Bradford Shingleton, MD, has been featured in the Harvard Business Review on his techniques to improve quality and efficiency in cataract surgery. Dr. Shingleton practices at 32-physician Ophthalmic Consultants of Boston and at Cape Cod Eye Surgery & Laser Center. Students at Harvard Business School closely observed his work and wrote about it in a 2008 article in the Harvard Business Review. Dr. Shingleton identifies the following 10 steps he has taken to improve quality and efficiency in cataract surgery.
1. Maintain a high volume of cases. A cataract surgeon should carefully schedule his time to allow for a high volume of cases. Dr. Shingleton performs 75-100 operations a week. "When I do a high volume of cases, I find I am actually a better surgeon," he says. At a fast clip, he becomes so familiar with the task at hand that he can quickly anticipate potential problems. But to maintain high quality at this speed, each case has to be done deliberately and should not be rushed, he says. Despite his high volume, "I do not feel exhausted at the end of the day," he says. "I'm not working hard because everything flows."
2. Delegate non-surgery tasks. A cataract surgeon can achieve a high volume of cases only by delegating all non-surgery tasks to others on staff. "I should not be doing anything that is not part of the surgery at hand," Dr. Shingleton says. He quotes Lee Iacocca, the legendary Chrysler Corp. CEO, who said: "The main thing is to keep the main thing the main thing."
To allow him to focus on his surgery, Dr. Shingleton even delegates to staff many of the meetings with patients and their families that many other surgeons handle personally. "Unless I am needed, my tech can talk with the family," he says. But he notes his staff makes a point of directly involving families at the ambulatory surgery center. If they wish, they can watch Dr. Shingleton performing the surgery and join the patient in the recovery room afterwards. "The ombudsman goes in there to talk to them," he says. "We have 'people' people to do this."
3. Only surgery patients go to the surgeon. Dr. Shingleton's staff and non-surgery colleagues triage patients so that he only deals with patients who need cataract or glaucoma surgery, his two specialties. The other patients are sent to optometrists, general ophthalmologists or other subspecialized ophthalmologists. "In order for me to do my job well, we have to narrow down the patients who see me," Dr. Shingleton says.
4. Use efficiency techniques. Dr. Shingleton uses techniques developed by Toyota to improve quality as well as efficiency. "At Toyota factories, everything has a physical place," he says. "If you need a wrench to tighten a bolt, you should be able to reach for it with a short movement of the hand." This also means that when the surgeon enters the OR, "he should not spend his time adjusting things," he says. His surgery team adjusts equipment such as foot pedals and the operating microscope, based on predetermined grids that allow for quick changes. Dr. Shingleton says this step alone saves 30-60 seconds per case. "That may not seem like much, but it cuts 25 minutes of time in one day," he says. "That's four more surgical cases."
5. Deal with errors immediately. When an error is uncovered, it should be dealt with as soon as possible. "Immediate correction tends to reduce the chance of the same error happening again in the future," Dr. Shingleton says. "There is no punishment here. The whole point is not to make people feel guilty." He also makes sure to communicate praise.
6. Nurture the referral network. Dr. Shingleton puts time into maintaining his network of outside ophthalmologists, optometrists and primary care physicians who refer patients to him. He makes frequent lectures to them on his surgical techniques and personally responds to their concerns. Staff members keep close tabs on these sources, even monitoring volume of referrals from each referring doctor. A downturn in volume might mean the doctor has an issue with Dr. Shingleton or his practice that needs to be addressed and resolved.
7. Personally respond to patient complaints. Dr. Shingleton's staff monitors patient satisfaction through surveys handed to every patient after surgery. Patients also evaluate the surgeon back at their referring doctors. All this information is relayed to Dr. Shingleton's staff. If patients are unhappy, he personally responds to every patient complaint.
8. Switch to mini-block anesthesia. In most cases, Dr. Shingleton has switched from topical anesthesia to mini-block anesthesia, which requires a smaller injection. The mini-block has been more effective for a number of reasons, he says. For example, his outcomes data shows that about 5 percent of patients felt less comfortable with topical anesthesia. Also, since the mini-block is a smaller injection, patients can recover faster.
9. Track patients post-operatively. To evaluate the effectiveness of his surgical techniques, Dr. Shingleton makes sure to track patients' post-operative conditions many years out. "We monitor every single patient on cataract and pseudoexfoliation glaucoma," he says. With the help of his staff, he has developed one of the largest surgery databases in the world for an individual surgeon, encompassing more than 30,000 surgical procedures. This rich source of information is the basis of many articles he has written on the effectiveness of surgical techniques and procedures, published in leading journals.
10. Provide post-op instructions before surgery. Nurses at Dr. Shingleton's Cape Cod ASC suggested providing post-op instructions to patients while the patients were still in the waiting room, before even being called into pre-op. It turned out that many patients who received the instructions at this point remembered them more clearly than if they first received them after surgery. This was possibly due to post-op patients feeling groggy from the effects of surgery.
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