Jeff Bernhardt, Clinical Director at Main Street Specialty Surgery Center, discusses 10 ways ambulatory surgery centers can improve their efficiency and become an even stronger business as a result. 1. Watch surgeons who tend to over or underestimate surgical times. Schedules are tight at surgery centers, so it becomes a problem when a surgeon grossly over- or underestimates surgical times; it disrupts the surgery schedule when cases run over and delays the following cases. Surgeons get upset and patients are frustrated.
"I conducted a QA study when we were encountering surgeons who were estimating inaccurate times," says Mr. Bernhardt. "We had a group of surgeons that were underestimating them, and with our limited schedule, following those surgeons was creating inefficiencies. We monitor them closely and direct our schedulers to add time to those surgeons' cases."
Mr. Bernhardt might add 30 minutes to a surgeon who is consistently slower than estimated times so the schedule is more appropriate. "There can be no gaps in between cases," he says. "We look at our schedules daily and weekly and I have the power to readjust them and move the surgeries around so they flow smoothly and have no gaps."
2. Allow for early starts. Instead of adding cases at the end of the day, Mr. Bernhardt allows surgeons to add additional cases in at the beginning of the day to keep clinical times moving smoothly. This allows staff members to anticipate when they will be leaving the center each day. Also everyone must agree to the meaning of 'Start Time.' Their start time is when the patient enters the OR room.
"We have three early start rooms, which will normally start at 7:30 am," says Mr. Bernhardt. "Surgeons can add cases before their clinical hours; I oftentimes add a microdiscectomy or a quick arthroscopy in the morning. We can do two cases at 6:30 am and one case at 7 am starting time. The flexibility is in the schedule and not having any gaps during the day, you can allow early cases in the morning to drive additional patient volume."
3. Optimize OR selection. Coordinate operating rooms so similar cases follow each other. The goal is to minimize the movement of equipment. For example, Main Street Specialty Surgery Center can do all shoulder surgeries in one room and all knee surgeries in another. You can coordinate even further by doing all left side surgeries first before switching to the right side. Another way is to do all the knees in a row and then do the shoulders.
"You have to schedule similarities in the operating rooms so things flow smoothly," says Mr. Bernhardt. "We are a multispecialty ASC, so for example we put all the general surgeries in one room and line up hand surgery cases in another. Managing the surgical schedule can create efficiencies every day."
4. Maintain a consistent staff. Build a quality team at the surgery center and maintain the same staff members for as long as possible. Surgeons appreciate working with the same team from year to year, and knowledgeable employees are more efficient and effective than new hires.
"We put the same people with the same surgeons 80 percent of the time, and we cross train staff members to back up our team," says Mr. Bernhardt. "They easily shave 10 minutes from each case just because we have a consistent staff."
The staffing must also be adequate, which can come to a great expense to the ASC. However, moving patients through efficiently can improve ASC revenue and enhance the bottom line in the long run.
5. Assign float staff for room turnover. In an attempt to run a lean business, many surgery centers charge their regular staff with room turnover. However, with a limited team, turnover times are slower. Instead, ASCs can designate "float" staff to move from room to room and help with turnovers as necessary.
"We try to have extra staff members in the hallways so people who were working on the cases in those rooms don't have to come back and turn over their rooms," says Mr. Bernhardt. "The minute the circulating nurse transports the patient, our float staff comes in and cleans the room, and then opens it up for the next case. Our average room turnover is three to six minutes. ASCs try to cut costs and expect the room staff to clean their own rooms, but their turnover times are abysmal."
Quick turnover times are crucial, because they are one of the big advantages many surgeons see for surgery centers over hospitals. Mr. Bernhardt also has surgical techs and support techs available to help with room turnovers because they ensure the equipment is ready for the next case.
"Our surgeons want to flip from one room to another if we have extra rooms — they'll do a shoulder and then flip to the knee," says Mr. Bernhardt. "If we aren't running all five operating rooms, we flip rooms. That requires a commitment from the staff to help them does that. It costs a little more to hire these employees, but their help pays for itself."
