Ballet is considered the strictest form of dance. It requires precise and highly formalized steps and gestures. Balance and control are key.
These concepts can also be applied to an ophthalmic ASC that is striving to maximize patient flow. A team must work together seamlessly, following set rules and protocols for every patient—every day, every week. Ultimately, practice makes perfect.
At an ASC, completing any tasks that can be done before a patient’s surgery day will help to optimize flow. For example, Nikki Hurley, RN, MBA, COE, director of surgical services at Key-Whitman Eye Center in Dallas, says patients come in within 30 days of their surgical date to choose their intraocular lens (IOL) and any desired upgrades, sign all consent forms, provide their medical history, list any allergies and medications, and undergo a physical examination by the physician. This allows staff to check paperwork ahead of time for completion and accuracy.
To ensure that an ASC has enough lenses and supplies, physicians are required to provide their lens calculations five business days before surgery, Hurley says. On their surgery day, a patient only needs to check in at the front desk, pay their portion, and proceed straight to the preoperative area for surgery. Key-Whitman performs cataract, refractive, glaucoma, and oculoplastics procedures in their ASC.
Yvette Rodriguez-Arce, MSN, director of nursing at UHealth Bascom Palmer Eye Institute Ambulatory Surgery Center Naples in Naples, Florida, gives patients a surgical packet when scheduling them, which includes a document that answers frequently asked questions about the procedure, a list of urgent care centers that offer medical histories and physical exams if needed, information about anesthesia and its potential side effects, and a clear explanation of how much their procedure will cost.
Staff members make preoperative calls two weeks before surgery to ensure that patients’ questions and concerns have been answered, Rodriguez-Arce says. The patient’s medication list is reviewed, and instructions are provided on what medications to take or avoid the morning of surgery. The nurse also documents the name of the person who will drive the patient home after surgery.
Scheduling Tips
Scheduling patients is a balancing act of its own. Connie Fields, BSN, RN, CMSRN, center manager at Pankratz Eye Institute in Columbus, Indiana, says the ASC has two operating rooms and two laser rooms. They try to schedule the majority of right eye surgeries in one room and left eye procedures in the other one. “This reduces the number of times equipment has to be reset, such as the foot pedal, microscope, and surgeon’s chair,” she says. The ASC performs cataract surgeries and minor procedures.
“Grouping patients improves efficiency and flow,” says George O. Waring IV, MD, FACS, founder and medical director of Waring Vision Institute in Mount Pleasant, South Carolina. For example, surgeons often start their day performing femtosecond laser procedures or surgeries for intraoperative aberrometry. More complex surgical procedures are done toward the end of the day, which reduces the possibility of impacting flow during the day.
At UHealth Bascom Palmer Eye Institute Ambulatory Surgery Center Naples, which mostly performs cataract surgeries, the first surgeries of the day are reserved for diabetic patients, in order to reduce the likelihood of postsurgical complications such as hypoglycemia, Rodriguez-Arce says. Pediatric patient surgeries are also done early in the day because these young patients are given a general anesthetic and need at least a few hours to recover safely.
Morning Preparations
When each day begins, ASC staff will perform specific tasks like clockwork. Controls are run for all point-of-care testing equipment, biologicals are run in the sterilizer, each room’s humidity and temperature is verified before opening sterile supplies, and the defibrillator’s functionality is checked, Rodriguez-Arce says. A bag of intra-venous (IV) fluid along with IV tubing is placed at the bedside, so it’s ready for the first patient to arrive. Anesthesia medication bags are prepared for providers to sign out as needed.
The surgery team at Ophthalmic Outpatient Surgery Center for Sight in Baton Rouge, Louisiana, organizes and cleans each department in the ASC every morning in a similar way. Jayne Bacot, MSN, RN, CNOR, CASC, the director of nursing and surgical services, says staff also confirm the day’s surgery schedule to ensure that they reconcile any cancellations from the nurse line or answering service. Staff members who are assigned to each area set up preoperative bays, prepare instrument and sterile processing rooms, make surgery beds, and open operating rooms based on scheduled procedure start times.
Handling Delays
If a surgical procedure takes longer than expected, Rodriguez-Arce informs patients waiting in the preop rooms about the delay. There are no clocks in the preop or postop areas, so patients don’t fixate on time, which could increase their anxiety levels. Patients who have not yet arrived are contacted by front desk staff, who inform them about the delay and provide their new expected arrival time so they don’t have to wait in the lobby longer than necessary.
