Finding a Better Way To Financial Health
Here are some practical tips from an ASC specialist.

Moving certain surgical procedures from the traditional hospital setting to the ambulatory surgical center (ASC) or office-based surgical suite has proven safe, efficient and cost-effective, particularly in ophthalmology. Surgeons enjoy the autonomy, flexibility and time savings; patients appreciate the shorter stays.

But the trend toward more ASC-based procedures has brought some challenges. While patients expect the same standards of care and safety they associate with a hospital, third party payers have set expectations lower for overall costs. Thus ASC owners and administrators are constantly juggling quality of care issues along with profitability pressures. This is why it's imperative that organizations find better ways to maximize profitability without compromising the choice of goods and services. A myopic focus on costs can trigger a payer to consider lowering reimbursement, creating a downward spiral and reducing our ability to serve.

When my clients ask for help sorting out these challenges, we usually look at what I call the four S's of surgical throughput: Scheduling, supplying, staffing and setting. While all four have significant impact on quality of care and economies, I'll focus on the first two in this article.

SCHEDULING

Tips for Staying on Time

Best practice organizations understand the importance of eliminating wasted surgeon time. Their goal is to eliminate the word "delay" from their vocabularies -- and for good reason. Delays are not isolated events; they have a domino effect on the rest of the schedule. Scheduling must be flawless. To ensure on-time execution of a procedure, incorporate these practices into your routine:

1. Confirm that the patient's demographic and insurance information is complete and accurate.

2. Verify that pre-op testing is timely and complete so the results will reach the facility when needed.

3. Make sure test results are reviewed by a clinician. Document abnormal findings, stating the disposition of the information (who was contacted, date contacted and what information was given). Initial all test results to ensure that no abnormal findings are missed.

4. Ensure that all necessary paperwork is on the patient's chart by noon the day before surgery. This includes the informed consent, the anesthesia consent (if separate), the history and exam data and the patient's health questionnaire, if applicable.

5. Confirm that any required medical clearance has been obtained. The release should be attached to the medical record before the day of surgery.

6. At the initial scheduling call, note the need for any special materials, equipment or staff for the case.

Having a policy that describes the record requirements will eliminate the 'paper chase' on the day of surgery.

Scheduling is one function that should be automated in your facility. Use database scheduling to assist with all aspects of the scheduling process. You can generate reports to provide baseline information on block time utilization, overbooking, cancellation rates, case mix, payer mix, case length, type of anesthesia and delays. Recording your data electronically will help take the guesswork out of your scheduling process.

If you're considering block scheduling, an automated system will show trends and track individual surgeons as well as group practices. If you're already using a block system, a fact-based system will provide a level of assurance that decisions to increase or decrease a surgeon's block time can be made objectively.

Make every attempt to fill in any gaps in your day. Develop an incentive for physicians to use these undesired slots. Perhaps your rules for block time permit a decreased utilization rate.

Growing Pains

When is it time to increase capacity? Organizations often struggle with this decision. If your scheduling function is proficient, objective and accurate, you have much of the requisite information at your fingertips. Undertake a needs assessment and look at your utilization statistics.

Any increase in volume also will affect your staff scheduling. For instance, when using two rooms simultaneously, you definitely need two teams, as it's impossible for one team to adequately set up and prepare for the next patient. An option might be to use one primary team to go from room to room with an aide or tech cleaning and setting up between cases.

You also can become creative with how your patients are transported from point A to point B without compromising quality of care or safety by using anesthesia staff or pre- and post-op care personnel.

Make sure your volume will support additional space. Grow into it and staff smart. Begin by hiring/assigning staff to the morning hours, then add the afternoon slots. Perhaps you should schedule only on specific days of the week and then add other days as needed. Have a consistent need before you incur unnecessary additional expense.

On-time Is Everybody's Business

The whole ASC team's performance must focus on eliminating delays. The medical staff -- including the surgeon -- needs to fully understand and support the concept as well, recognizing that on-time starts benefit everyone.

