Turn your OR staff into a pit crew

We can’t control reimbursements, but we can hone efficiency.

By James C. Loden, MD

In 17 years of private practice, I have not seen an appreciable increase in my cataract surgery reimbursement. Don’t believe me? My father received over $2,500 for a cataract surgery in 1980; in 2015, our average collection for cataract surgery was $593. And if you look at how buying power has changed, $1 in 1980 has the same buying power of $3.08 in 2016, with an annualized inflation rate of 31.8%, so if you take into account a 3% cost of living adjustment over 19 years, it is enough to see that I now take home 51% less buying power than I did when I first started my practice. While we cannot stop “shrinking” reimbursements, we can improve efficiency to make life in the operating theater more productive.

Add a dash of NASCAR vibe

Efficiency starts with well-trained OR and management staffs who make it a priority. I have found that this environment most often exists in an independent, surgeon-owned ASC. To be efficient, your surgery center staff needs to function like a well-disciplined NASCAR pit crew. Think about it: All the teams on the track can refuel a car, change the tires and make modifications to the car in increments measured by fractions of a second in the same way a well-orchestrated surgery center staff can have a patient in the door and discharged in under an hour. However, fractions of a second in NASCAR make a big difference, and the same goes for every minute the patient spends in your office.

Attitude adjustment

So, how do you shave minutes off each “pit stop?” First and foremost, hire team members who have the right attitude. That means someone who is compassionate, outgoing and willing to learn. Our executive training courses have taught us that if someone has the right attitude, they can be trained. Conversely, if employees don’t have these traits, the system will fall apart regardless of their training and experience. Nurses and techs should be hired for both their service-minded personality and innate desire for competence.

Block scheduling

Efficiency starts with consistent scheduling. For example, block like cases together in which every patient will have nearly identical pre-op and postop instructions. So, place basic blade cataracts in a block and your femtosecond cases in another block. We even schedule left eyes consecutively in one OR and right eyes consecutively in another OR. This saves your staff time moving foot pedals, the phaco machine and the microscope between cases.

This logic extends to your femto cataract cases. Don’t intersperse them with complicated cases such as a pterygium, a DSEK or a vitrectomy with a sutured IOL. These cases could take between 30 minutes to 90 minutes. If you schedule one of these procedures at 9:00 a.m. — which then runs late — with 15 cases to follow before lunch, those 15 patients will be mad about waiting. Rather, place these complex cases at the end of the schedule or on different surgical days.

Pre-appointment instructions

Another way to maximize pre-op flow is by having all your patients use dilating drops at home the day of surgery. The patient arrives dilated, which (at least partially) minimizes the number of drops that pre-op nurses need to place.

The biggest benefit is eliminating the patient’s need to wait to dilate in the pre-op period. So, if Mr. “X” shows up 20 minutes early and Mrs. “Y” shows up late, we can take Mr. “X” directly back to surgery as he is already dilated.

In the OR

I have visited more than one center that purchased different custom-surgical packs, two brands of phaco machines, four lens manufacturing products and different surgical trays for every surgeon. The impact: wasted time between cases, staff confusion and excessive layering of costs. Consistent standardization of procedures and protocols is key to OR efficiency.

If the staff sets up the case and positions the patient the same way, and the surgeon sits in the same position and uses the same instruments, phaco machines and lenses, efficiency builds. Even if this uniformity saves 30 seconds per case, 30 cases later, the practice has 15 minutes saved. In 15 minutes, an efficient surgeon can perform at least one more case. Based on my statistics for standard Medicare cases from last year, this would equal an extra $593 in average collection per week by the surgeon. If you find three areas to save 30 seconds, you can save 45 minutes and fit in three extra cases.

With too many inconsistencies, the staff might open the wrong pack or set up the wrong phaco machine for the surgeon. This could lead to an irritated surgeon who could display that irritation in front of both staff and patient. Decreased work satisfaction by all could follow; as for the patient, he too could experience a diminished customer service experience (not to mention the cost of a wasted pack, tubing, viscoelastic and time).

On surgical trays

Depending on your autoclave size and capacity, newer sterilization guidelines have slowed down instrument tray turnover in many facilities. Smaller trays with fewer instruments facilitate case turnover with less staff confusion regarding which instruments are needed; don’t overload your trays with instruments you will rarely need. For a standard cataract case I have a 0.12 forcep, a Kelman-McPherson forcep to help load the lens implant, a chopper, drape scissors, a Bechert Nucleus rotator and a Kuglen hook on the tray with the IOL injector. Other instruments that are rarely needed for phaco surgery, such as Gills-Welsh scissors, needle drivers and tying forceps are in ready-to-go peel packs. Trypan blue, extra viscoelastic and a Malyugin ring are at the ready as well.

Be a commander-in-chief

A surgeon’s gentle yet assertive and in-control presence creates an environment of organization and stability. Enter the OR with thought and purpose, and look at your notes for cues so that you are mentally prepared before you begin. Also, don’t bring your cell phone into the OR.

When you sit down at the surgical microscope, get comfortable and get your foot pedals in position before starting the case. Don’t look up from the microscope; ask that your technician pass you the instrument correctly. Try and perform the cataract procedure as close to the same way as possible every time. In this way, your technician can anticipate your next move and have your next instrument ready for you.

Also, do not skip steps until your skill level is advanced. Skipping steps could turn a 12-minute case into a 25-minute case. For instance, while performing the divide-and-conquer cataract technique, I have observed my past fellows not completely crack the center groove in the nucleus. Often they may rotate the lens and start the second groove without properly cracking the first groove. The second crack is again not completed, and the case time goes up as well as the risk of a complication as the surgeon struggles to disassemble the cataract. Sometimes the tortoise beats the hare!

Finally, never create chaos by yelling at staff. This always results in counter-productive stress and anxiety that (at minimum) lasts the rest of the surgery day.

Minimal anesthesia

Our goal is to keep our patients as comfortable as possible while using as little anesthesia as possible. More than 50% of our patients use sublingual Versed (midazolam, various manufacturers) with no IV sedation. This helps to save time because lightly sedated patients recover quicker and ambulate quicker. Also, the patient avoids the needle stick and the risk of bruising or infection. From our vantage point, light sedation speeds up the process of getting the patient safely from the OR to postop, and ultimately discharged safely home.

Conclusion

I can’t tell you that improving efficiency in the OR is the answer to low reimbursements. Efficiency can only take you so far, but it is helpful nonetheless and easily built-in if surgeons and OR directors put themselves in the position of their staff and, most importantly, of their patients. Think of what you would want if you were the patient. Do you want rigid, confusing protocols encumbered with constant change or a well-structured, fast-moving NASCAR pit crew? OM

About the Author
	James C. Loden is a board-certified ophthalmologist and president and founder of Loden Vision Centers with offices in Nashville and Paris, Tenn. He is a clinical assistant professor at the University of Tennessee and teaches refractive surgery to the residents.