Surgery centers can improve profitability, efficiency and satisfaction by creating clear goals and tracking progress toward those goals, says Bryan Wright, administrator of Florida Hospital Surgery Center in Orlando. He says the process starts with a culture that engages staff and physicians in the plan to improve the center. "The key to success in all these areas is setting clear accountabilities and goals with every stakeholder," he says. The surgery center leader should create a vision of exceeding expectations and providing the best customer service possible in a competitive environment.
"Things have to make sense to everyone, or they will never work," he says. With all these goals, he emphasizes providing information about your target to employees in a clear, easy-to-understand manner. "In order to create buy-in at all levels, you need to involve staff and physicians in the planning, implementation, execution, sustainment and recognition phases."
For example, Mr. Wright says a staff member may see the schedule only has two surgery cases for the day and decide to stretch out the day to get their hours. If you share that you need to keep turnover times low to market to new physicians, the staff member will be more likely to work quickly in accordance with the center's plan.
Here he shares six goals for surgery centers to meet or exceed benchmarks in 2012.
1. Achieve 100 percent on-time case starts. On-time case starts can affect surgery center efficiency and profitability significantly, as a late start at the beginning of the day can push back other cases and increase labor costs. Mr. Wright says his hospital system defines first case starts as occurring between 7 AM and 8:30 AM for the first case for the room with a five minute grace period. In December 2011, the surgery center reported 64.5 percent on-time case starts — a number Mr. Wright calls "alarming," It was frustrating to say the least, he says. "We can't market our facility to new physicians if we don't start our cases on time, regardless of the cause." The surgery center has since increased on-time case starts to 100 percent in March 2012 and 98 percent in April 2012 so far. Here's how:
• Post information on case starts for staff and physicians. In order to increase visibility around first case starts, they posted a notice on every OR door that lists the first case of the day, the physician, the expected start time, whether that time was met and — if it wasn't — why not. Mr. Wright then collected the sheets at the end of every day and addressed the cause in real time if the case started late. He also posted a monitor in the surgery center break room that charts the center's progress with all their key metrics, as well as first case starts for the day, week, month and year. If a physician has been consistently late, his or her name will appear on a bar graph that demonstrates that lateness. Mr. Wright says the bar graph is color-coded to explain the reason for lateness: For example, if the physician caused the delay, the bar graph will be colored red to indicate "surgeon late." Mr. Wright says that posting physicians names and results has motivated those physicians that were chronic offenders to improve.
• Make sure staff know what you expect. Mr. Wright also set clear expectations with his staff: The circulator had to be by the bedside 15 minutes before case start no matter what. If the physician was absent 15 minutes prior to the case, the staff had to call the physicians or alert the facility leadership. Staff members had to be prepared for the first case of the day by the night before. Staff also had to identify any barriers that could delay an on-time start in advance with anesthesia, supplies, equipment and vendors and make sure those issues were addressed.
• Remind surgeons of case start times prior to surgery. He says surgery center physicians are reminded about their case start times the day before surgery with a call or text (based on their preference) from the surgery center. This increases physicians' accountability to the center and decreases the likelihood that they will forget to come in.
2. Decrease room turnover times to around 12 minutes per case. Room turnover times at Mr. Wright's surgery center were as high as 18.68 minutes in April 2011, a number that has since been reduced to 12.04 minutes (excluding flips) and 10.91 (including flips), putting them in the 99th percentile nationally. Mr. Wright outlines several steps the staff and physicians took to decrease turnover times:
• Sit down with all stakeholders. Mr. Wright formed a committee of OR stakeholders and asked them to list every variable that could affect turnover times. "We came up with a tracking sheet that had orders, anesthesia, equipment issues, clearing issues, and we put down every single thing on one piece of paper," he says. This meeting started the conversation about why turnover times were so high in the first place — a critical step to lowering them, he says.
• Inform staff members, physicians and anesthesia of your goal. One problem causing high turnover times was the fact that staff members had no idea what to aim for, Mr. Wright says. In the past, he received data on room turnover times a month and 10 days after the data was collected, which had little significance for staff members. He instead implemented a system where staff members track turnovers for each physician on a sheet of paper. Each sheet has a place to list the turnover time and identify which problem caused the delay. The sheets are then gathered at the end of the day, and one of the facility's leadership creates a weekly and monthly report that lets staff members know their progress. "Now the staff can answer on the spot whether they had a good turnover or not, and they watch the clock in-between cases," Mr. Wright says.
