Blake Williamson, MD, MPH, MS, is president and managing partner of Williamson Eye Center, a large generational practice with eight locations in Louisiana, including a high-volume ambulatory surgical center in Baton Rouge. During our conversation, which has been edited for length and clarity, Dr. Williamson provided his observations on efficiency in the operating room.
Let’s talk through your typical day of surgery. What do you and your team do in advance to ensure a highly efficient day in the operating room?
Dr. Williamson: I’ll start a typical day of surgery around 7 am. First, I’ll do about 20 lasers, meaning YAGs and SLTs, and then I will do 30 to 35 cataracts, and we will be done by 1 pm usually. The main reason I’m able to do that is because of the team around me.
As I am driving into my ASC, I do a little Waze calculation of when I’m going to be walking into the surgery center. I can let my director of nursing know the exact time, plus or minus 60 seconds, that I’ll walk in the door. She will literally have the first patient of the morning on the YAG laser, waiting for me. So there’s no wasted time getting a patient ready—everything is anticipated a full 15 minutes before I even get to the ASC.
We make sure all the lens calculations and biometry are done about a week before the actual procedure is scheduled. Literally, once I’m done with surgery on a Wednesday, the very next thing I do is walk into a room with my scribe, who hands me the 35 charts for the following Wednesday. This way, all the workup is done a full week in advance and we’re not struggling on the day of surgery.
We also make sure all the lenses have been ordered. Sometimes patients need lenses that aren’t in our consignment. I might need to implant a different type of lens, or want to have an unusual lens on backup, just in case. If you anticipate that a full week in advance, there won’t be any delays or problems on surgery day
Tell me some more about your team. How do they enable you to handle so many cases in a short time?
Dr. Williamson: I have a staff of about 20 nurses and technicians, so we’re pretty big; in fact, it’s a little bit overstaffed. But we like that because there’s always call outs or people get sick and so it’s good to have more staff than you need. Plus, when they’re all working, we can be very efficient and they have a lot of support. This really allows us to provide a sort of “white glove” experience for our patients.
A lot of ophthalmology surgical practices are considered either low volume but very high quality and high touch, or high volume and kind of low touch. We think it’s possible to achieve both, and part of that is having enough staff members. It can be tough on payroll, but it provides a wonderful experience for our patients and allows our team to keep the turnover time between patients very low.
Within the ASC, we have two surgery rooms and a laser room. We also have several waiting areas, which is important—you need places for patients who are waiting for surgery. I also think that having your femtosecond laser in a room that’s separate from your operating room is important. That way, you can have a “shooter”—who in our practice is my uncle, Dr. Bill Williamson—who performs the femto part of the procedure, then I perform the manual part in the operating room. What’s great about that approach is, 30 percent of the case is already done for me by the time I get to it. That also aids efficiency.
Does case scheduling play a part in efficiency?
Dr. Williamson: I typically have all my bilateral procedures come in earlier, so if I’m doing an ICL [implantable collamer lens], for instance, we do one eye and then we check the patient in the slit lamp, and then bring them back to do the second eye right afterward. I like to do patients needing more complex procedures toward the end of the day.
One other thing I do for efficiency is, if a patient has an intumescent cataract or a white cataract, I strongly encourage the femtosecond laser. But if the patient can’t afford to upgrade, I’ll gift it to them—we have a “hardship” femtosecond laser package. That usually speeds up those cases quite a bit because if it’s a white cataract, when I get an Argentine flag sign that could slow me down, or if it’s a dense progressive cataract, having some prior fragmentation will help speed the case along. That makes it more of a straightforward case, not a difficult case where I could have problems with the capsulorhexis formation or cataract removal.
How does your surgical center’s technology affect your workflow and help you save time?
Dr. Williamson: We use the Catalys femtosecond laser from Johnson & Johnson, and that goes a long way toward making us more efficient. We will schedule our shooter, a second surgeon, to see clinic patients on surgery days, because our ASC is connected to our clinic. When it’s time for him to do a laser procedure, the staff will pull him from across the hall and he’ll do the femto laser and then feed the patient to me in the operating room where I’ll do the manual part. That gives us great efficiency, because the shooter completes some of the most pivotal and time-consuming steps of the surgery.
