Time management is a crucial issue in achieving profitability.
By Beth Hurley, R.N., B.S.N., C.R.N.O., C.O.E.
Scheduling 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.
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
Staying on Schedule
Here are some basic tips for efficient scheduling that are easy to
implement:
- Be on time for your surgeries: the staff will follow your lead.
- As the surgeon, assist with turnovers: Instead of leaving the room,
clean around the eye, put on the dressing and transport the patient to
the recovery room. This allows the surgical technician to process the
instruments and the circulating R.N. to start the turnover process.
- Do not plan on seeing patients between cases (exception to this rule:
long turnover times due to facility design or resources provide
opportunities to schedule a YAG laser between surgical cases).
- Have only basic items that you will use on every case on your tray.
Keep others in sterilized packages that are readily available.
- Having a sufficient number of instrument trays is imperative to low
turn-over time and allows for appropriate cleaning of instruments prior
to sterilization.
- Scheduling the same side cases together will decrease the amount of
time needed to rearrange the OR and equipment.
- Depending on the surgeon�s preference, schedule the most difficult
cases either first thing in the morning or last of the day.
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.
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