The Two-Room OR

Efficiency + Volume = Success

BY BRAD BLACK, MD

For those of you who've added an ASC to your practice and are looking for opportunities to improve its performance, you can boost profitability with the added efficiencies of a second OR, but how do you go about justifying this addition? While my practice has doubled our number of surgeries since adding a second OR, we also had the necessary volume prior to building our ASC to warrant the added capacity. So the question is: when is it time to add a second OR and how do you make the transition to a two-room OR?

Things to Consider

I asked my practice administrator, Sarah Cwiak, to research several questions. Before committing to the second room, she compared our input and output with cataract patients and how backlogged we were with the scheduling of our surgeries. She concluded that one OR was not sufficient for our practice, as we had patients waiting a month or more. We have found that our patients want to be seen more quickly. The long wait time was more than just a patient satisfaction issue; it also impacted our surgical volume. She found that when we were scheduling out past three weeks, we had an increased number of cancellations.

So, you must ask yourself: Am I having trouble fitting my surgical cases in within a three-week range? How much time does it take you to schedule your surgeries compared to the time you're in the office? Is one out of every 20 patients a surgical appointment, or do nearly all of the 20 patients who have been pre-screened schedule surgeries?

You also need to consider what type of surgeon you are. If you are one of those doctors who use three tubes of viscoelastic and takes 45 minutes for a procedure, then you obviously don't need a second room or at least might have difficulty justifying the added expense. Similarly, if you are routinely taking a half-day off or have trouble filling your schedule, then you might not be able to justify that second room.

You must certainly weigh your input against the costs of more space, more personnel and more equipment. Will adding a second OR increase your per-case costs or actually lower them?

For the sake of argument, let's suppose an ophthalmologist, or group of ophthalmologists, performed 2,000 cataract surgeries a year in this facility. Our administrator considered a four-day work week with four “sessions” per week, each lasting approximately four hours — and calculated the annual volume (the remaining time used for YAGs, retinal cases, plastics, stocking rooms, patient calls, etc.). If you do the procedures in one room, one might routinely average three cases per hour — which translates to about 2,000 cases a year. If you are an ophthalmology-only practice that consistently maintains that volume or is looking to grow, it might be time to consider a two-room OR. By doubling your production to six cases in an hour, you could easily expand your potential capacity to 4,000 cases per year, provided the caseload is able to fulfill that.

If you are an ophthalmology-specific ASC and you're doing fewer than 12 cases a week in one or two sessions, it would not be profitable to go to two rooms. In other words, if you are doing between 600 and 800 cases annually, perhaps the practice can only support one operating room. However, as one's practice grows to say, 20 to 30 cases a week, 1,200 cases a year, I believe that's probably justification enough to consider a two-room set-up.

Multi-Specialty ASCs

If you are in a multi-specialty group, I think the diversification and limited OR time might help support a second OR even at a lower cataract surgical volume, especially if you're doing upwards of 20 cases per week. As mentioned earlier, it is difficult to consistently complete more than three to four cataract cases an hour in one room. Other specialties obviously may take longer to complete their cases. Perhaps if we had not brought in other surgeons, it might have been more difficult to justify the cost of the second OR.

In our practice, we have an outside retina group that functions as an independent contractor. We bill and collect for their services and give them a percentage of revenue generated by their patient base. They use our OR, but do not have an ownership stake at this point in time. We provide the equipment, supplies and personnel, all of which is considered part of the overhead. Of course, in the first year, most of the revenue generated from their surgery went directly to new equipment expense. We have the capacity to further condense our day to fit in additional retina volume. It has, of course, required additional staff training to add retinal procedures to the mix.

As a side note, Medicare reimbursement for retinal ASC procedures has been significantly increased in recent years. This, along with the fact that retinal procedures have become relatively quicker, makes it really quite feasible to add these surgeries to an ASC schedule.