If a patient doesn't show up on time, Rodriguez-Arce says her team will continue with the next patient that is ready to avoid delay in the ASC. Once the late patient does arrive, Rodriguez-Arce says staff will try to work them safely into the schedule if possible.
Organizing a Team
To create an efficient team, the best team members need be chosen and trained. When a nurse is hired, they typically don’t have ophthalmology experience so they are rotated through several preceptors, Bacot says. Newer staff are paired with experienced nurses.
Each new employee is given a binder to serve as a reference guide. It includes information about the eye’s anatomy, an overview of eye diseases and cataract surgery, eye terminology, and surgery forms. On an ongoing basis, staff members learn about new products and attend hands-on in-service training conducted by company representatives. “We constantly get new processes and technologies, so everyone has learned to adapt to change,” Bacot says. “That’s why we have such a strong clinical staff. They roll with whatever comes their way.”
For Hurley, the most important part of training is cross-training. Depending on a staff member’s credentials, they should be trained in the main area they will be used first, but also be trained in other areas where they could work. Scrub techs could be cross-trained to work in sterile processing, front float, back float, and postop, she explains. Shadowing an experienced staff member in the same job role works best.
At orientation, Fields recommends using mandatory skills testing to verify all associates’ skill levels, which helps to place them where they fit best. Then, additional training is provided in any areas where they are less confident or experienced.
The Importance of Retaining Staff
The more opportunities that a team has to work together, the greater their productivity. “Associates that have worked together build a rapport and can begin anticipating their teammates’ needs,” Fields says.
Focus on creating a healthy workplace culture, Dr. Waring says. “Get the right team member on the bus, and then into the right seat on the bus,” he suggests. You can do this by helping individuals to achieve their potential, he says. Each staff member should meet with leadership semi-regularly for a full evaluation. Provide opportunities for growth, lay out a strategy for agreed upon goal setting in writing, and have stretch goals to give the employee an opportunity to grow in their career.
Leaders should be willing to invest in their employees. “Offering professional development opportunities is a key to retaining good staff,” says Reuben Cruz, MSN, RN, AMB-BC, senior manager of nursing and clinical education at UHealth Bascom Palmer Eye Institute. “Encourage them to further their education and make them feel their worth, which builds up staff morale and helps the organization. By empowering staff to attain their specialty certifications, they become experts in their roles and enhance their skills for more efficient and safe patient care. In return, patient flow is positively impacted as errors and delays are prevented.”
Letting employees know that you value them results in their loyalty, Bacot says. The center is always doing fun things, such as bringing in lunch on high-volume days and hosting an annual crawfish boil, during which prizes are given, such as a voucher for LASIK surgery, a complimentary Botox injection, designer sunglasses, and paid time off.
Practicing Safety Measures
Employing safety checks can also optimize patient flow as well as prevent mistakes. When a patient checks in at Key-Whitman Eye Center, for example, they are given a color-coded arm band that is placed on the side of surgery. In the preoperative room, a color-coded sticker is placed above the eye of surgery after a nurse confirms the site, type of lens, and any additional procedures (such as glaucoma procedures) that will be performed. During each step of the process, the patient is required to provide their name, date of birth, and surgery site.
Always have whatever might be needed in the operating room ahead of time, Hurley says. Vitrectors, capsular tension rings, iris expanders, sutures, and suture sets are stocked and ready to go. Every staff member should know where crash carts are located, how to evacuate patients if needed, and how to handle emergencies such as a fire, inclement weather, and active shooter.
Staff should be trained at least once a year. Running frequent drills gives staff members an opportunity to ask questions, familiarize themselves with their role in each situation, and feel confident if an emergency should arise, Cruz says.
Review patient safety culture surveys with staff to identify issues and collaborate as a team on process improvements for the department, says Rodriguez-Arce. She ensures that all staff are updated with the latest guidelines, standards, and recommendations set by regulatory agencies as well as from Bascom Palmer itself.
Staff Contributions
Hurley’s best advice for optimizing patient flow at an ophthalmic ASC is to have the entire team review surgical processes. “Look at them through your patients’ eyes,” she says. “Then, have the whole team come up with plans to improve your processes and efficiency, and implement those plans.”
“If everyone buys in, then everyone is more likely to be a willing participant in implementation,” Hurley continues. “When volumes can increase, profitability, of course, will also increase. This is a direct result of a team’s efforts and should be awarded as such. A good bonus can be a great motivator.” ■
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