The Efficient Ophthalmologist

Efficiency Can Begin With a Simple Checklist

By Steven M. Silverstein, MD, FACS

The title of this new column, The Efficient Ophthalmologist, is deliberately vague so that the topics selected may be timely and diverse, and that the column itself remains malleable and responsive to changes that affect the practice of our specialty. But confronting change also requires that we do not discard tested mechanisms of practice management. It is these mechanisms that will help reveal the solutions, or at least identify the problems, that best ensure that our practices remain viable, progressive and profitable.

Testing the waters outside of our comfort zone sounds simple enough, but is actually quite difficult, especially when such changes can be costly and may represent an enormous shift in our practice culture. These paradigm shifts (EMR adoption, practice expansion, significant change in payer mix, adding ancillary services, for example), are both disruptive and speculative, leading us down uncharted and uncertain paths.

However, with appropriate due diligence, outside consultation and a finger on the pulse of our marketplace, these changes may not only ensure our survival, but be the catalyst for otherwise unlikely growth and further success.

The Value of the Checklist

For this first column, I know of no area more deserving of our inspection than that of the checklist. First popularized by the airline industry to improve its safety record and efficiency, it has been adapted and introduced to medicine by Dr. Atul Gawande, a general and endocrine surgeon at Brigham and Women's Hospital in Boston and associate professor of medicine at Harvard Medical School.

His book, The Checklist Manifesto (How to Get Things Right), is a must read and will make you a believer in the value of making checklists for a wide range of tasks.

Checklists are essential for safety, consistency and efficiency. They are now mandated by federal law in every hospital operating room and ASC. The OR checklist, sometimes referred to as a mandatory “time out,” is a critical component of every state and federal facility inspection. In our ASC, just such a checklist has prevented dosing errors and surgery performed on the wrong eye. Most recently, a patient's cataract surgery was scheduled for the right eye. He was properly consented and correctly prepped by the circulating nurse. The surgical scrub, however, mistakenly draped the fellow eye (presumably out of habit from the preceding two cases) before the surgeon entered the room. The surgeon approached the patient, and thankfully, the error was identified by the circulating nurse as she was going through the final checklist prior to the start of the case. While very rare, such examples of near or actual mistakes are well documented. Nothing has been shown to lessen this risk more than the adoption of the “time out” checklist.

While checklists that “save the day” in the hospital or ASC provide dramatic examples, they are essential for much more than safety. Checklists are an efficient and cost-effective mechanism for ordering and restocking expensive medical supplies where excessive inventory can decrease profitability and worse, lose you money due to unreturnable expired medications and sterile, single-use items. One such checklist we use in our facility recently saved us over $1,000 as the nursing supervisor was checking for items soon to expire and discovered that we had a large box of about-to-expire phaco packs for a phaco machine that we used mainly as a back-up. We then used this phaco unit until these dated packs were consumed.

In my next column, I will examine the role of the checklist in the practice/clinic setting, where economies of scale, patient scheduling and flow, and, yes, safety, are of paramount importance. It is my hope that you will find the information and ideas provided in The Efficient Ophthalmologist useful in everyday practice. Please contact me with any thoughts or questions that you may have. OM

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.