Making the Transition

How do you transition to adding the second OR? Obviously, personnel is the biggest consideration aside from space requirements. An ASC needs efficient and flexible staffing to be profitable, but it's especially critical in order for a two-OR setup to run smoothly. In our facility, we now have five RNs, which include our director of nursing. We added three RNs because we did not want to overburden the existing staff once we transitioned to two rooms. We have an RN in each room as well as one for preop and one for postop. There are five other employees: a “float” between the two rooms, a circulator in each room, someone at the front desk, and lastly, our “jack-of-all-trades” who fills in wherever needed. That is a total of 10 employees, each working up to four days a week, a sufficient number to allow for excellent patient care and a great work environment.

We are huge advocates of cross training and delegating with our staff. They handle most of the discussions with the patients; even the postop discussion with the patient and family is handled by a staff member. As my practice administrator says, patients want and deserve attention as well as information given on a level they can understand, so we make sure that the staff member who does this does it well. Our staff is very patient and very proficient at their job. We want them to have a pleasant interaction with the patients.

This reliance on staff delegation allows me to concentrate on surgical procedures. I do call all my patients personally every night after the surgery — and that could be up to 30, 40 or even more on some nights. I make those phone calls because I think it's very important to maintain that contact, especially if I don't have a chance to talk to the patient immediately after the procedure.

After we added our second surgical suite, the staff felt the volume increase. Even though they individually might only be involved in four or five more surgeries a day, they felt they were working a lot harder. We paid a lot of attention to morale and gave “rewards” to reach the level of efficiency we needed. Simply complimenting the staff on their efficiency goes a very long way. However, we occasionally give out gift cards for staff members who come up with ideas that make the OR run more efficiently. Emphasizing teamwork, and providing both verbal and financial expressions of gratitude to our staff, allowed for a smoother transition.

Equipping and Scheduling

You must very carefully consider the cost of equipping a second room. The necessity of having two full sets of equipment and multiple sets of instruments is obviously a sizable investment and unwise purchasing could jeopardize the endeavor. Look for opportunities to keep the initial outlay manageable. For instance, we re-use instruments when possible, which helps with cost and efficiency, though certifying agencies are frowning more and more on re-use of blades, cannulae and even tips. Since we attempt to do right eyes in one room and left eyes in the other room, we simply move our endoscopic cyclophotocoagulation (ECP) machine to the other OR during lunch having scheduled accordingly all ECPs for either eye in the same session. Purchasing two units to prevent going back and forth would have been cost prohibitive. Checking with distributors for certain “used” equipment at a “bargain” can be very helpful. There are also the smaller purchases such as trays, handpieces and sterilizers to consider. Your typical case may take less time than one “sterilization cycle,” therefore requiring multiple instrument sets and sterilizer units to prevent delays in starting your next case. As well, with the recent emphasis on sterilization cycle time, make sure your unit provides the necessary times required.

As far as the OR schedule, I obviously do not handle this myself. I send all of the patients' names along with the procedure to my staff and they put together the schedule. Originally this was done by the RNs at the ASC. More recently however, we have asked our clinic schedulers to handle this, which we feel is more cost effective and provides better “continuity.” Then, weekly at a designated time, a “roundtable meeting” is convened with one of the RNs from the OR and our clinic scheduler to review each and every chart. Surgeons' schedules are typically closed two days before surgery day, though exceptions can be made for last minute additions. These meetings may seem a little tedious, but this is our final check from which each patient's IOL is pulled ahead of time and op times are finalized.

Tweaking our schedule for maximum efficiency took a fair amount of trial and error. There are so many small yet important scheduling items to consider: If you have a patient with latex allergies, you will want to schedule those as the first procedure of the day. You may also want to handle a MRSA case last so that the room can be “terminally cleaned” at the end of the day. Personally, I like to finish the day with the tough cases.

The increased use of premium lenses adds another layer of complexity to scheduling. We try to avoid scheduling toric lens implantations back to back if possible, given the added preop step (i.e., marking the cornea with the patient sitting upright) and use of single item instruments, e.g., axis markers, that need resterilization prior to use. Similarly, when performing LRIs, we separate those procedures as well so we can re-sterilize the blade between cases and prevent unnecessary delays.

