Most surgery centers are using industry benchmarks to set goals for staff to improve processes. But some goals are harder to meet than others, and difficult benchmarks may be left unaddressed when a physician component contributes to the problem. Jean Day, RN, CNOR, director of clinical operations for Pinnacle III, discusses three tough benchmarking goals for surgery centers, as well as several strategies to improve performance in each area.
1. Compliance to completing medical records in 30 days. Ms. Day says she has seen ASCs struggle to complete medical records within the 30-day industry standard. Completing medical records in a timely fashion is essential to speed up the coding and billing process, which in turn results in ASC payment. She notes the process is often held up when physicians fail to complete dictation on the date of service, or at least within a few days of surgery. When a physician procrastinates on dictation for a week or two, the average number of days for medical record completion rises and reimbursement is significantly delayed. She recommends the following steps to speed up the process:
• Use the collegiate method first. If you encounter a physician who's several days late with his or her dictation, approach them gently with a reminder. "Usually that means picking up the phone and saying, 'Doctor, we haven't received your op report — might we expect it later today?'" she says. "It's a courtesy call. We're not trying to be unpleasant or difficult, and typically, physicians are responsive."
• Escalate problem physicians to administration. Like most people, physicians are habitual; therefore, incidental dictation delays are of little concern when the physician is not historically prone to untimely dictation. Benchmarking brings non-compliance to the forefront — chronic offenders consistently appear within the data collection. Staff members know who these providers are but they are not in positions to effect change. When data is utilized to dispassionately convey facts, real change becomes possible.
"Corrective action on something like medical record delinquency has to be elevated," Ms. Day asserts. "It has to be raised to the administrator, or medical director." She recommends one of the ASC leaders sit down with the physician and explain how her lateness impacts reimbursement and therefore profitability and distributions. Presenting hard data that compares her timeliness with other physicians should be enough of an incentive to curb the problem.
• Implement "house rules" about dictation. The surgery center should implement expectations about dictation, Ms. Day states. "Our house rules set the expectation that physicians complete an op report on the day of service," she says. "If the dictation is dictated today, the transcription should be ready tomorrow." She indicates the house rules should be repeated to all physicians and staff so that there's no confusion about what's expected.
2. Fewer surgery delays. Surgical delays are another problem area for many ASCs, Ms. Day says. She notes delays can be caused by a number of factors: an overextended anesthesia interview, an unprepared patient, a late surgeon, etc. The problem with delays is that they affect surgeon and patient satisfaction immensely; most patients will consider a wait in excess of 30 minutes a bad experience, and a surgeon won't be happy to receive a phone call that says his case has been pushed back. She says every center has occasional issues that make delays inevitable, but it worries her when a center presents with a significant number of delays every quarter. Ms. Day recommends a few processes to decrease the number of delays at your center:
• Compile data to decrease underbooking. Underbooking occurs when an ASC scheduler allots too little time for a surgeon's case. This can happen when, for example, the physician's office scheduler calls the ASC scheduler and asks for 120 minutes for the surgeon to perform a shoulder arthroscopy. In this case, Ms. Day notes, you typically have two clerical people with little to no clinical experience, booking time specific events. When underbooking by a single surgeon goes unaddressed, it sets the stage for a grueling race against time for the OR team.
Ms. Day indicates the surgery center's OR manager should use patient accounting system data to compile trends on average case times per procedure and surgeon. That way, the OR manager can sit down with a physician and begin a purposeful dialogue: "Based on our data, you consistently request 120 minutes for shoulder arthroscopy. The data also indicates an average of 150 minutes of OR time is required. We are experiencing a decrease in patient satisfaction due to extended wait times. Our investigation reveals these are clustered on your surgical day. Will you allow us to schedule shoulder procedures for 150 minutes?" Physicians may push back but, at the very least, the conversation has been initiated. Continuous monitoring of time management allows the OR manager to revisit the concern if necessary.
• Make sure the scheduling request is specific. Underbooking can also occur when the scheduling request is not specific about the kind of surgery being performed. For example, a shoulder arthroscopy with an acromio-clavicular decompression and an arthroscopic rotator cuff repair with anchor placement will take a significant amount of time, whereas an arthroscopy to clean up the glenohumoral joint won't take as much time. "Make sure the surgeon’s office is accurately describing the case they believe is going to be performed," cautions Ms. Day.
3. Fewer cancellations. While cancellation rates are not as significant a problem for ASCs as delays and late medical record completion, they can still have a considerable impact on center efficiency, says Ms. Day. Cancellations after admission or within 24 hours of surgery are the ones to target. Using data collection, the ASC can drill down to determine if higher cancellation rates are specific to a specialty or surgeon, and then a more focused study can ensue. "Cancellations create disruptions which result in a sudden push of the ASCs stop button," Ms. Day says. She recommends several steps to immediately decrease your number of cancellations:
• Ensure a thorough pre-operative interview is conducted. Day-of-surgery cancellations are uncommon, but they do occur. This is often due to a poorly conducted pre-operative interview or among patients who are poor historians or those presenting with an undiagnosed co-morbidity condition. "There's a whole new class of patients with undiagnosed sleep apnea," Ms. Day says. "A detailed health history can often identify these individuals prior to admission. Many anesthesia providers will insist on sleep studies before delivery of general anesthesia. If their risk for OSA is not detected until date of service, the case must be cancelled and rescheduled after diagnostic studies have been performed."
