SUBSPECIALTY SERIES | PART 3

Going Live

Practical tips to ensure your ASC is ready for a new subspecialist’s first surgery day

By Virginia Pickles, Contributing Editor

You’ve done your due diligence and decided that integrating a new subspecialty into your ophthalmic ASC makes sense for its long-term success. Soon, your team will need to spring into action to prepare themselves and the facility not only for a new surgeon, but also for a whole new set of procedures. In this article, clinic directors and ASC management offer their recommendations for a smooth transition.

Share Goals with Surgeons and Staff

Even before you begin your search for a surgeon or group for a new subspecialty, it’s important to discuss the reasoning behind this decision with everyone in your organization, says John Swencki, CEO of The Eye Associates in Bradenton, Fla.

“Once you’ve identified a goal that necessitates bringing in a new subspecialty — whether it’s to increase revenue, better utilize sunk costs or assets, or offer a more complete continuum of ophthalmic care — the leaders of the organization should brief everyone on the goal and then involve them in the process,” he says. “In my experience, staff members tend to be more receptive to change when they are part of the process from the start. What’s more, one of the current doctors or staff may even be aware of a subspecialist in need of ASC time.”

Tap Multiple Training Opportunities

Once you’ve found a surgeon or group that will be a good fit and worked out the contractual details to everyone’s satisfaction, the on-site integration process begins in earnest. One of the most critical tasks is staff training.

Some of the best staff education is provided by instrument and equipment manufacturers, says Cathleen M. McCabe, MD, medical director of The Eye Associates. “They are valuable resources, often providing staff training along with support for the surgeon, including additional supplies during the first days of a new procedure with new equipment,” she says. “A transitional time can be an opportunity to try different manufacturers to find the best fit for a particular setting, especially if new equipment is being purchased. During this time, surgeons may have access to choices that are new or upgraded versions of tools they’ve used in the past.”

Casey Hertz, RN, BSN, clinical director of Empire Eye Physicians and Empire Eye Surgery Center, Spokane, Wash., also regards manufacturers’ representatives as important educational resources for staff. “The company reps can lay the groundwork for us by providing baseline knowledge,” she says. “I always invite them to our facility when I hire new staff, because they are such good teachers. In addition to teaching us how to use the equipment, they are well-versed in the anatomy of the eye.”

A retina surgeon recently joined Empire Eye Physicians and will likely start operating in the surgery center in about a year. Before the surgeon moves from the hospital setting to the ASC, Hertz plans to schedule mock surgeries so the surgeon can describe the various procedures in depth, and staff members can ask questions. She also plans to observe some retina procedures in other local ASCs to better understand what’s required of support staff.

Such reciprocity is not unusual, says Gwyn Grassett, clinical director of Surgisite Boston, Waltham, Mass., where surgeons perform a range of ophthalmic procedures, including cataract, cornea, glaucoma, oculoplastic, and retina. “There’s a strong bond among ASCs,” Grassett says. “We’re competitors, but we also help one another. If a piece of equipment fails, for example, I know I can borrow a replacement from another surgery center. Because of that rapport, if I know an ASC is bringing in a new subspecialty, such as retina, I invite the staff to our facility when we have a day of retina procedures scheduled, so they can observe, talk to our staff, and learn the basics.”

When integrating retina in particular, Grassett recommends intensively training a few key personnel first. “Retina surgery is more complicated than other ophthalmic procedures,” she says. “Because of the specialized equipment and instruments, we spent a tremendous amount of time training staff. We trained only a few people initially to form a strong knowledge base before we trained the rest of the staff. The goal at our surgery center is to have all staff members trained to work with all surgeons for all procedures.”

Get to Know Your Surgeon(s)

Every surgery center has standard protocols, including a to-do list to which staff refer when a new surgeon comes on board. Among those tasks are verifying the surgeon’s credentials, updating standard office forms, and documenting and learning the surgeon’s preferences. The importance of the latter is heightened when the new surgeon will be performing procedures that are unfamiliar to the staff.

“It’s helpful for the new surgeon to provide procedure cards that list instrument preferences and the order of the steps of the surgery prior to the ‘go live’ date,” Dr. McCabe says. “The surgeon can then review the procedures with the nurses and technicians so everyone understands the process for different surgeries, and there are no surprises.”

