In any economic climate, you want to strive to increase your efficiency in cataract surgery. But in today’s challenging landscape, with staff in short supply and wages on the rise, efficiency in cataract surgery can be critical to keeping your practice flourishing.

In this article, I’ll offer techniques we employ at Cleveland Eye Clinic to maintain and increase our efficiency in cataract surgery. Those include methods such as the use of physician extenders, same-day cataract surgery, leveraging technology and refining workspace design to get the most from our layout. But first, let’s take a deeper look at the forces that are making efficiency an absolute necessity for today’s ophthalmology practices.

ECHOES OF THE PANDEMIC

Practices are still feeling the effects of the COVID-19 crisis, with some struggling to reclaim the efficiency they maintained prior to the pandemic. In fact, those reverberations may present more of a challenge and threat to ophthalmology practices than did the pandemic itself.

If your practice resembles mine, you’re facing an unprecedented staff shortage, from nurses to techs to front-office staff. Nurses, for instance, have left the profession in droves. An April 2022 study published in Health Affairs found that growth in the RN workforce plateaued during the first 15 months of the pandemic.¹ Factors likely included early retirements, pandemic burnout and frustration, interrupted work patterns from family needs such as childcare and COVID-19 infection and related staffing shortages.² The US Bureau of Labor Statistics projects more than 200,000 openings on average for RNs each year from 2021 to 2031.

What’s more, with fewer nurses in the health-care workforce, large health systems have increased wages to attract nurses. This upward wage pressure has trickled down to ophthalmology practices, which has led to higher wages to retain staff. This wage pressure is felt across the board, from front desk staff to ancillary technicians, surgical techs, medical assistants, billing and more. This can create challenges in health-care systems where reimbursement is often fixed or declining year over year.

PHYSICIAN EXTENDERS

With this as a backdrop, some practices have started to use physician extenders to free surgeons from various tasks to maintain and gain efficiency. Historically, ophthalmology practices have worked with optometrists to co-manage cataract patients, outsourcing some pre- and post-op care. At our practice, we use internal co-management, with ODs on staff working with patients for diagnosis and education. The BLS projects 1,700 openings for optometrists each year, on average, from 2021 to 2031.³ Recently, we added a nurse practitioner to our extender mix.

Physician extenders can also be used to help add services. For example, we have an optometrist who specializes in dry eye and leads our practice in dry eye therapies. We also have a nurse practitioner who specializes in cash-pay cosmetic procedures like Botox and fillers. These strategies allow our surgeons to stay busier in the OR.

SAME-DAY SURGERY

You can also leverage a change in Medicare that allows you to diagnose and treat cataracts the same day to increase your efficiency. If a patient has been diagnosed with cataracts by an outside optometrist, we can use telehealth to handle pre-surgery tasks. One of our internal ODs performs a virtual exam, discusses symptoms, answers questions about IOLs and so on. Having lived through COVID-19, patients today — as well as staff — are far more accustomed to and comfortable with telehealth encounters. With COVID-19 now an endemic disease, patients still want to reduce their exposure to the virus, and telehealth presents an excellent way to accomplish that.

This allows the surgeon to meet the patient, confirm the diagnosis of cataract and perform surgery — all in one day. Once the internal OD has done an exam, interpreted all typical diagnostic testing, explained findings and completed the appropriate education based on those findings, the exam and discussion the MD must conduct is much quicker and more efficient. All typical testing and new testing required based on the OD exam is performed before the MD’s confirmatory assessment.

LEVERAGING TECHNOLOGY

Using technology pre-surgery can help increase your cataract efficiency in other ways. For instance, Surgiorithm created a software application that uses online education and an interactive, personalized questionnaire to generate a report and introduce the patient to a customized, practice-branded IOL package comparison followed by video education. Along with an increase in conversion rates and patient volume, this program has increased our quality of patient education by helping to ensure that patients better understand their surgery options.

Another system, called Navigate, which is part of the Patient Navigator Training Collaborative, employs trained patient “Navigators,” who are experts in cataract education. Using talking points provided by your practice, this offering prepares patients for their consultation with the surgeon. Then, Navigators share what they learn with surgeons and their teams.

The education process is the most time-consuming portion of the patient visit. Navigate can educate patients on the technology options and guide patients on which may be most suited for them based on their situations and personal goals.

