Game Plan for a Winning Practice

Ten strategies to improve efficiency, simplify workflow, cut costs and eliminate waste — without compromising care.

By F.W. Fraunfelder, MD

With pressure mounting for physicians to find new efficiencies in the delivery of healthcare — so as to help improve the sustainability of the delivery system in the US — it can be fruitful to look to industry for inspiration. Manufacturers have a much more robust experience with the concepts of workflow efficiency. By applying manufacturing process methodologies to ophthalmic procedures, the following 10 suggested changes could improve efficiency, control or lower costs and maintain quality within ophthalmology.

Some of these ideas may be new; others are already being instituted (i.e., comparative effectiveness, electronic health records) but only sporadically. All suggestions derive from the principles and the manufacturing industry process tools discussed in last month's article, “Make Yours a Lean Practice” (December 2011).

1. Limit Surgeon Choice

Surgeons are notorious for wanting exactly the instrument, material or machine they want when they want it. It takes a tremendous amount of confidence and independence to take responsibility for a patient's vision, so one can understand the physician culture of being highly specific in requests for materials. What if each surgeon used different instruments for the same procedure? The operating room would have to stock a variety of products that probably achieve the same result, ultimately without much difference.

A simple example is suture material. To close the conjunctiva, a surgeon has a number of choices. He or she could use 6-0 plain gut, 6-0 fast gut, 6-0 vicryl or choose any number of different sizes or materials of sutures with different types of needles. Say the only choice was an absorbable 6-0 suture with the same needle — which choice should the surgeon make? The cheapest suture is the 6-0 plain gut, and there is no published research that shows 6-0 fast gut or 6-0 vicryl is more effective or safer than 6-0 plain gut. According to lean manufacturing process theory, the surgeon should only have the choice of the 6-0 plain gut for closing the conjunctiva.

Limiting the surgeon choice in instances such as this, and hundreds of other situations, would probably lead to significant savings on a yearly basis. The question is, will the surgeon allow his or her choice to be limited? Outcomes will not be affected by the decision, but physician autonomy would. That is a dynamic that we as a profession need to confront, and the sooner the better.

2. Limit Vendors to Gain Leverage

Industry wants to sell their products to large eye hospitals and medical practices. If a practice decides to stock five different kinds of antibiotic eye drops, it is likely that the cost difference between these eye drops is significant. Some drops may cost $5 and others may cost $70. However, there is no evidence that an expensive eye drop is better at decreasing the incidence of endophthalmitis than a cheaper eye drop. Limiting the surgeon choice to just ofloxacin is an obvious decision. If the hospital only stocked ofloxacin in the operating room, the vendor will, more likely than not, provide a discount. It also simplifies the ordering and stocking process for the administrative staff.

Buying in bulk allows pharmaceutical companies to provide discounts that would otherwise not be feasible if only small amounts of product are purchased. Limiting vendors in areas such as phacoemulsification machines, surgical instruments, drapes, sterilizing solutions and even surgical gowns could lead to significant savings over time. Again, will the surgeon allow his or her surgery to be performed with only what the operating room provides, or will special requests eliminate the anticipated cost savings?

3. Make Decisions Based on Comparative Effectiveness

Ophthalmologists are surgeons, and surgeons are early adopters more often than not. New technologies are exciting, and many of us want to be the first to try the latest devices. Early adopters of new technology abound within ophthalmology and throughout medicine. However, just because a new instrument is available doesn't mean it provides better results.

A good example of this is the advent of femtosecond laser-assisted keratoplasties (FLAK). Traditional corneal transplants are performed with a trephine, or a circular blade, to prepare the donor tissue and the host tissue. FLAK uses a laser to prepare the host and the donor. It would seem the accuracy of a laser in preparation of tissue would lead to better visual results and less astigmatism. At a cost of more than $2,000 per eye, FLAK has not been shown to improve visual results or improve astigmatism long-term after corneal transplant surgery.¹ The ophthalmic community still frequently performs FLAK — because they have purchased the laser (for approximately $400,000). However, it should be realized that examples exactly like this are significantly responsible for the increased cost of healthcare in the US.²

If feasible, comparative effectiveness should be analyzed for every surgery and procedure an ophthalmologist performs. The NEI-funded CATT study comparing Lucentis and Avastin did our profession a great service; more studies in that vein are urgently needed.

