Measuring physician performance in an ambulatory surgery center has become essential, says Sandy Berreth, administrator of Brainerd Lakes Surgery Center in Baxter, Minn. "It is the only way we know if we have been effective and if we need to change behavior," she says. "You don't know how well you are doing unless you can measure."
Data collected on physicians can direct budgeting, staffing and financial policy. Results can be put into their credentialing files and reported to the ASC board. "We want to make sure that the physician is falling within a certain standard," Ms. Berreth says.
When presented to physicians in the form of blinded comparisons of in-house colleagues, she says this data can be a powerful motivational tool. "You can benchmark very nicely with doctors within the same ASC because they are competitive," she says.
When there is a choice of metrics, "you want to pick measurements that are near and dear to your heart," she says. ASCs can use required metrics or choose their own to report to physicians, Ms. Berreth says. Some metrics are mandatory but not very useful, such as hair removal on patients, and others are both mandatory and useful, such as completing medical records within 30 days.
Here are 10 physician performance metrics chosen by Ms. Berreth and Ann O'Neill, director of clinical operations at Regent Surgical Health in Westchester, Ill.
1. On-time starts. When one surgeon or anesthesiologist frequently starts late, it creates a pattern of inefficiency across the schedule and the ASC, leading to increased costs. "Late starts can have a domino effect on the surgery center and can be a patient dissatisfier," Ms. O'Neill says. Regent tracks physicians' surgery starts that are at least 15 minutes later than the scheduled time. She says this can easily be measured through the scheduling component of standard business software that many ASCs have.
Ms. Berreth warns that for on-time starts to be comparable between physicians, the metric has to be measuring the same thing for all physicians. If the start of surgery is measured as the point when the physician walks into the OR or when the patient is put under sedation, the metric may be lopsided, because it could include extra steps that some physicians do after this point and some do before it. This could throw off the start times.
For example, some plastic surgeons may mark the patient in the pre-op hold area while others mark patients after sedation. To create a fair measurement, Ms. Berreth identifies the start time as when the physician "makes knife," when the first incision is actually made.
2. Utilization of block time. Blocking out surgery schedules is no good if block times are not being used. "We want make sure our OR is being utilized to its full potential," Ms. Berreth says. "As a rule, the surgeon should be using 80 percent of his OR block time." If the surgeon is using less than that amount, he may be asked to cut back to a shorter block time. For example, "if he is blocked for whole morning and puts in just two cases, then maybe he should end his cases at 10 a.m. rather than noon," she says.
3. Case volume. The ASC reviews each physician's volume from quarter to quarter, looking for early warning signs of changes in his practice. For example, a reduction might be a sign that the physician is preparing for retirement or is sending more cases to the hospital. Current volume could determine whether young physicians will be able to fill the shoes of older physicians. However, Ms Berreth does not compare one physician's volume with another's. "Physicians are not being held accountable for this, but this information does go into their credentialing file," she says.
4. Cost of staff per case. Measuring the cost of labor per case can identify surgeons who are taking longer to complete a case, using more staff per case or using more expensive staff, such as all RNs and no techs. "This metric explains variances and provides opportunity for improvement," Ms. O'Neill says. She again advises being careful to compare the exact same procedure when comparing physician performance.
To compare this metric with other ASCs, this metric can also be measured as RN hours per case or tech hours per case, which avoid regional variations in labor costs, she says. Cost of staff per case should cover all labor costs for a case, including pre-op and post-op, as well as staff costs in the OR, Ms. Berreth adds.
5. Cost of supplies per case. Ms. O'Neill says prices of supplies can be entered either manually or by using automated software, such as through the inventory management software that is part of many ASCs' business software package. "Make sure you enter the supplies the physician actually used, rather than what is on the preference card," she says. Again, be careful that comparisons are equal, she says. For example, one surgeon may be doing an additional procedure that would boost his supply costs.
Ms. Berreth says showing physicians blinded comparisons is a particularly good motivational tool with supply costs per case. "All cataract surgeons, for example, want to have similar case costs," she says. "If one of them costs $1,000 per case and the other just $650, it will be noticed."
6. Infection rates. Reviewing physicians' cases, Ms. Berreth says she follows skin infections based on the CDC definition, which involves such factors as redness, swelling and heat at the site. "The CDC has four different levels of infection and we count them all," she says. A case is also included in her center's infection rates if the physician puts the patient on an antibiotic afterwards. Infections will be detectable by the time the patient makes the post-op visit to the physician, which generally occurs 7-10 days after the operative procedure.
In addition, when ASC representatives make their 30-day post-op call to patients, "we ask them how their follow-up appointments have gone and infections can be reported in that way," she says. That information is then verified with the physician's office.
7. Surgical complications. Ms. Berreth says her ASC also measures surgical complications, which can often be found in the physician's dictated operative record. For instance, the physician might report he accidently cut a nerve in carpal tunnel surgery. But if the complication involves the staff instead of the physician, she is careful not to put it on the list, she says. For example, "when the surgical staff electrically grounds a cautery device with a gel pad on the patient's skin and a sore develops, it would not be put on the list," she says.
Ms. O'Neill uses a similar statistic, called the unexpected complication rate. As of Jan. 2010, Medicare will require all ASCs to report surgical complications 30 days after the procedure and one year afterwards for implants. She says the information has to be collected manually from the physician's office after surgery.
8. Handwashing compliance. Ms. O'Neill says Medicare requires that centers track handwashing practices of physicians as well as staff. "This is one of the areas that a lot of ASCs are getting dinged on in Medicare surveys and, in many cases, it's the physicians who are not properly handwashing," she says. Surveying handwashing compliance requires periodic observation by a designated staff members and filling out a standardized form. Being careful not to look obvious, the monitor watches how others handwashing and makes sure they are using the proper technique" she says.
9. On-time completion of medical records. This metric is not only mandatory –– Medicare surveyors use it to judge centers –– but is also useful to improve operations. Physicians are the very appropriate to measure here, because a medical record cannot be turned in until the physician completes it. "We track this with all physicians," Ms. Berreth says.
Ms. O'Neill says Medicare sets three different deadlines in this area: The patient's history and physical must be updated and documented within 24 hours of the procedure, the post-operative report must be completed within 72 hours and the full medical record must be completed within 30 days. Even though the history and physical is generally done at the physician's office, it impacts the ASC, Ms. Berreth says. Her ASC measures five components of the H&P while some centers measure as many as eight components.
10. Patient satisfaction. Ms. O'Neill says this metric is important because it influences whether patients will use the facility again. "Everybody measures patient satisfaction in some way or another," she says. "Whatever measurement is used, you want to determine whether the physician has a top-box rate," the highest level of the rating. Since patient satisfaction surveys are standardized, results can be compared across the industry and with national benchmarks.
In addition to scrutinizing survey results, Ms. Berreth tracks every patient complaint about a physician. She says the complaint usually has to do with the physician not conversing with the patient enough about the procedure or what to expect afterwards. "Sometimes the physician said he did talk to the family, which does count for something," she says. The metric is reported to the ASC board. "No physician has more than two or three of these a month, but we don't want them to have even one," she says.