staffing
Staffing Your ASC for Efficiency and Patient Safety
BY RICHARD J. RUCKMAN, M.D., F.A.C.S.

In 1993, the growth of my practice required that I build a larger facility. As part of the office expansion, I included an ambulatory surgical center (ASC), which was one of the best decisions I have ever made. My ASC has remained profitable over the years, despite significantly reduced surgeon fees and ASC reimbursements that remain fairly flat. This reimbursement squeeze led me to investigate ways to remain profitable without sacrificing quality of care.  

Dr. Ruckman and his staff at The Center For Sight.

In 1999, our ASC became certified by the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC). This process of accreditation has given us an opportunity to maintain quality of care and, at the same time, has provided an excellent opportunity to participate in benchmarking studies with facilities that have met the same standards. Our latest involvement in benchmarking through the AAAHC was the Institute for Quality Improvement study, Cataract Extraction with Lens Implant Insertion, 2005.1 Among the 88 ASCs surveyed, we were ranked 71st by volume of surgical cases, but we were ranked first in average facility time, which represents the total time the patient is in the facility.

A time study such as this is the first step in achieving cost-effectiveness. If you look at the typical expense ratios for an ASC, supply costs represent only 23% and overhead 33%, while staffing is 44%, which means that the majority of the costs of doing surgery are time-dependent expenses.

Becoming More Efficient

The first step in efficiency does not have to be a formal process. Our own first step was to look at my cataract procedure and recognize that temporal clear-cornea surgery was certainly a marked improvement in efficiency. With the help of an outside consultant, who acted as observer and timekeeper, we were able to evaluate how long it took from the time the patient entered the room to the time the doctor started and finished one case and then entered the next room.

This initial study showed that we could decrease our turnover time by 81.8%, which would allow us to add five more cases per day in the same amount of time. Once we felt we had achieved improvement within the operating room, we looked at the entire surgical experience from clinic to postoperative and made changes gradually. This gave the staff an opportunity to adjust and maintain consistency of care.

Looking at Specifics

The surgeon is key. He or she must be committed to being on time for surgery and minimizing interruptions as the day proceeds. Our ASC has one full-time RN manager with one full-time assistant. We also have five RNs who are either part-time in the ASC or share responsibilities with the clinic. On surgery day, we have 11 personnel for a caseload of 20 to 25 patients, with a goal of performing four cases per hour. There are two to three RNs in the preop area. These RNs are usually the ones who have been involved in the preop assessment and are already familiar with the patient upon their arrival on surgery day. As much of the paperwork is completed prior to the surgery day as is possible. RN efficiency is further enhanced through forms designed to be completed by check boxes with minimal writing.

In each operating room, there is one RN/circulator and one scrub technician to act as a team and remain in the room throughout the day. Two sterilization techs oversee four instrument trays. These trays are designed with the minimum number of instruments needed for a routine case, with specialty instruments such as for vitrectomy available in peel pack. The close proximity of preop and recovery allows one technician in the recovery area to be supervised by an RN who floats between pre- and postop, depending on patient needs. The patient remains on a stretcher with the monitor attached from preop through recovery. The preop RN "hands off" the patient to the RN in the operating room, but a transporter does the actual moving, the goal being to keep the licensed personnel (also the most expensive staff members) focused on their responsibilities.

Good Communication

Since so many different people are involved with the patients as they move through the facility, communication is critical. I communicate first with the preop staff and deliver any significant health issues as I identify and mark the patient in the preop area. The time out in the operating room, although it takes just a few seconds longer, is actually an opportunity for a "preflight check list." At this time, not only are the correct patient, eye and procedure confirmed, but lens type and specific medical issues are identified.

Our most important tool for communication has been a worksheet summary of the day's cases. I am provided with the worksheet's list of cases several days prior to the date of the surgery. I review the order of cases with the goal being to schedule the more routine cases early in the day. The OR staff is then able to develop a routine for the day that benefits the surgeon in that the patients are at their peak level of relaxation before their anesthetic starts to wear off, their backs hurt or their bladders are full.

The worksheet allows me to select the IOL and identify special needs or pre-existing health issues. I also provide comments for second-eye surgery such as need for extra sedation. This worksheet is posted in the preop area as well as in each operating room, with a master copy going to the billing office at the end of the day to make sure all chargeable procedures have been identified. By having this information available prior to the surgery day, the OR supervisor has an opportunity to make sure that all specialty lenses are on hand and that the concerns I have identified are addressed.