SURGICAL INTEGRATION

To leverage technology and increase efficienc, use systems that bring pre-operative information into the OR and thus streamline surgery days. For example, the Zeiss CALLISTO eye platform brings preoperative planning data into the OR allowing for intraoperative guidance for lens placement for astigmatic patients. Similarly, the Alcon ORA system is an intraoperative aberrometer to provide real-time confirmation. Also, Lensar Inc. offers the ALLY Adaptive Cataract Treatment System that combines imaging, dual-pulse femtosecond laser and intraoperative toric lens marking all in one system. These technologies can save a minute or two per patient, which can add up quickly during a busy surgical day.

IOL TECHNOLOGY

Besides surgical tools, you can also leverage IOL technology itself to increase efficiency. For instance, if you implant the RxSight Light Adjustable Lens, you can realize efficiencies in a few ways. First, because the lens will be adjusted postoperatively using UV light treatments, you don’t have to perfectly align the toric lens intraoperatively, saving a minute or two of OR time. Second, because the lens is adjustable after implantation, chances of enhancement and reoperations decrease.

Of course, postoperatively, you’ll have to perform treatments to fine-tune and lock in the lens. Some physicians are using physician extenders to perform these treatments.

STREAMLINED SPACE

Proper flow of your workspaces may seem fundamental, but effective use of your space can provide significant efficiency gains. For instance, in the OR, with the right setup, you can use one nursing station to monitor both pre- and post-op areas. If your pre- and post-op areas are separate, you will probably have to maintain two nursing stations and potentially double the staff.

In our clinic, we hired Practice Flow Solutions, an architect firm that specializes in practice efficiency, to analyze our setup (Figure). With a few changes, we should be able to increase our flow from five patients per hour per provider to eight patients per hour per provider. One example involves creating “treatment” pods where physicians and support staff use a designated area in the clinic to help decrease patient movement across far distances.

ATTACHED ASC

On a related note, our ASC is physically attached to our clinic — the clinic and ASC are just a hallway apart. This increases efficiency in two ways.

First, surgeons save time by not having to drive between the clinic and ASC. Depending on the traffic in your location, that could easily add a half hour to a surgeon’s day.

Second, this allows a surgeon to move back and forth easily between clinic and ASC depending on need. If, for instance, we’re short-handed in nursing staff in the ASC, we might be able to handle only four patients per hour instead of our normal six per hour. If that’s the case, I can quickly jump over to the clinic and see a preoperative cataract patient or two, helping the surgeon to maintain his flow.

SMART SCHEDULING

As with layout, basic scheduling changes can increase efficiency. For instance, if you intersperse operating on right and left eyes, you’re probably losing time changing your microscope and phacoemulsification machine to adjust from right to left eyes or vice versa. These changes might take just a few seconds, but in a busy practice, that time adds up. In my practice, I’m handling 30 cataracts per surgical day and operating twice a week. Other surgeons are handling a similar patient load. Instead, consider scheduling all right eyes during a portion of a block of time, then left eyes during another portion of the block time.

Most of your practice’s revenue is going to be generated in your OR or the ASC. If you’re using only 75% of its capacity, you’re losing revenue.

Being efficient can mean converting from day scheduling to block scheduling. For instance, one surgeon can work a full day but will have to take perhaps one-quarter of the time out of the OR for breaks. What if, instead, you had two surgeons operating continuously, one from 7 a.m. to noon and the other from noon to 5 p.m.? The result would be more surgical hours per day.

SETTING UP FOR SUCCESS

With economic pressures likely to remain challenging, investing effort in finding ways to gain efficiency will be time well spent. When these pressures ease, you’ll be prepared to reap even more significant benefits. OM

REFERENCES

1. Buerhaus PI, Staiger DO, Auerbach DI, Yates MC, Donelan K. Nurse Employment During The First Fifteen Months Of The COVID-19 Pandemic. Health Aff (Millwood). 2022;41(1):79-85.
2. Auerbach DI, Buerhaus PI, Donelan K, Staiger DO. A Worrisome Drop In The Number Of Young Nurses. https://www.healthaffairs.org/do/10.1377/forefront.20220412.311784/ . Health Affairs. Accessed January 3, 2022.
3. US Bureau of Labor Statistics. Occupational Outlook Handbook. https://www.bls.gov/ooh/healthcare/optometrists.htm#tab-6 . Accessed Jan. 3, 2023.

William F. Wiley, MD, is the medical director of the Cleveland Eye Clinic and an assistant clinical professor of ophthalmology, University Hospitals/Case Western University.
Disclosures: Dr. Wiley is a consultant for Alcon, J&J Vision, RxSight, Surgiorithm Inc. and Zeiss.