Efficiency and volume, not cost cutting, are the keys to profitable cataract cases.

Day Surgery Centres have a built-in advantage over hospitals when it comes to cataract cases. Just as a certain manufacturer advertises that they just make copiers, we just do surgery. That means we could do the cases more cost effectively with equal or better outcomes. Increasingly technology and the health fund contracting climate are adding pressure on the profitability of ophthalmic centres. Therefore, it is time to take a closer look at how we do things – and NO I don’t mean merely cost-cutting. “Cost-cutting” is strictly an exercise in bean counting. With that in mind, here are some strategies for improving profitability in cataract cases that any Day Surgery Centre can use.

Staff smart

Take a close look at how you currently staff your day surgery. There are many ways that you can move the patient smoothly from pre-op to theatre to recovery to discharge.

The key is to make sure everyone has a clearly defined role in moving the patient through the process. Let’s take the case of patient transport. Rather than having the scout nurse get the patient and transport him to and from the theatre, this can be the task of the anaesthetic RN or tech, leaving the scout nurse free to help set up the theatre.

Just as you need the right actors and costumes to put on a good play, you need to find which staff members enjoy working with ophthalmic cases, especially if you are a multi-specialty centre. It is worth your while to make an effort to develop specialized teams. It’s true when they say “practice makes perfect”, the more skilled and practiced your team the  greater the efficiently and the ability to handle a higher volume with a higher patient satisfaction rates.

Pause for a cause

By practicing some simple safety precautions, not only can you make cases safer for the patients, but you can also reduce your insurance liability. In a climate where insurance costs are spiraling upward, everyone on staff needs to think in risk management terms as well as patient care. A good example of this is surgical site verification.

At many facilities, surgical site verification simply involves putting a red dot over the correct eye. Follow the same familiar site verification guidelines that you would for any specialty for which correct side and site applies. Every staff member the patient comes in contact with should verbally verify the correct eye with the patient — at reception, in pre-op and with the Anaesthetist. Finally, require your surgeon and theatre team to take a pre-op timeout in the theatre for a final verification.

Streamline your instrument trays

Too many facilities are guilty of having too many instruments on their trays and having too many instrument trays available.  Ask your surgeons which instruments they really use and eliminate the extras — most surgeons require no more than five to seven instruments for a case. If you want to be on the safe side, you can have single steri-peel items available in case a surgeon were to make a special request.

Maintain an appropriate but adequate number of trays for the facility. I recommend six trays for a two-theatre facility: one in each theatre, two being sterilized in your decontamination area and two backup trays. The backup trays will come in handy if the instruments being cleaned aren’t ready for the theatre when the next cases are ready. It beats the alternative of having your theatre schedule thrown off, which ultimately costs more than the extra tray (not to mention inconvenience to patients and staff).

Simplify your medical records

I recommend reviewing forms twice a year to assist coding and billing personnel. When you review the forms, you should ask the following questions:

§          Are there lines that are consistently left blank? For example, if there are lines for procedures that are no longer given, you can eliminate them.

§          Are there redundancies? The more the same questions are asked, the higher the risk of discrepancies.  Is the information already provided in the medical record – is there a need to repeat it?

§          Are there lines that are too complicated? Too vague? For example, do you have tick boxes to assist the coder with the correct diagnosis?

§          Is there information missing that would delay the billing and coding process?

Dress for success

There is a lot of controversy over whether you should have your patients remain fully clothed, partially disrobe or completely disrobe for cataract cases. I believe you should have a consistent patient attire standard for all related procedures at your facility; you should have the same policy if you do both ENT and ophthalmology, for example.  Having such a policy helps streamline your pre-op processes and maintain a consistent standard of care.

There are some major benefits of allowing patients to remain in their street clothes or only partially disrobe. It decreases prep times and post-op discharge. Your patients will be more comfortable. Lastly, it decreases laundering expenses.

Ultimately your Surgeons, Anaesthetists, theatre staff, pre-op and recovery staff and management need to come to a consensus on what your patient attire policy should be.

Keep two theatres accessible

Once you reach a certain volume of cataract cases and turnover time, I recommend having two theatres available for each surgeon. This way, while a surgeon performs a case in theatre 1, theatre 2 is being cleaned and the next patient is being prepped and brought to the room. The surgeon then simply walks to theatre 2, where the next patient is ready. For the most part, the theatre team stands in one place during cataract cases, so set-up and turnover is fast, especially if you have an experienced team. Turning over a cataract theatre shouldn’t take any longer than 10 minutes.

Appoint a Purchasing Nazi

A good purchasing nazi will maintain inventory as though the money is coming out of her own pocket. Having a single person analyze how you use your materials will help you economize properly and maintain adequate supplies without excessive extras.   Set up a routine of weekly and monthly ordering which will minimize the amount of time taken for ordering and ensure nothing is missed.

The purchasing nazi can be the point person for dealing with your supply reps, as well. Sometimes you will need a little more, sometimes less. This is especially true if you have just-in-time delivery for your cases.

Review your pre-op drop routine

Here are three ways to expedite your pre-op eyedrop routine. Consult with your medical director before implementing any of these policies.

§          Some facilities prepare the drops ahead of time and line up cups for the pre-op staff to start the drops as soon as the patient enters the facility. This can be an effective method provided that you have a strong line of communication to bring the patient in at the proper time and begin work-up for the case.

§          Other facilities allow the patient to start drops at home. This can work if you have an especially strong patient education program and are confident that patients will follow pre-op instructions precisely.

§          Lastly, some facilities have established a method of expediting the pre-op drops by creating “cocktails,” or mixing concentrations of different drugs. There is no set formula, of course, as different facilities use different combinations and concentrations. Consult with your pharmacy services first to determine how the drugs in the cocktail will interact in tandem and what concentrations to use.

Improve your pre-op screening

I strongly recommend doing a pre-op telephone consultation a few days before the patient comes in for surgery. An RN should perform the telephone consultation using a set format which includes the following:

§          Establish line of communication with patient

§          Evaluate suitability for Day Surgery

§          Identify special needs

o         Physical

o         Social

o         Dietary

o         Communication

o         Transport

§          Provide additional education as required

§          Ensure carer is available for discharge

All testing and diagnosis should be done before the patient comes in for the surgery.

Without a good pre-op screening system, inevitably, you’ll have cases held up or even cancelled on the day of surgery because the anaesthetist requires one more test (an EKG, for example) before the patient can be safely brought to the theatre.

Work smarter, not harder

The old adage “work smarter not harder” applies to every aspect of your cataract surgery procedures. Every step you take toward greater efficiency has an economizing effect that makes your cataract cases more profitable.

Elizabeth Rankin
Elizabeth Rankin Consulting

elizabethrankin@optusnet.com.au