Scheduling

The first three to four patients of the day are scheduled to arrive at the same time. At this time, more personnel are available to get the patients ready. There is a slight delay in the scheduled arrival time of the next set of patients, which creates a wave schedule. Maintaining this wave schedule throughout the day reduces the pre-procedure waiting time.

Maintaining Momentum

Our goal is to be able to do as many cases in the last hour of the day as we did in the first. This desire can only be met if the surgeon and staff work smoothly throughout the day. Interruptions and delays in surgery can be more fatiguing than maintaining a smooth workflow. It is sometimes easy to get into the mindset of "let's just do one more case before we break," so a lunch break is built into the schedule for all personnel. Similar to patient scheduling, this is also done in a wave so that preop personnel are returning to their duties as the surgeon and his OR crew are breaking. We do this early enough, and with enough time, for all to get their second wind.

How Much is Enough?

Your certification requirements will specify a certain number of personnel needed for OR staffing, but you also need to make sure you are covered for both changes in personnel and vacations. To run with a lean staff requires significant cross-training so that RNs who work primarily in the OR can, if needed, staff the preop or postop area and vice versa. I am fortunate to have several RNs who are flexible part-timers. They have been more than willing to go the extra mile on busy surgery days yet leave early if the surgical schedule is light. It is the responsibility of the ASC supervisor to anticipate these days and plan accordingly.

Staffing Costs

Once you have determined the appropriate level of staffing, what should it cost? The Cataract Extraction with Lens Implant Insertion, 2005 study reported that the salary for RNs had a median of $24/hour with a range of $17/hour to $70/hour, while technicians had a salary range of $9/hour to $33/hour with a median of $16/hour. For staffing numbers, the report was as follows:

 The weakness of these numbers is that they do not truly reflect the total cost of staffing.

In calculating our ASC staffing costs, I look at all personnel including business office, receptionist and housekeeping. In addition, benefits, which can add up to 20% more per employee, need to be included in determining staffing costs. Also, realize that the bottom-dollar salary is not always going to be the most cost-efficient. An RN with experience and a proven work ethic, even at a higher salary, can provide time savings and, most importantly, allow you to worry less about what is going on outside the OR.

How do you get your team to work together? New team members will see how smoothly the OR can run and buy into the concept. I did not realize the power of peer pressure until I talked to the ASC staff (see sidebar). They are proud of what they do and want team members who share their enthusiasm.

Crew Resource Management

A concept in aviation, crew resource management (CRM), is now being applied to surgery. The Bulletin of the American College of Surgeons reviewed the principles of CRM: "The theory behind team training and CRM is that complex systems break down not because of flaws in their engineering, but rather because the people operating within the system fail to interact in a manner that ensures efficiency and good outcomes."2

The Seven Principles of CRM help define consistency and efficiency:

► Command starts with the surgeon himself as the leader and is tied to the second principle of

► Leadership, which would represent effective delegation. It is all tied together by formal means of

► Communication from the top to the bottom of the organization. In theory, each cataract operation should be the same, but

► Situational Awareness makes everyone consider that each patient and each procedure is unique.

► Workload and Resource Management recognize the planning that must go into each surgery day to maximize efficiency. This is all tied to the final CRM concept, which is

► Decision Making. The surgeon/leader must ultimately decide when he/she has enough information to make a final decision.

These principles go to the heart of efficient operation and patient safety. We have adopted the CRM principles by use of our preop "worksheet," a more detailed time-out in the operating room and active encouragement of each staff member to be aware of the patient's status at all times.

Conclusions

ASCs can be profitable. Success includes recognizing that staffing is the single greatest expense and that time is ultimately the most important factor in controlling this expense. It requires that the surgeon constantly reinvent the process to critically evaluate each step from clinic to postop. Benchmarking with outside organizations helps set the bar for realistic goals, but it ultimately depends on the staff who buy into the program, realizing first of all that without efficiency they may not have a job, but at the same time feeling that they have "a nice place to work."

Richard J. Ruckman, M.D., F.A.C.S., has been in practice since 1978 specializing in cataract surgery. He is medical director of The Center For Sight, located in Lufkin, Texas, and may be reached by e-mail at rruckman@thecenterforsight.com.

References

1. AAAHC Institute for Quality Improvement. Cataract Extraction with Lens Insertion, 2005. Wilmette, IL: AAAHC Institute for Quality Improvement, 2006.

2. Healy GB, Barker J, Madonna G. Error reduction through team leadership: Applying aviation's CRM model in the OR. Bull Am Coll Surg. 2006;91:10-15;24-26.