4. Pursue Cost Effectiveness

Measuring cost effectiveness frequently uses a statistical tool called “quality-adjusted life years” (QALY) — in other words, how many years of life would a patient gain by having an eye surgery or other type of treatment? The NHS in the UK rations care based upon the amount of dollars per QALY.³ For instance, if a medical treatment costs £50,000 per QALY, it would not be approved. Determining what is cost effective in the US has been studied as well, especially for cataract surgery.⁴

What about less common surgeries? Which surgeries are cost effective in restoring eyesight? Taking the example of FLAK above vs. traditional corneal transplantation, it has become clear that FLAK is not more cost effective than traditional corneal transplants at a cost of $2,000 more per surgery with the same surgical results. This was borne out through a patient survey using a commonly performed statistical method called a “standard gamble” (unpublished research).

Although ophthalmic surgeons do not always have cost effectiveness peer-reviewed literature to refer to, subjective results and experience can lead surgeons to the correct choice in most instances. Using cost effective practices will help keep costs down while maintaining quality.

5. Embrace Electronic Health Records And Meaningful Use Criteria

EHRs are going to be important to the future quality of healthcare. Meaningful use, although currently ill defined and not universally adopted throughout healthcare, can be summed up by the concept of keeping good electronic records so as to maintain quality patient care. Being user-friendly with sharing EHR information between providers, computer provider order entries, problem lists, E-prescribing, active medication lists, medication allergy lists, patient demographics, vitals, body mass index, growth charts, smoking status, incorporating clinical lab tests, electronic access for patients and after-visit summaries are all tracked to assess compliance with meaningful use based upon Medicare guidelines.

It is somewhat perplexing to see physicians — so naturally predisposed to data-driven decision making — resist the implementation of EHR and thus deprive themselves of the treasure trove of data it records and makes available for later analysis.

One challenge of EHR is that not all hospitals and physicians use it. Up to one-third of doctors are in solo practice, and they are less likely to use EHR than doctors who are part of large group practices. Currently, approximately 50% of physicians (of all stripes) have a basic EHR; however, only 10% have a fully functional meaningful use type system.⁵ This will have to change if quality of care is to be achieved and cost savings realized. Savings on letter dictations, staff time, record storage, postage, reprints of photographs and the cost of paper itself can all make an EHR worth the investment. The most important aspect, however, is improved record keeping to improve quality of care for patients. The push for meaningful use is pertinent and probably worth the investment of time and resources. Medicare reimbursement will be tied to meaningful use of EHR.⁶

6. Remove Redundancies And Eliminate Waste

There are a number of redundancies within the healthcare system. Some are probably worthwhile for safety reasons, as surgeons do not want to miss an allergy to a medication, operate on the wrong site or put in the wrong intraocular lens during cataract surgery. Still, there are some key steps in the preparation of a patient for surgery that can be removed without harm.

Peer-reviewed evidence has shown that eliminating the preoperative electrocardiogram, routine blood work checking for blood counts and electrolytes, internist visits prior to surgery, the postoperative day-one visit with the surgeon in lieu of a phone call by an ophthalmic technician all would continue to protect the patient and maintain quality of care while decreasing the cost and time of caring for ophthalmic surgical patients. None of these measures — which are routinely performed in the US — add any benefit except in a small percentage of patients who may be in a higher risk category. These steps can still be ordered in those instances where it is deemed necessary.

7. Eliminate Bottlenecks

Almost any process reaches a bottleneck at a certain point. Sometimes the best way to identify bottlenecks is to create a process map and study where workflow slows down the most. Identifying the bottleneck and either eliminating it or minimizing its effect can have profound implications on efficiency of care, decreased wait times, increased patient satisfaction and also decrease costs due to using less OR time.

In many ophthalmic operating rooms, the rate-limiting step is room turnover in preparation for the next surgery. It is up to the hospital or ambulatory surgical center to decide how best to deal with bottlenecks. Some surgeons employ more than one room so one can be turned over while another surgery is being performed.

Surgeons could hasten room turnover by actually doing some of the jobs not necessarily associated with the operating surgeon — such as wheeling the patient back to the OR, starting the dilating eye drops, starting the intravenousline, marking which eye should be operated on, and preemptively informing the surgical technician and nursing staff what equipment will be needed. The idea of the surgeon in the surgeon's lounge drinking coffee or visiting with colleagues may be behind us as we attempt to increase efficiencies and lower costs.