6. Standardize equipment trays and sterilization. Poorly-managed supplies and equipment leads to increased sterilization and slow turnaround times. When supplies and equipment are standardized ASCs can move through cases more efficiently. Many surgery centers have just enough trays available to complete a few cases before the sterilization process begins. This slows down the turnovers and may end up costing the ASC more in the long run due to decreased efficiency.
"ASC's sometimes for budgetary reasons and don't have enough trays, so they are forced to sterilize those trays for turnovers. This can create problems with turnover times and infection control," says Mr. Bernhardt. "You might have to have enough trays to get well into the third case before beginning the sterilization process. We rarely have to delay a case because of sterilization issues."
Mr. Bernhardt also uses standardized custom packs and automated fluid removal. "You can't have pails or bottles of contaminated fluid carried down the hallway; you have to have automated draining systems," he says. "This is especially important if you have orthopedics cases in your ASC."
7. Use technology to decrease paperwork and tailor paperwork to different specialties. Part of the standardization at Main Street Specialty Surgery Center is patient forms; many providers are frustrated with the time and effort it takes for charting. Mr. Bernhardt tries to minimize the writing by tailoring their forms to specialty and utilize charting by exception. He also uses online ordering to reduce paperwork and streamline materials management.
"Our preop forms are engineered to help reduce interview times. Our GI and pain procedures have forms that are tailored for them specifically," he says. "We want to tailor the form to fit the process and not have a generic form that asks questions that may not be relevant. Every ASC should review their forms annually to simplify and reduce redundancies."
The center also tries to limit staff paperwork so they can meet regulatory requirements without adding extra paperwork. Each OR includes a laminated poster of the Surgical Safety Checklist. When the surgical staff completes the safety checklist it is checked off on the nursing intraoperative form. This process eliminates adding another form to the chart.
Mr. Bernhardt also uses Supply Management Online and McKesson's Data Transfer to manage costs, optimize inventory, and to help his materials management save time and to be as efficient as possible.
8. Promote teamwork and leadership. Team leaders report to the Director of Nursing (DON). They carry out the plan as directed by the DON. Team leaders at the surgery center are in charge of making sure everyone knows the plan for the day. They make the assignments and oversee the schedule. Team leaders gather their team every night to make sure surgical equipment and trays are ready for the next day.
"Everybody is a niche player on our team," says Mr. Bernhardt. "I try to look where they add the most value. So even if someone isn't as strong overall as someone else, there is an area where they will excel and add value to the team. I try to instill that in our culture."
9. Communicate constantly with staff members. Team leaders should have constant communication with their staff members during the day so everything runs smoothly. If a patient arrives late, everyone on the team communicates to know the case should be fast tracked and people can rotate over to get the patient in as quickly as possible.
"We use the SBAR communication process as part of our culture here," says Mr. Bernhardt. "We want to communicate about potential issues before they happen, not while they are happening. We need to anticipate problems and avoid them instead of just responding after they occur. I try to empower my employees, so they can think independently and creatively. My door is open to any employee who wants to talk and have some 'Boss Time.'"
10. Address problems immediately. The efficiency of an organization is directly related to the morale of the employees. Employees will be motivated and loyal when they are treated with respect, challenged by their work, and have access to management. Main Street Specialty Surgery Center has an open door policy to immediately address staff issues that haven't been resolved thru the normal chain of command. When someone isn't behaving appropriately, or has an issue that they want addressed, it's important to work with this employee instead of letting the problem fester.
"When someone has a problem, I try to talk to that person immediately. One of the worst things to do is let someone ruminate with their issue. Anger and resentment almost always increase," says Mr. Bernhardt. "You have to be interactive and preemptive when someone comes into the office with a problem, they might not want to address the issue directly because they know something negative may happen, but a manager must be a coach and a counselor in order to resolve their issues."
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