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Ophthalmology Management

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Bringing the ASC Mindset to the Hospital

Frustrated by inefficiency at the hospital? Here's advice from a doctor and administrator who changed things for the better.

By: John S. Jarstad, M.D.
Ophthalmology Management April 1, 2001

Bringing the ASC Mindset to the Hospital
Frustrated by inefficiency at the hospital? Here's advice from a doctor and administrator who changed things for the better.
By John S. Jarstad, M.D. and Richard Boudreau, COE, Federal Way, Wash.

One of the most frustrating aspects of being an ophthalmologist is having to work in an inefficient clinic or hospital system. Today, effective use of time and resources is critical, and this is no less true in the hospital than in a practice or ambulatory surgery center (ASC).

At our physician-owned ASC we became sensitive to this after we made changes that caused dramatic increases in our productivity and profitability. As the efficiency in our ASC improved, we began to notice a significant drop in efficiency (and profitability) whenever we scheduled cataract cases at the nearby hospital. Faced with this reality, and the Draconian cuts in Medicare reimbursement, we began to dread managed care cases that we were required to schedule at the hospital.

 

From the Administrator's Point of View

 

As hospital administrator, I'm well aware that creating an exemplary surgery service requires a strong spirit of cooperation between surgeons, anesthesiologists, surgery staff and administration. I'm also aware that this spirit of cooperation may not be evident in every hospital setting.
Achieving the efficiency of a freestanding surgery center in the hospital may require significant change. Our story demonstrates that this is indeed possible. But when changes need to occur, frank and open communication is the key to success. Communication begins with you approaching your hospital administrator and telling your story.

Making Changes

In our case, once Dr. Jarstad made it clear that a serious problem existed, we took a number of concrete steps that made a big difference. In addition to those described by Dr. Jarstad:

  • I met with the OR supervisor. We analyzed the existing procedures and brainstormed ways we could improve them.

  • We re-evaluated which staff members were performing which tasks. (While OR supervisors value "generalists," some surgical specialties require dedicated and consistent personnel.)

  • We looked for ways to improve systems, such as eliminating problems in central sterilization that caused lengthy delays.

  • We inventoried equipment and purchased duplicates of commonly used instruments.

  • We conducted a skills inventory for central processing personnel and scheduled mandatory Saturday classes.

  • We revised the daily schedule and empowered team members to do whatever was required to complete it on time.

  • We involved the staff in the entire process.

Throughout this process, we made a concerted effort to evaluate systems and processes objectively, especially when we heard, "Yes, but we've always done it this way."

We Benefit As Much As You

Since we began making these changes, we've enjoyed a steady increase in case volume in all our surgery service lines. We plan to use what we've learned to continue to improve the quality of our surgery service.

By Cheryl Payseno, Chief Operating Officer at St. Francis Hospital, Federal Way, Wash.

Although we wanted to make changes, we initially felt helpless in the face of hospital bureaucracy. However, we realized that this lack of efficiency hurt the hospital as much as it hurt us. So, we decided to see if we couldn't convince the hospital to make some changes.

To our surprise, they agreed to work with us. And as a result of the changes we've made, our hospital cases are now just as efficient as the cases in our ASC.

It's our hope that by sharing the details of our experience, you may decide to work for constructive changes in your hospital OR, too. We made it happen -- and so can you.

Getting to the heart of the problem

What causes the lack of efficiency so many of us experience when performing ophthalmic surgery in the hospital?

Sometimes, a big part of the problem is the way hospital employees are paid. If a hospital nurse is paid by the hour, he or she has no incentive to be efficient. Why would a registered nurse who's paid $25 per hour finish a day of cataract surgeries in 6 hours instead of 8 hours if it means taking home $50 less pay?

Most nurses are talented, capable people with the best of intentions. But some get sidetracked as a result of this financial issue and find ways to stretch out time spent in the OR. (For a list of some of the personality types I've encountered over the years and the strategies they've employed to undermine efficiency, see "Profiles in Inefficiency")

At first, I tried to deal with this kind of individual by using frank and candid discussion and light-hearted sarcasm ("What movie are they showing in that break room today, 'The Never Ending Story?' ") Unfortunately, this had no effect.

Eventually I realized that the system was a big part of the problem. So, I arranged a formal meeting between myself, our clinic administrator (Rick Boudreau) and the hospital administrator, Cheryl Payseno. The purpose of the meeting was to see whether we could find ways to restore efficiency to the hospital environment.

Working together

Much to our surprise, Ms. Payseno was an ally in our quest for improved efficiency. She had noticed the decreasing efficiency (and corresponding dwindling numbers) of surgical procedures, and she was delighted to meet with us.

We met in my office at 7 a.m. We were joined by Laurie Nichols, president of Franciscan Hospital Systems. Ms. Payseno thanked us for initiating the meeting. Ironically, she mentioned that it was rare for physicians to take time out of their busy schedules to discuss administrative issues!

After introductions, we discussed the history of the hospital and my practice and talked about our long- and short-term goals. I mentioned my frustration with hospital turnover times and with certain staff members who seemed to sabotage our efficiency. Rick and I explained how we'd cut our ASC turnover time to about 5 minutes, and what a difference it made in efficiency and profitability. We offered a number of constructive suggestions for duplicating this at the hospital.