8. Draw on Venture Capital

The pathway for devices that require FDA premarket approval now typically spans 8-12 years and $80 million to $120 million to navigate. A genuinely novel drug may take even longer and cost as much as $500 million to $2 billion. This process severely limits innovation, creating a need and opportunity for venture capital investments.

Up to 60% of the ophthalmic global market is now outside of the United States, and there is real opportunity to build companies outside the US. While not advantageous for the US surgeon, innovative products can still be developed elsewhere for use in the US when efficacy and safety are proven either through FDA approval or through approved standard of care from published peer-reviewed literature. Examples of successful venture capital investment include accommodating intraocular lenses, femtosecond laser-assisted cataract surgery, intracorneal lenses for presbyopia, and new medications for dry eye and surface eye disease.

The annual Ophthalmology Innovation Summit (www.ophthalmologysummit.com) meets yearly with its purpose to support innovation by facilitating deal-flow and business partnerships between the leading CEOs, venture investors, corporate strategic executives, physicians and academic scientists in the field of ophthalmology. With the advent of dwindling healthcare dollars and impending healthcare reform, embracing venture capital for ophthalmic device and drug innovation will be an important aspect of future quality care.

9. Improve Clinical Practice Using Clinical Decision Support Systems

One of the most effective means of improving quality of care within medicine is the use of clinical decision support systems through EHR. Kawamoto et al. analyzed 70 randomized controlled trials and identified four features strongly associated with a decision support system's ability to improve clinical practice.7 These are systems that:

1. Provide decision support automatically as part of clinicianworkflow.
2. Deliver decision support at the time and location of decision-making.
3. Provide actionable recommendations.
4. Use a computer to generate the decision support. These tools derive from ideas garnered from project management process tools available in the business world.⁸

Although it would be impractical to apply electronic, computer-based decision support systems to all disease processes, there is strong evidence these tools can be helpful in the management of more common conditions where the body of medical knowledge has already arrived at so-called “best practices.” These include management of inpatient diabetic patients and postop care for cataract patients. Many hospital-based EHR systems already incorporate automatic and immediate electronic notification of adverse medication interactions or allergies when medication orders are entered on the computer. Adoption of electronic clinical decision support systems is a promising area for quality improvement of medical care both within ophthalmology and medical care in general.

10. The Ophthalmologist Must Lead, And Champion, the Process

Physicians are independent-minded, and many ophthalmology chairs of large departments state that building consensus among eye surgeons can be challenging. The future of medical care is going to change drastically due to legislation and also because the current increase in medical costs as a percentage of GDP is unsustainable. The spiraling costs of care will force changes upon the US healthcare system, and if physicians don't impart their healthcare and disease management process knowledge, the transition will be more difficult than it needs to be.

Throughout the process of healthcare reform, when talking about instituting lean practices, benchmarking or Six Sigma, it is imperative that top administrators have a constant presence. Evidence is overwhelming that if the physician leads, operational process changes have a much greater chance for success. The top administrators of most academic departments and group practices almost always have an MD as the leader or co-leader. A hands-off approach will not suffice if meaningful change and buy-in from staff is expected.

Ophthalmic leaders should educate themselves on meaningful use, quality improvement, EHR, benchmarking, lean business practices and any other quality and costsaving initiatives that they feel will help their organization. With these tools at our disposal, surgeons can lead the charge for change. The sociotechnical aspects of applying business processes to medicine are not trivial. In fact, such barriers may prevent success in many instances. But who better than the physician — who understands both the goals of change (improved quality and decreased cost) and the language of medicine — to problem-solve for the stakeholders in our collective drive for greater success in cost effective healthcare delivery? OM

References

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3. Mason H, Jones-Lee M, Donaldson C. Modelling the monetary value of a QALY: a new approach based on UK data. Health Econ 2008, Oct 14
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6. Chiang MF, Boland MV, Margolis, JW, Lum F, Abramoff MD, Hildebrand PL; American Academy of Ophthalmology Medical Information Technology Committee. Adoption and perceptions of electronic health record systems by ophthalmologists: An American Academy of Ophthalmology survey. Ophthalmology. 2008;115:1591-1597.
7. Kawamoto K, Houlihan CA, Balas EA, Lobach. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005 Apr 2;330(7494):765.
8. Kaufman DS. Using project management methodology to plan and track inpatient care. Jt Comm J Qual Patient Saf. 2005 Aug;31(8):463-8.