• Involve physicians. Physicians are crucial to this as well, Mr. Wright says. They can improve turnover times dramatically by doing things such as: staying in the immediate proximately of the operating rooms, scheduling cases in an order that takes all turnover variables into account, or seeing multiple patients in advance of the first case to ensure they are ready and doing blocks. Anesthesia is also a crucial component in getting patients to recovery and then quickly flipping over to pre-op. "Every person has to be on board with the goal," he says.
• Talk to vendors about your plan. Mr. Wright recommends speaking to vendors about the plan to decrease turnover times. His center performs urology cases that require lithotripsy equipment, so vendor techs must understand that equipment needs to be moved out of the room quickly following the case. He says the vendors were open to this conversation and worked with the techs to improve their efficiency.
3. Increase block time utilization to above 75 percent. Mr. Wright's center and physicians have increased block time utilization to an average of 81 percent in February, with a first quarter average of 76 percent — well above the health system's goal of 63 percent. He says this issue also came down to analyzing the root cause of low block time utilization. He says center leadership worked with physicians to install reminders that prompted them to release block time in advance of their 48 or 72 automatic drop if they weren't going to use it. This reminder to drop block time manually improved the statistics because the physicians didn't realize that allowing the computer to drop block time automatically counted negatively towards utilization statistics.
He says he also reduced hours for physicians if he noticed they were consistently not filling their block time. "One physician had 7 AM to 3 PM, and we noticed he wasn't utilizing it fully over a three-month period," he says. "They also didn't understand that they might have one case booked for their whole block and should drop part of it." They also communicated the consequences of low utilization to both the facility and the physicians in terms of potential loss of block time.
4. Achieve more than 76 percent upfront cash collections. Mr. Wright and physician leadership came to the current surgery center with a philosophy that patients should meet their co-pays, co-insurance and deductibles prior to surgery to avoid bad debt and increasing health care costs. "This is a patient’s financial responsibility based on their individual insurance plan," Mr. Wright says. "We started to really understand that there was a cultural problem with people who don't understand insurance and think their procedure should be covered 100 percent." In order to increase cash collections to above 75 percent, he implemented the following tactics:
• Expect 100 percent upfront collection from staff members. Staff members at Mr. Wright's surgery center know they are expected to collect 100 percent of a patient financial responsibility defined by their insurance provider prior to surgery for their outpatient elective procedures. Two days before surgery, a staff member calls the patient to explain how their insurance works and what they will owe. The staff member explains the surgery center has a policy of collecting in full rather than billing after the fact. Mr. Wright says if the staff member has a legitimate reason for not collecting 100 percent, they are allowed to reduce collections to 75 percent and then 50 percent with a interest free payment plan of one or two years. However, payment plans should only be used when the patient truly cannot pay the bill upfront.
• Offer payment plans to patients who need them. If a patient can't pay the bill upfront, don't let him walk through the door without setting up a payment plan, Mr. Wright says. The patient should be expected to provide credit card information and make substantial payments to the surgery center on a regular basis until the debt is cleared. The only exception to this is if a patient truly is a hardship case or it is deemed medically necessary. In those cases, Mr. Wright says, "The mission of Florida Hospital is to extend the healing ministry of Christ, and we absolutely display this compassion to those that are need through our financial assistance programs The expectation is that those that have the ability to pay make a good faith attempt, and that is why we offer payment plans to work with them."
• Reward employees who report high collections. Mr. Wright says it helps to motivate team members with rewards for those who collect in full. If surgery center staff members meet their monthly total or percentage goals, they can receive additional compensation incentives.
