Gaining Efficiency and Boosting Productivity

Tips to help you cut down on OR time and better organize your ASC.

By Lou Sheffler, Co-founder of American SurgiSite Centers

American SurgiSite Centers is an independent company; we design, manage and may participate as owners in ASCs. Our current portfolio consists of nine discrete centers in the northeast, in which 400 physicians perform surgery. In addition to operating our own centers, we also provide consulting services to independent ASC clients and construct surgery centers for surgeons who wish to own their centers. We've developed more than one hundred such centers around the country.

Small single-practice surgery centers that are operational 1 or 2 days a week have part-time employees crossing over from the practice to the ASC. In comparison, large ASCs with 5-day surgical schedules require their own surgical teams. The greatest advantage for the surgeon in either scenario is time efficiency.

In order for an ASC to run more productively and economically, we focus on three areas; clinical, administrative and financial issues. The following approaches can help ASCs run more productively and economically.

CLINICAL

From a clinical standpoint, it's necessary to gain efficiencies from the doctors and nurses. Only the surgeon has the decision-making power in selecting what supplies, implants and instruments are used in each surgical case. Therefore, the doctor needs to evaluate surgical quality preferences in the OR first, and work on quantitative pricing issues second. Doctors can study and learn how to be more efficient in surgery to lower costs per case. Those who are setting up ASCs should consider surgical routines, anesthesia formularies and clinical efficiencies to identify the best methods. For example, while the latest technology may be safer and more efficient, familiarity with earlier versions, which may be less expensive, can be a determining factor in making purchasing decisions.

Most doctors who've worked in hospitals recognize that a great deal of time is lost between cases. They've also learned that a full selection of medical supplies and instrumentation isn't generally available in the hospital setting. In hospitals, capital budgets and caps determine how much can be spent on instrumentation each year. Ophthalmologists in hospital settings must compete with other subspecialties for that budget.

When you open your own surgery center, the budget is allocated for your project. In opening a surgery center, it's crucial to have the right staff members in place to determine the budget, allocating overall project costs and supply purchases.

Cost per Case

At American SurgiSite Centers, we run cost per-case, per-surgeon benchmark analyses. We set up an Excel spreadsheet and list everything each doctor uses on a case. Often, a doctor is surprised to learn that certain routinely used items are very expensive — and are being used more out of habit than necessity. This is especially true of medications. For example, dilating drops are utilized prior to cataract surgery. Some surgeons may inject drugs to constrict the pupil at the end of the surgery routine, while others think this is an unnecessary step because the dilating drops wear off. These constricting drugs can cost $35 per case, depending on the brand used. Eliminating this step can save a great deal of money.

For us, it's important to evaluate all of the supplies, medications and instruments, and then make the doctor aware of the costs. This is a beneficial step because we usually uncover a cost that can be eliminated or reduced.

Efficiencies for Multiple Doctors

• Block-booking schedule. If there are multiple doctors at an ASC, it's best to implement a block-booking schedule in which each doctor is assigned a specific time to operate each week. This helps to maximize the doctor's time — a step that is often overlooked in hospitals. When doctors arrive on time to perform surgery and the OR isn't ready, they waste time and money by waiting for the previous operation to conclude so their room can be set up. Block-booking helps ensure that the OR is ready for the surgeon on time, with the OR optimally utilized.
• Standardized instruments. We recommend conducting a staff meeting to determine if it's possible to standardize instruments at the ASC and avoid having duplicates of instruments that perform the same functions. A standard surgical set, where there are fewer instruments to clean, can result in decreased wear and tear, since delicate, crowded instrument sets that are close together due to limited tray space get scratched and can be ruined. Additionally, extra instruments require more time to clean and instrument techs are forced to rush the cleaning process and may bend or dull these instruments.
• Number of ORs. For ASCs where surgeons perform cataract extractions in less than 15 minutes, we recommend having two ORs in the surgery center so there are no intermissions between cases. For oculoplastic or retina surgeons who have longer cases, it can be wasteful to have more than one OR.
• Anesthesia. Generally, there are two different anesthesia types offered for cataract surgery: topical and block. When using either, an anesthesiologist or CRNA must be present. A good anesthesiologist can perform the block on the operative eye. In the hospital setting, the surgeon often must perform this task, which takes time. We recommend using an independent contractor who comes only on the doctors' operating day or as needed, based on case types. Independent contractors do their own billing and buy their own malpractice policies, and are not on the ASC payroll, thus keeping costs down.
• Single-specialty ASCs. Single-specialty surgery centers are inherently more efficient than multi-specialty centers. There are set routines and the nurses know how to perform their jobs more efficiently in a single-specialty setting. Multi-specialty centers require more equipment, staff and supplies, which increase overhead.