Our workflow can get quite complex, especially if 40 or 50 surgeries are scheduled in a single day. It's daunting, but not overwhelming. This is where the staff's creativity can really shine, as each practice develops unique protocols that work best in that particular setting. Below are some of the ideas that have helped us streamline our workflow:

► We use highlighters of various colors directly on the day's schedule to identify “special consideration” patients who might need to be marked in the preop area for cylinder (for a toric lens or PLRIs) or require any special equipment in the OR such as an ECP unit.
► We mark the floor with different colored dots for each surgeon so that if machinery needs to be moved for different doctors, it is done more efficiently.
► We attempt to have one OR room set up for the right eye and the alternate room for left eyes.
► We schedule two patients every 15 minutes, but average about six cases an hour. This creates a slight backlog but allows for cancellations or those days when “things just happen faster.”
► Our patients stay dressed and are simply covered with a sheet. Not asking patients to change into surgical gowns eliminates an unnecessary step in the preop process and frees up a changing room. Plus, patients prefer being clothed.
► We very rarely start IVs. We use sublingual Versed 2 mg to 5 mg for most patients, and this can easily be supplemented as well.
► Monitors are attached to the end of each bed. Patients are therefore hooked up only once throughout the entire procedure — a real time-saver. The only difference now is, with two rooms, it requires six beds — and they're continually being moved in and out.
► We also have a “cheat sheet,” our version of the patient information sheet that is considered the “final answer.” We like to put down anything and everything out of the ordinary besides the eye and IOL power: whether we're doing ECP, if the patient is on Flomax, if they've had a vitrectomy, if they are mentally challenged or hard of hearing. We keep this sheet clearly visible at all times so that I can just glance up and take a look at the sheet when needed.

What's Behind Door Number Two?

So what happens in room two while I'm operating in room number one? All prep work must be completed so that there's no downtime between cases. We tell our patients that we have an “efficiency line” and not an “assembly line” — everything is streamlined and ready to go in that second room.

After the patient is brought into the OR, a staff member will position the patient in the bed and bring in the oxygen. The patient's head will be gently taped down and the eye prepped. I also delegate draping of the eye to the OR staff. They will actually cut the drape and place the lid speculum — all while I'm working in the other room. The patient is ready about the time I'm walking out of the other OR.

As I walk out of that room and enter the hallway, I can block a few patients ahead and/or answer “relevant” questions from the staff. The waiting patients are all on monitors. Our CRNA is with me. The scrub will take the drape off the patient postop, instill any meds in the eye, place a small piece of tape on the eye and take the patient out of the room. While I'm getting ready to start my next case, they are in recovery reassuring the family and the patient, saying, “Dr. Black just wanted to let you know that everything went great and he'll be calling you tonight to make sure you're doing well.”

Focus, Focus, Focus

Lastly, remember to stay focused on the details. If you're doing a large volume of cases in a day, it's often the small things that can make a big difference. For instance, assuming you have 10 or 12 instrument passes per case, and you delay each step only 15 seconds, that's three minutes a case! If you do 40 cases — that's a total of two hours of wasted time. Imagine what that does to your time and your overhead! Similarly, if you learn to stay focused through the scope while your scrub anticipates your every move, they will have your next instrument waiting for you as close to the field as possible, minimizing hand movement and time out of the eye.

Basically, in justifying a second OR, you need to do a cost-benefit ratio for your individual situation. You have to look at your capacity time wise, your personnel and your lifestyle requirements. If your overall schedule is packed, get a second OR and gain another day to schedule additional cases or, if for nothing else, your mental health. OM

Brad Black, MD, is the founder of Eye Associates & the Vision Surgical Center Jeffersonville, Ind. He maintains an Ophthalmic Surgical Center of Excellence. In practice for 20 years, Dr. Black specializes In anterior segment eye surgery and Is one of the most experienced surgeons In the region.