5. Get to the 90th percentile in patient satisfaction. Patient satisfaction is a clear driver of success: It increases case volume, bolsters your reputation in the community and keeps staff morale high. Mr. Wright details several ways his surgery center has prioritized patient satisfaction in the last year, reaching the 90th percentile in the health system in the first quarter:
• Improve your physical plant. Making improvements to your physical plant can affect patient satisfaction significantly, Mr. Wright says. His surgery center added more televisions to the surgery center waiting area, improved the ambience and inviting feel in the center and added amenities throughout. The surgery center also offers a guestbook with an introduction from Mr. Wright and visitor information to make their stay more comfortable, as well as gourmet coffee and a souvenir bag that gives patients a place to put their personal possessions. "The team's goal was to take the best practices from the customer service industries and apply them to our healthcare facility," Mr. Wright says.
• Increase staff professionalism. Mr. Wright says his center took a cue from the hospitality industry: No staff members walk through the waiting area with their lunch or wearing street clothes. All staff members are attired in logoed uniforms, and Mr. Wright and the front desk staff wear suits. The team has bought into being “On Stage” in front of patients and do not display use of cell phones or anything else that would be of a personal nature.
• Take care of patients before and after surgery. Patients want to feel "looked after" for the entire surgical experience, Mr. Wright says. Prior to surgery, staff members call the patient to remind them of their appointment time, go over financial details and answer any questions. After surgery, one of Mr. Wright's nurses calls every patient to see how their recovering. Each patient also gets an email from Mr. Wright, thanking them for using the surgery center and inquiring if there was anything they could have done better.
• Distribute satisfaction scores to staff regularly. Mr. Wright's center uses Press Ganey to calculate satisfaction scores, and those results are distributed to staff on a regular basis via email. "They see the patient comments along with the overall scores, as well as an executive summary on the monthly scores from me," he says. He adds the staff meets as a team after the scores come out to determine how the surgery center could improve. "The team takes the scores and patient comments very personally and analyze all the variables," Mr. Wright says. "They identify the opportunities for improvement and make an action plan to address each item."
6. Achieve these results without increasing costs. During the first quarter 2012, the surgery center was under budget on labor, supplies and total expense while accomplishing these results. "It is possible to make improvements without increasing costs," Mr. Wright says. "The most important driver goes back to the first recommendation: Have the right team of staff and physicians that are engaged in the vision."
Learn more about Florida Hospital Surgery Center.
Related Articles on ASC Turnarounds:
Start to Finish in 3 Months: 8 Reasons Why Prairie Surgicare Could Make It Happen
113 Surgery Center Administrators to Know
8 Critical Areas for Monthly Surgery Center Benchmarks
"Things have to make sense to everyone, or they will never work," he says. With all these goals, he emphasizes providing information about your target to employees in a clear, easy-to-understand manner. "In order to create buy-in at all levels, you need to involve staff and physicians in the planning, implementation, execution, sustainment and recognition phases."
For example, Mr. Wright says a staff member may see the schedule only has two surgery cases for the day and decide to stretch out the day to get their hours. If you share that you need to keep turnover times low to market to new physicians, the staff member will be more likely to work quickly in accordance with the center's plan.
Here he shares six goals for surgery centers to meet or exceed benchmarks in 2012.
1. Achieve 100 percent on-time case starts. On-time case starts can affect surgery center efficiency and profitability significantly, as a late start at the beginning of the day can push back other cases and increase labor costs. Mr. Wright says his hospital system defines first case starts as occurring between 7 AM and 8:30 AM for the first case for the room with a five minute grace period. In December 2011, the surgery center reported 64.5 percent on-time case starts — a number Mr. Wright calls "alarming," It was frustrating to say the least, he says. "We can't market our facility to new physicians if we don't start our cases on time, regardless of the cause." The surgery center has since increased on-time case starts to 100 percent in March 2012 and 98 percent in April 2012 so far. Here's how:
• Post information on case starts for staff and physicians. In order to increase visibility around first case starts, they posted a notice on every OR door that lists the first case of the day, the physician, the expected start time, whether that time was met and — if it wasn't — why not. Mr. Wright then collected the sheets at the end of every day and addressed the cause in real time if the case started late. He also posted a monitor in the surgery center break room that charts the center's progress with all their key metrics, as well as first case starts for the day, week, month and year. If a physician has been consistently late, his or her name will appear on a bar graph that demonstrates that lateness. Mr. Wright says the bar graph is color-coded to explain the reason for lateness: For example, if the physician caused the delay, the bar graph will be colored red to indicate "surgeon late." Mr. Wright says that posting physicians names and results has motivated those physicians that were chronic offenders to improve.