Make sure you have a clear definition of 'start time' and that this definition is communicated to everyone. Don't take this simple concept for granted. Without clarity, you may find yourself working on a totally different page from members of your medical staff.

Although there's little time for committee meetings today, a spirited task force with members who are interested, motivated and challenged could make the difference with an organizational strategy that's being drafted and proposed. Use the data you have amassed to help ensure understanding of the recommendations and targets and to avoid perceptual (gut feel) analysis.

SUPPLYING

What Do You Really Need?

To be efficient in your practice, you must have the necessary tools, supplies and materials to get the job done.

One important task, for instance, is to inspect your instrument trays. Most cataract trays contain between five and eight instruments. If your trays have more than this, review the contents and consider eliminating some instruments you don't use routinely. Set up an accessory tray that can be terminally sterilized and kept for those cases when other tools are needed. This simple strategy should reduce your turnaround time.

For best results, a one-room facility should have a minimum of three (3) cataract trays -- one that's in use, one for the next case and one that's been terminally sterilized in case of an emergency. What do I consider an emergency? Perhaps the back table becomes contaminated and the sterilizer cycle with your other set of instruments hasn't been completed. Bring in the backup tray to avoid a delay in the current procedure. A two-room facility should have a minimum of five (5) trays.

Also, consider the size of your tray. If it's large, the tendency is to keep unnecessary instruments on it, so use trays that are just big enough for the necessities.

Maintaining an adequate inventory is essential to a smooth and efficient operation. Seek a volunteer to be your supply chief. This person should be enthusiastic about the duties and responsibilities of this job and also have a basic understanding of math as well as supply and inventory principles. Practical experience often is more valuable than book knowledge in this area.

Calculating True Costs

When calculating the true cost of acquiring an item, be sure to include the following questions in your analysis:

► What's the purchase price?

► What's the reorder point? How often must I reorder it? Is there a minimum reorder amount?

► Do I have enough space for inventory? Do I need that many items? What's the cost of tying up inventory dollars?

► Do I have to pay for shipping? Can I negotiate free or reduced shipping costs if I guarantee a certain volume, or does the vendor have another program, such as standing orders?

► Does the sales representative seem knowledgeable, dependable and willing to help?

► What are the costs associated with handling, cleaning, testing, preparing and stocking the item?

► What are the costs for ongoing maintenance of reusables? This would include the cost to prepare an item for the next patient: Personal protective equipment, detergent, water, Instrument Milk, lubrication spray, cleaning supplies (brushes, pipe cleaners, instrument wipes, 4x4s, biological/chemical indicators, integrators, instrument wraps or peel packages), marking pens, sterilization tape and the maintenance contract on the ultrasonic cleaner and/or sterilizer.

Patient and staff safety should be your first priority. The cost of compromise in this area can expose significant risks and needs to be avoided wherever possible.

Maintaining Quality

It's a fact of life that payers, including Medicare, continually examine whether reimbursement levels are aligned with procedural costs. For example, the Office of Inspector General recently recommended that Medicare substantially lower its payment to ASCs that use less expensive, older technology IOLs. Thus, rather than prioritizing cost reductions, the financially responsible ASC should focus on fostering a culture of improving processes.

You can maximize your efficiency by continuously reviewing your organizational processes as they relate to surgical throughput: Practice setting, scheduling of patients, staffing levels and types, and supplying of goods for your procedures. Continuing education is another key element in the improvement process.

Providing a blame-free environment will help keep the lines of communication open and fosters honest and ethical behavior.

Implementing efficient processes enables the facility to enjoy a high volume of procedures while producing good patient outcomes. Satisfied patients are your most effective and proven marketing tool. The financial benefits of a high volume of good outcomes always outweigh the savings realized from cutting costs.

Barbara Ann Harmer is founder and president of MedAssist Consultants Inc., headquartered in Celebration, Fla.