During the 1-hour session we exchanged viewpoints and brainstormed more ways to make needed changes. We emerged from the meeting with several ideas for constructive change:

  • Nursing staff would be paid in a way that encourages efficiency. Ms. Payseno agreed to consider paying staff on a per-case or per-day basis.
  • The administrator would observe surgeries and identify rate limiters. An outside observer can easily spot a weak link in the chain.
  • We'd set standards for mutual respect. This made considerate behavior an official policy, complete with guidelines.
  • The surgeon would help more. Ms. Payseno pointed out that surgeons (myself included) occasionally arrive late for surgery. I agreed to improve in that area. We also agreed that surgeons should assist with room turnover or anesthesia when the hospital was short-staffed.
  • Paperwork and supplies would be ready before surgery. We agreed that all office paperwork should be received and in order prior to the surgery day, and any supplies needed in the OR should be ready at the start of the day.
  • When necessary, the hospital would provide more resources to keep patient flow moving. We agreed that this would be more of a priority.
  • We'd set goals, especially for improvement of turnaround time. We agreed that having specific, realistic goals was necessary in order to actually create improvements. To this end, the hospital sent the ASC clinical nurse director on a trip to a neighboring state to observe an ASC that we considered to be highly efficient. She was instructed to pay particular attention to turnover times. (We thought that having her visit our ASC -- only one block away -- was too politically sensitive).
  • We'd monitor our progress. We agreed to provide periodic reports summarizing our progress, and we agreed to meet again later to reassess the situation.

Teamwork pays off

As a result of our efforts, improvements were immediate and long lasting:

  • Turnover time decreased from 15 to 20 minutes to about 5 minutes per case.
  • One of the nurses who'd been holding back our efficiency for a long time became so enthused with the entire process that she was made clinical director in charge of turnover and efficiency, answering directly to the hospital administrator.
  • The respect between hospital and physician surgical staff improved dramatically. Stress levels dropped; productivity increased. (Morale in the OR has never been better.)

Our combined efforts were rewarded in another way as well. The hospital was recently selected as one of America's Top 100 Hospitals for 2000-2001. (This is especially gratifying considering that the majority of surgical cases handled in this hospital are eye cases.)

Setting the wheels in motion

If you're feeling frustrated because of insubordinate, uncooperative or inefficient staff at your local hospital, we encourage you to arrange a formal meeting with the hospital administrator. With luck, you'll find the administrator to be an unexpected ally, just as we did.

When you meet, be sure to have preliminary data available, including the number of cases and revenue currently being produced, along with expected projections if efficiency goals are met. Then brainstorm and work together. You should be able to eliminate most of the factors that are causing you frustration, and increase the quality of your patients' care in the bargain. And that's definitely a win-win situation. 

John S. Jarstad, M.D., is medical director of Evergreen Eye Centers and president of Washington Academy of Eye Physicians & Surgeons for 2000-2001. He's served as chief of ophthalmology at St. Francis Regional Hospital in Federal Way, Wash. Richard A. Boudreau, COE, is administrator of Evergreen Eye Centers in Auburn and Federal Way, Wash., and a graduate of the Wharton course for ophthalmic administrators.

 

Profiles in Inefficiency

Most nurses today are highly educated, efficient "angels in comfortable shoes," and I don't mean to imply otherwise. But over the years I've observed that some hospital employees who are paid hourly will devise ingenious strategies to "sandbag" the efficiency of the ophthalmic surgery day.

Here are a few examples of personality types I've encountered:

  • Super-conscientious Sarah. This nurse arrives 2 or more hours early "to make sure all the paper work is ready and all the equipment is available and running properly."
    She fills all this time by reviewing and reorganizing charts and supplies, making sure that every conceivable instrument is autoclaved and prepared, and testing every device that will be used in surgery that day. She sets up IV tubing, prepares eyedrops, counts and recounts sterile packs, warms blankets, and prepares snacks, drinks and post-op instructions.
    While most of this is important, there's a fine line between necessary preparation and wasting time. And the real problem crops up later in the day; this person, having started working early in the morning, has often finished her 8-hour day by 1:00!
    Request that more than one person be assigned to prepare the OR. A team of people with an established routine can complete preparation in an hour or less. Then no one has to come in -- or leave -- quite so early.
  • Loquacious Larry. Everyone enjoys socializing with this nurse before, during and between cases. He has "all the latest gossip" and can be a real "human resource." He can also be quite manipulative, and so distracting that he undermines your efficiency and the efficiency of everyone else on the team.
    Unfortunately, if you object to all this talking, he may complain to the hospital that you're uncommunicative. This can cause all kinds of political fallout. (I've seen it happen.)
    To resolve this, have the hospital administrator observe a day in the OR so she can see the situation for herself.
  • Vanishing Vivian. This person -- usually found in an overstaffed surgery center -- is never around when you need her. She's frequently "on break" or "over at Central Supply" or "running errands." She may be an unmotivated individual with "supervisory status" and a nebulous job description (possibly a "float" who does just that). She can be difficult to reach and a tremendous expense as a "lost" resource.
  • Social Sam. This person doesn't work well on his own. He may be a new hire who is learning but "isn't quite ready to function by himself yet." He likes people; he's a great communicator; and he'd be great as a discharge nurse. But in the wrong position -- circulating, recovery, admission or instruments -- he ends up being a rate-limiting spectator. He needs to "fish or cut bait."
  • Blatantly Obvious Bobbie. This person is out to sabotage your efficiency to increase his own hours. He'll say:
    • "The autoclave door didn't shut so I had to do another 10-minute sterilization cycle on the instruments."
    • "I thought you (or the patient) touched the eyelid, so I have to prep them all over again." (He then takes extra long to make sure the area is aseptic.)
    • "Oops . . . I dropped the lid speculum. I'll have to resterilize it."
      Never tell this person you need to leave by a certain time to meet your spouse or attend a school play or make an afternoon clinic. He'll make sure you miss your deadline.

Now don't get me wrong. These people are the exception, not the rule. But encountering any one of them can be frustrating and demoralizing and add to the stress of your daily practice.

The key to altering this kind of behavior is to work with the hospital to change the circumstances that reward inefficiency, and get everyone working toward a common goal.

-- John S. Jarstad, M.D.

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