• Make sure staff know what you expect. Mr. Wright also set clear expectations with his staff: The circulator had to be by the bedside 15 minutes before case start no matter what. If the physician was absent 15 minutes prior to the case, the staff had to call the physicians or alert the facility leadership. Staff members had to be prepared for the first case of the day by the night before. Staff also had to identify any barriers that could delay an on-time start in advance with anesthesia, supplies, equipment and vendors and make sure those issues were addressed.
• Remind surgeons of case start times prior to surgery. He says surgery center physicians are reminded about their case start times the day before surgery with a call or text (based on their preference) from the surgery center. This increases physicians' accountability to the center and decreases the likelihood that they will forget to come in.
2. Decrease room turnover times to around 12 minutes per case. Room turnover times at Mr. Wright's surgery center were as high as 18.68 minutes in April 2011, a number that has since been reduced to 12.04 minutes (excluding flips) and 10.91 (including flips), putting them in the 99th percentile nationally. Mr. Wright outlines several steps the staff and physicians took to decrease turnover times:
• Sit down with all stakeholders. Mr. Wright formed a committee of OR stakeholders and asked them to list every variable that could affect turnover times. "We came up with a tracking sheet that had orders, anesthesia, equipment issues, clearing issues, and we put down every single thing on one piece of paper," he says. This meeting started the conversation about why turnover times were so high in the first place — a critical step to lowering them, he says.
• Inform staff members, physicians and anesthesia of your goal. One problem causing high turnover times was the fact that staff members had no idea what to aim for, Mr. Wright says. In the past, he received data on room turnover times a month and 10 days after the data was collected, which had little significance for staff members. He instead implemented a system where staff members track turnovers for each physician on a sheet of paper. Each sheet has a place to list the turnover time and identify which problem caused the delay. The sheets are then gathered at the end of the day, and one of the facility's leadership creates a weekly and monthly report that lets staff members know their progress. "Now the staff can answer on the spot whether they had a good turnover or not, and they watch the clock in-between cases," Mr. Wright says.
• Involve physicians. Physicians are crucial to this as well, Mr. Wright says. They can improve turnover times dramatically by doing things such as: staying in the immediate proximately of the operating rooms, scheduling cases in an order that takes all turnover variables into account, or seeing multiple patients in advance of the first case to ensure they are ready and doing blocks. Anesthesia is also a crucial component in getting patients to recovery and then quickly flipping over to pre-op. "Every person has to be on board with the goal," he says.
• Talk to vendors about your plan. Mr. Wright recommends speaking to vendors about the plan to decrease turnover times. His center performs urology cases that require lithotripsy equipment, so vendor techs must understand that equipment needs to be moved out of the room quickly following the case. He says the vendors were open to this conversation and worked with the techs to improve their efficiency.
3. Increase block time utilization to above 75 percent. Mr. Wright's center and physicians have increased block time utilization to an average of 81 percent in February, with a first quarter average of 76 percent — well above the health system's goal of 63 percent. He says this issue also came down to analyzing the root cause of low block time utilization. He says center leadership worked with physicians to install reminders that prompted them to release block time in advance of their 48 or 72 automatic drop if they weren't going to use it. This reminder to drop block time manually improved the statistics because the physicians didn't realize that allowing the computer to drop block time automatically counted negatively towards utilization statistics.
He says he also reduced hours for physicians if he noticed they were consistently not filling their block time. "One physician had 7 AM to 3 PM, and we noticed he wasn't utilizing it fully over a three-month period," he says. "They also didn't understand that they might have one case booked for their whole block and should drop part of it." They also communicated the consequences of low utilization to both the facility and the physicians in terms of potential loss of block time.