Amy Wiatt, RN, director of surgical services for Pepose Vision Institute in St. Louis, says surgeons’ preferences may differ widely, particularly among the various ophthalmic subspecialties.

“We need to determine how a surgeon wants the room set up, how the patient should be positioned on the bed, how the eye should be prepped for surgery, and so on,” she says. “For example, in our surgery center, the cataract surgeons use betadine swab sticks, while the retina surgeon prefers that the circulating nurse sterilely prepare the eye using betadine and gauze sponges. In addition, the retina surgeon uses a wrist rest for surgery and has us place a clear plastic shield over the patient’s nonoperative eye.”

Wiatt, who was a circulating nurse for a retina surgeon for 2 years, notes that anesthesia preferences may be significantly different as well. “We generally use only midazolam for our cataract cases,” she says. “However, our retina surgeon uses retrobulbar blocks for every case, which require deeper anesthesia, so we now stock propofol and fentanyl in our ASC.”

The best way to prepare, Dr. McCabe says, is to observe the surgeon in surgery. If that’s not possible, then the surgeon may be able to provide videos for staff to watch. Dr. McCabe also recommends that staff members assemble an emergency kit with less frequently used but critical tools to ensure that they are prepared for unexpected events prior to the first day of surgery. “For instance, available sclera and tube shunts were requested by our glaucoma doctor,” says Dr. McCabe, “and our cornea specialist requested that fibrin glue, sealant, and amniotic membrane be on hand.”

Avoid Scheduling Dilemmas

As “go live” day approaches for the new surgeon, the question of scheduling looms large. The universal advice: Start slow!

“We build extra time into a new surgeon’s schedule to allow for learning,” Swencki says. “And we always perform ‘after-action reviews’ to discuss what worked and what did not work.” (See “After-action Reviews.”)

At Surgisite Boston, approximately 40 surgeons operate with the assistance of a medical staff of 25 nurses, technicians, and orderlies. To say this requires meticulous attention to accuracy in scheduling is an understatement.

“I invest a great deal of time compiling historical data for each surgeon,” Grassett says. “I note the type of procedure, the duration of each case, and how much time we need to turn over the room. These statistics help me schedule cases appropriately within each surgeon’s block times. I factor in a big cushion for a new surgeon, because he or she is new to the facility, using new instrumentation, sometimes new equipment, and working with new staff.”

Staff who are accustomed to the relatively rapid turnover of uncomplicated cataract surgeries may be surprised by the time required for some retina cases, Wiatt says. In addition to allowing an appropriate amount of time for each case, schedulers must be aware of the potential for delays in certain cases.

“Some retina cases can be quite complex and time-consuming,” Wiatt says. “That’s why we schedule simpler cases, such as a vitrectomy to remove floaters in a healthy patient, at the beginning of the day and more complicated cases, which may take longer than expected, toward the end of the day. It’s also important to remember that many patients with retinal disease requiring surgery have other serious health problems, such as diabetes (often uncontrolled) and cardiovascular disease, and these concomitant conditions increase the potential for complications, such as a drop in blood pressure or an irregular heartbeat.”

Communication is Key

The Eye Associates, which initially offered only cataract and refractive surgery in its ASC, has subsequently integrated three additional ophthalmic subspecialties: glaucoma, cornea, and oculoplastic. What is the key to their success? “Good communication between new and existing parties,” Swencki says.

Grassett adds two more recommendations: 1) To any ASC clinic director preparing for a new subspecialist, she says, “Always expect the unexpected, particularly during a new surgeon’s first several surgery days;” 2) To the ASC management team, she advises, “Encourage your staff to be open-minded. For some, change is difficult, so the management and the surgeons need to be very positive and help people overcome that.”

According to Wiatt, scheduling frequent staff meetings that include the new surgeon will help ensure a smooth transition. “The surgeon and staff members may have ideas on how to make things run more smoothly that they may not remember to bring to management on a busy day,” she says. “In addition, be sure to keep surgeons’ preference cards up to date and readily available, as advancements in eye surgery can occur rapidly.”

Hertz adds this advice to clinic directors: “Don’t be afraid to admit what you don’t know. Although something may be new to you and your staff, it’s not new to your surgeon. Rely on his knowledge and expertise.” ■