equipment challenges. Many different personnel of varying backgrounds can step in to address each of these evolving issues so they can be resolved, and patient flow goes on seemingly uninterrupted.

"We all like each other and enjoy the work we do to improve the lives of our patients," says Mr. Horowitz. "Are there occassional stresses? Of course. But having a well-trained, well-choreographed and competent team eases them immensely."

If it's an option, upgrading to electronic medical records can improve your center's productivity and accuracy. "In 2018, we went to an EMR system, which we built from the ground up to specifically meet the needs of our surgery center," says Ms. Cowart. ?"We continue to tweak and add procedures as needed. ?The system is user-friendly and flows in the same manner as our previous paper charts. ?Even our older staff members — myself included — adapted easily. Everything's on an iPad. There's no more flipping around in charts."

She says it's now a simple finger-press to see if a patient gave consent, access pre-op vitals or quickly determine what medications a patient is taking.

When fields on electronic charts need to be updated, it's a snap. Ms. Cowart can even set certain fields to pre-populate. "That way, we don't have to input every single medication the patient is on," she says. "It's a lot easier to ask patients, "Are you still taking Plavix? Are you still taking ibuprofen?' If they're not, you just delete the medications from their records, which is a lot faster than having to put it all in.

"On a paper chart, you're writing, and crossing things out, and you have to initial the changes. Working with an EMR is just a much cleaner and faster process."

When your business is a well-oiled machine, there's a risk that employees end up feeling like nameless cogs in it. So it's important to remember the human factor. "When I know I'm going to push my team — which is often — I will supply lunch or snacks and they all love it," says Ms. Sawyer. "And don't forget to say "thank you' to celebrate jobs well done. People want to feel appreciated and it goes a long way, especially during these difficult times." OSM