4. Achieve more than 76 percent upfront cash collections. Mr. Wright and physician leadership came to the current surgery center with a philosophy that patients should meet their co-pays, co-insurance and deductibles prior to surgery to avoid bad debt and increasing health care costs. "This is a patient’s financial responsibility based on their individual insurance plan," Mr. Wright says. "We started to really understand that there was a cultural problem with people who don't understand insurance and think their procedure should be covered 100 percent." In order to increase cash collections to above 75 percent, he implemented the following tactics:
• Expect 100 percent upfront collection from staff members. Staff members at Mr. Wright's surgery center know they are expected to collect 100 percent of a patient financial responsibility defined by their insurance provider prior to surgery for their outpatient elective procedures. Two days before surgery, a staff member calls the patient to explain how their insurance works and what they will owe. The staff member explains the surgery center has a policy of collecting in full rather than billing after the fact. Mr. Wright says if the staff member has a legitimate reason for not collecting 100 percent, they are allowed to reduce collections to 75 percent and then 50 percent with a interest free payment plan of one or two years. However, payment plans should only be used when the patient truly cannot pay the bill upfront.
• Offer payment plans to patients who need them. If a patient can't pay the bill upfront, don't let him walk through the door without setting up a payment plan, Mr. Wright says. The patient should be expected to provide credit card information and make substantial payments to the surgery center on a regular basis until the debt is cleared. The only exception to this is if a patient truly is a hardship case or it is deemed medically necessary. In those cases, Mr. Wright says, "The mission of Florida Hospital is to extend the healing ministry of Christ, and we absolutely display this compassion to those that are need through our financial assistance programs The expectation is that those that have the ability to pay make a good faith attempt, and that is why we offer payment plans to work with them."
• Reward employees who report high collections. Mr. Wright says it helps to motivate team members with rewards for those who collect in full. If surgery center staff members meet their monthly total or percentage goals, they can receive additional compensation incentives.
5. Get to the 90th percentile in patient satisfaction. Patient satisfaction is a clear driver of success: It increases case volume, bolsters your reputation in the community and keeps staff morale high. Mr. Wright details several ways his surgery center has prioritized patient satisfaction in the last year, reaching the 90th percentile in the health system in the first quarter:
• Improve your physical plant. Making improvements to your physical plant can affect patient satisfaction significantly, Mr. Wright says. His surgery center added more televisions to the surgery center waiting area, improved the ambience and inviting feel in the center and added amenities throughout. The surgery center also offers a guestbook with an introduction from Mr. Wright and visitor information to make their stay more comfortable, as well as gourmet coffee and a souvenir bag that gives patients a place to put their personal possessions. "The team's goal was to take the best practices from the customer service industries and apply them to our healthcare facility," Mr. Wright says.
• Increase staff professionalism. Mr. Wright says his center took a cue from the hospitality industry: No staff members walk through the waiting area with their lunch or wearing street clothes. All staff members are attired in logoed uniforms, and Mr. Wright and the front desk staff wear suits. The team has bought into being “On Stage” in front of patients and do not display use of cell phones or anything else that would be of a personal nature.
• Take care of patients before and after surgery. Patients want to feel "looked after" for the entire surgical experience, Mr. Wright says. Prior to surgery, staff members call the patient to remind them of their appointment time, go over financial details and answer any questions. After surgery, one of Mr. Wright's nurses calls every patient to see how their recovering. Each patient also gets an email from Mr. Wright, thanking them for using the surgery center and inquiring if there was anything they could have done better.
• Distribute satisfaction scores to staff regularly. Mr. Wright's center uses Press Ganey to calculate satisfaction scores, and those results are distributed to staff on a regular basis via email. "They see the patient comments along with the overall scores, as well as an executive summary on the monthly scores from me," he says. He adds the staff meets as a team after the scores come out to determine how the surgery center could improve. "The team takes the scores and patient comments very personally and analyze all the variables," Mr. Wright says. "They identify the opportunities for improvement and make an action plan to address each item."
6. Achieve these results without increasing costs. During the first quarter 2012, the surgery center was under budget on labor, supplies and total expense while accomplishing these results. "It is possible to make improvements without increasing costs," Mr. Wright says. "The most important driver goes back to the first recommendation: Have the right team of staff and physicians that are engaged in the vision."
Learn more about Florida Hospital Surgery Center.
Related Articles on ASC Turnarounds:
Start to Finish in 3 Months: 8 Reasons Why Prairie Surgicare Could Make It Happen
113 Surgery Center Administrators to Know
8 Critical Areas for Monthly Surgery Center Benchmarks