Time management is a crucial issue in achieving profitability.

By Beth Hurley, R.N., B.S.N., C.R.N.O., C.O.E.

cheduling is one of the vital spokes in the wheel for a profitable ambulatory surgery center (ASC). In my experience, there must be protocol in place that allows the staff to handle the inevitable add-on cases and delays. Let�s examine the ways an ASC can make its schedule more profit-friendly.

The Flexibility Issue
Before entering into any lengthy discussion of scheduling, ASCs should address the following question: While the primary mission of the ASC is to provide excellent patient care, is a major goal of the facility to be as profitable as possible, or is it to provide the maximum amount of convenience and flexibility for the surgeons who own and/or utilize the facility? Neither goal is right or wrong, nor are they mutually exclusive, but when it comes to making choices, your answer is the basis for developing the protocol needed for the staff to make appropriate decisions. ASC owners who want a facility that works around their schedule may find it difficult to adhere to the scheduling process that is most conducive to profitability.
This issue can have an important effect for non-owner surgeons. If the owner-physicians want to have other surgeons utilize their facility, they must be flexible with their scheduling � that is, give priority to non-owners in scheduling the time they want, not limit the number of cases that non-owners bring and be willing to adapt their block times to accommodate. Surgeons will want to bring their cases to your facility if they can get the OR time they need, have knowledgeable staff to assist them, have the equipment and supplies necessary and are treated as customers.

Plan Ahead
Decisions in scheduling must be based on accurate data � knowing the facts about the surgeons who use the ASC is essential to appropriate scheduling. Retrospectively, review medical records from the last quarter and assess the following for each surgeon:
- patient arrival time to OR start time
- scheduled time vs. actual start time
- length of surgical procedure: incision to close of case
- turnover time: close of case to next incision
- recovery room time.

An evaluation of each step is needed to ensure effective scheduling of cases. Consider arriving ahead of your scheduled start time to address any last minute issues so that surgery can start on time. Try to streamline the preop process. For example, some surgeons use a compounding pharmacy to mix patients� dilating drops and giving them to patients, along with all the instructions they will need, in a visit in the days preceding surgery, or use a compounded mixture of dilating drops instilled when the patient first arrives in the facility.
Assess the patient, and when appropriate, use a saline lock instead of starting an IV. In order to start on time, the patient must be ready. If a surgeon takes an average of 12 minutes for the procedure from incision time to close of case and 3 minutes to turn over, then it is appropriate to schedule four cases per hour. Remember that it may take more than 15 minutes to discharge the patient from the recovery room, so plan ahead by discussing postop instructions in advance. Because many of the patients are elderly, remember that the staff should not rush them. When an elderly patient in need of extra time is coming in for a procedure, have staff schedule additional time for admission and discharge.
In order to make changes that will increase efficiency, it is important to know what you are currently doing. By performing a retrospective study, you will be able to assess what areas your facility needs to address.

Time Well Spent
Another way to plan ahead is to have the admitting staff call patients the day prior to surgery. This is beneficial in many ways:
- to confirm the correct arrival time
- to ensure the patient knows where the facility is
- to complete a patient history, including medications and dosages
- to remind patients of requirements on their surgery day, such as NPO status, medications to take, what to wear, insurance cards, or deductibles and/or copays
- to remind patients that they will need a responsible adult to take them home.
Remember to have your staff evaluate patients preoperatively � before scheduling the case. Patient safety must always be the top priority. For example, patients with diabetes are usually scheduled first thing in the morning. However, if they are allowed a light breakfast and morning medication, with an NPO regimen afterward, these patients may do well when scheduled as the first case of the afternoon.

Built-in Efficiency
It is much more efficient to schedule full days vs. half days of surgery. If a facility can schedule four 10-hour days of surgery vs. opening 5 days a week, it will save a significant amount of time and resources. After all, it takes considerable time and resources to set up the facility and, at the end of the surgical day, to clean up. A substantial amount of time is required to open an OR and get it ready to start cases, as well as getting the equipment prepared for use.
Ideally, the best time to address scheduling efficiencies is when the facility is being designed. For example, if the ASC has only one operating room, having a sterilization room that is directly connected to the OR allows for the complete set-up of the next procedure. Having two operating rooms requires duplication of all the equipment and an additional circulating nurse, with a minimal gain in efficiency. Alternately, a sterilization room between two operating rooms allows two surgeons to operate at the same time with the same efficiency.

It is always most efficient to have a single-specialty ophthalmology ASC. For surgeons in multi-specialty facilities, it is essential to have a dedicated staff to process cases. Schedule topical anesthesia for patients who are good candidates. An appropriate evaluation is critical; have a protocol that allows staff to evaluate the patient the day of surgery. Although a block may take a few more minutes to accomplish, if the patient is unable to cooperate during the surgical procedure the whole process becomes much more difficult. If you utilize anesthesiologists, allow them to do the block in the preoperative area.
Chart Your Course
To ensure a productive surgical schedule, it is essential that the ASC owners determine what their goals are. Only then can the facility assess � quantitatively � where it currently stands. This information is necessary for the final step � establishing a path to get where the owners want the facility to go. OM

Beth Hurley, R.N., B.S.N., C.R.N.O., C.O.E., is the executive vice president of Provision Surgical, LLC. E-mail her at bhurley@provisionhealthcare.net.