ADMINISTRATIVE

The big story right now in ASCs is electronic medical records (EMR). With an EMR system, records may be accessed from multiple locations and patients can sign papers and register electronically. Also, there are no paper forms to file. In addition, templates can be established for different doctors' routines, representing a tremendous savings of time and staff.

We are familiar with an extremely busy surgery center that handles 12,000 cases per year. The ASC was using five employees for handling paper medical records. With EMR in place, that number has been reduced to just one employee — representing a huge administrative efficiency.

ASC software differs from practice software, with ASC nurses and anesthesiologists performing about 97% of the charting. Additionally, in an ASC setting, much is known ahead of time. Patients know why they are at the center — the diagnosis has already been made. Nurses handle the charts, registering patients and going over the pre-op, surgical and post-op procedures. The doctor knows he's performing a cataract extraction and the surgery information already has an existing template as part of the ASC software. In our ASCs, we prefer software with cloud capability. With client server systems, special programs must be loaded on to each computer. With cloud computing, all that's required is a computer or device with Internet access and a secure, wireless connection.

This is a much simpler way to run an ASC, but many people haven't purchased ASC software because, as of now, there's no federal incentive money. Nevertheless, ASC software helps to lower payroll and operating office expenses. There's no need for filing space, and no risk of losing files or faxes. We realized that our paper charts — including the reams of paper, toner cartridges, printers and employee time — cost $20 per chart. EMR has proven to be better, faster and less expensive than paper medical records.

FINANCIAL

There are significant differences between an ASC and a physician practice in the financial arena. In a physician practice, the greatest expense is personnel. In an ASC, it's the supplies. In our ASC facilities, 30-35% of our budget is spent on medical supplies, while personnel accounts for 21-25% of expenses.

To gain efficiencies in an ASC, it's best to fully understand medical supply costs and inventory. We feel it's worthwhile to invest in a robust accounting system with inventory tracking rather than an off-the-shelf accounting system. This system is not part of the medical software for scheduling, billing and medical record-keeping; rather, it's an accounting and inventory tracking system. Every supply and medication at the ASC comes from the manufacturer with barcodes. With most inventory software, an ASC won't need to assign barcodes. The system will simply recognize the company's code once it's listed in the ASC database. Pricing and inventory control become automated, instead of depending on personnel time.

At American SurgiSite Centers, we track over 1800 items. With our system, we order supplies which are then checked in using a barcode scanner. The scanner automatically loads the necessary information into a database. We can look at our computer screen and know exactly what we have in inventory. The system will also provide pricing on specific products from different vendors. It will tell every price paid for specific items, when more product should be ordered and how much to re-order.

In many centers, the person responsible for inventory tracking is the OR Supervisor nurse, who may fear running out of supplies, and thus over order. More importantly, nursing skills can be put to better use. Thus, it makes sense to invest in a system, such as Accpac (www.sageaccpac.com), a broad-based system that is used throughout the United States in many different industries. Accpac enables the user to order supplies and keep inventory at the right level. The system can even cut checks to suppliers and maintain books. Thus, everything fits together. Just like with an EMR system, rights and privileges can be assigned to limit access to sensitive information. This is a major cost savings. One facility we work with decreased their stock from $250,000 to $100,000. This also saves on supplies expiring — and software doesn't get sick or go on vacation.

A long list of efficiencies can be gained by learning how an ASC is running. A good first step is to evaluate what you're doing and putting it down on paper. Investing in automated systems may save time and money. ◊