In the operating room itself I use the Stellaris Elite phacoemulsification system (Bausch + Lomb). What I love about that is that it uses adaptive fluidics, which allows me to remove the nuclear pieces of the cataract very efficiently. You don’t have to reach full occlusion before the vacuum begins to build, and it pairs very well with a nucleus that has been prechopped via femto, because those pieces can come straight to the phaco tip. I think that having the Stellaris paired with the Catalys allows for one of the most efficient cataract suites on the market.
How do you train your ASC staff to complete so many cases in a day?
Dr. Williamson: We’ve been operating at this level for over three decades, and several members of our team have been with us for 20 to 30 years. As a result, our newer staff members get worked in on a “see one, do one, teach one” basis. The process gets passed down from our director of nursing and RNs and our scrub technicians. I have one scrub tech who has been with us over 15 years, so she’s kind of the chief scrub tech and helps teach newcomers how we like to move in the operating room. I think having those sorts of champions on your staff, whether it be on the scrub tech side or the nursing side, is critical to establish your goals and expectations in terms of safety and efficiency.
In other words, retaining good team members plays a big role in your efficiency?
Dr. Williamson: Basically, yeah. We know that people will stay if they have a good working environment. We pay them well and we also don’t make them come in on Friday. We don’t do surgery on Friday in the ASC, and our team loves the idea of a four-day work week. I think that’s a big part of why we’ve had so little turnover is that our staff knows if they work hard for four days, they’ll have a three-day weekend every single weekend.
You mentioned safety outcomes. What safeguards do you have in place to ensure that procedures are done correctly and produce the best possible patient outcomes?
Dr. Williamson: I personally look at every single chart a week in advance to make sure they’re perfect—the right patient, the right lens—and review the biometry and topography. I personally initial every single lens before they pull it. On the day of surgery, it’s very similar—we have our nursing coordinators in the room and they will show the lens power to myself and to the scrub tech so both of us have to visualize it before we move forward. I feel like by having multiple points of contact, multiple checks and balances, and multiple people looking at the same things, we are always making sure we are right before we proceed. Never skipping steps or cutting corners is why we’re able to have the safety level thatwe do.
Clearly, there are a lot of moving parts in your surgical ballet, and it seems inevitable that occasionally there will be problems and delays. How do you handle them and stay on track?
Dr. Williamson: If you’re a very busy high-volume surgeon, your instinct might be to throw your arms in the air and pout about it or yell and scream at someone. I try to have a good sense of humor about it. Sometimes, if I go in the next room and there’s no patient ready, I’ll step out and pantomime like I’m putting on my surgical gloves and getting ready to operate. The staff will get a kick out of that, you know, because I can joke about it while also accomplishing the goal of letting them know, “Hey, we don’t have a patient here,” without me having to say a thing. I use humor as much as I can.
If anything goes wrong, I tend to get calmer and speak slower. I try to relax in those situations because people expect you to do the opposite. If you want to have a good team culture, then throwing stuff or yelling at people is not ideal. It shows weakness on the part of the surgeon, in my opinion. So that’s what I do outwardly.
Now inwardly, of course, I want to know what happened. So after a case day when something has gone wrong, or if there were issues, I speak directly with my director of nursing one-on-one and say, “Hey, here’s some things that went great today, but here’s some things I really want to work on. This happened, and I want to understand why so we can game plan and protocol around it if possible.” That’s the type of conversation that I will have with my director afterward—but not when my teammates are on the floor with me.
This has been very enlightening. What tips would you suggest that younger surgeons can use to maximize their own efficiency in the operating room?
Dr. Williamson: First, I would say that trying to utilize two rooms is critical. Doing what you can to either build a surgery center or buy into a surgery center that has two rooms is going to make you very efficient. Second, I think maximizing and really investing your time in training your patient turnover staff is critical, because so much time can be lost when you have five or ten minutes waiting between cases.
Finally, I think “going slow to go fast” is always a good strategy. You never try to go fast, never go into a day saying, “I’m going to do seven cataracts this hour instead of six.” When you have that intention, that’s when problems can arise. If you’ve planned and prepared properly in advance, you can go about your business in the operating room at a comfortable pace and get a lot of procedures done without running into complications. OASC