• Inform patients of payment responsibility prior to date of surgery. Cancellations can also occur if patients do not understand their responsibility for payment prior to arriving for surgery, Ms. Day points out. This is especially important in an era of high deductibles and co-pays, when patients may not realize they have a significant fee to pay on the day of surgery. "Our patient population has more skin in the game than ever before," Ms. Day says.
• Understand when cancellations are inevitable. Certain cancellations are not a cause for concern because they are unpredictable and necessary, Ms. Day asserts. For example, if an internal or external disaster occurs and the surgery center has to implement its emergency management plan, cancellations are inevitable. Pediatric surgery centers will also experience a higher rate of cancellations because children get sick more suddenly than adults.
Learn more about Pinnacle III.
Related Articles on ASC Turnarounds:
10 Tips to Keep ASCs Profitable in Tough Economic Times
50 Statistics for ASCs With an Orthopedic Focus
10 Hospitals Building, Planning or Gaining Ownership of Ambulatory Surgery Centers
1. Compliance to completing medical records in 30 days. Ms. Day says she has seen ASCs struggle to complete medical records within the 30-day industry standard. Completing medical records in a timely fashion is essential to speed up the coding and billing process, which in turn results in ASC payment. She notes the process is often held up when physicians fail to complete dictation on the date of service, or at least within a few days of surgery. When a physician procrastinates on dictation for a week or two, the average number of days for medical record completion rises and reimbursement is significantly delayed. She recommends the following steps to speed up the process:
• Use the collegiate method first. If you encounter a physician who's several days late with his or her dictation, approach them gently with a reminder. "Usually that means picking up the phone and saying, 'Doctor, we haven't received your op report — might we expect it later today?'" she says. "It's a courtesy call. We're not trying to be unpleasant or difficult, and typically, physicians are responsive."
• Escalate problem physicians to administration. Like most people, physicians are habitual; therefore, incidental dictation delays are of little concern when the physician is not historically prone to untimely dictation. Benchmarking brings non-compliance to the forefront — chronic offenders consistently appear within the data collection. Staff members know who these providers are but they are not in positions to effect change. When data is utilized to dispassionately convey facts, real change becomes possible.
"Corrective action on something like medical record delinquency has to be elevated," Ms. Day asserts. "It has to be raised to the administrator, or medical director." She recommends one of the ASC leaders sit down with the physician and explain how her lateness impacts reimbursement and therefore profitability and distributions. Presenting hard data that compares her timeliness with other physicians should be enough of an incentive to curb the problem.
• Implement "house rules" about dictation. The surgery center should implement expectations about dictation, Ms. Day states. "Our house rules set the expectation that physicians complete an op report on the day of service," she says. "If the dictation is dictated today, the transcription should be ready tomorrow." She indicates the house rules should be repeated to all physicians and staff so that there's no confusion about what's expected.
2. Fewer surgery delays. Surgical delays are another problem area for many ASCs, Ms. Day says. She notes delays can be caused by a number of factors: an overextended anesthesia interview, an unprepared patient, a late surgeon, etc. The problem with delays is that they affect surgeon and patient satisfaction immensely; most patients will consider a wait in excess of 30 minutes a bad experience, and a surgeon won't be happy to receive a phone call that says his case has been pushed back. She says every center has occasional issues that make delays inevitable, but it worries her when a center presents with a significant number of delays every quarter. Ms. Day recommends a few processes to decrease the number of delays at your center:
• Compile data to decrease underbooking. Underbooking occurs when an ASC scheduler allots too little time for a surgeon's case. This can happen when, for example, the physician's office scheduler calls the ASC scheduler and asks for 120 minutes for the surgeon to perform a shoulder arthroscopy. In this case, Ms. Day notes, you typically have two clerical people with little to no clinical experience, booking time specific events. When underbooking by a single surgeon goes unaddressed, it sets the stage for a grueling race against time for the OR team.
Ms. Day indicates the surgery center's OR manager should use patient accounting system data to compile trends on average case times per procedure and surgeon. That way, the OR manager can sit down with a physician and begin a purposeful dialogue: "Based on our data, you consistently request 120 minutes for shoulder arthroscopy. The data also indicates an average of 150 minutes of OR time is required. We are experiencing a decrease in patient satisfaction due to extended wait times. Our investigation reveals these are clustered on your surgical day. Will you allow us to schedule shoulder procedures for 150 minutes?" Physicians may push back but, at the very least, the conversation has been initiated. Continuous monitoring of time management allows the OR manager to revisit the concern if necessary.
• Make sure the scheduling request is specific. Underbooking can also occur when the scheduling request is not specific about the kind of surgery being performed. For example, a shoulder arthroscopy with an acromio-clavicular decompression and an arthroscopic rotator cuff repair with anchor placement will take a significant amount of time, whereas an arthroscopy to clean up the glenohumoral joint won't take as much time. "Make sure the surgeon’s office is accurately describing the case they believe is going to be performed," cautions Ms. Day.
3. Fewer cancellations. While cancellation rates are not as significant a problem for ASCs as delays and late medical record completion, they can still have a considerable impact on center efficiency, says Ms. Day. Cancellations after admission or within 24 hours of surgery are the ones to target. Using data collection, the ASC can drill down to determine if higher cancellation rates are specific to a specialty or surgeon, and then a more focused study can ensue. "Cancellations create disruptions which result in a sudden push of the ASCs stop button," Ms. Day says. She recommends several steps to immediately decrease your number of cancellations:
• Ensure a thorough pre-operative interview is conducted. Day-of-surgery cancellations are uncommon, but they do occur. This is often due to a poorly conducted pre-operative interview or among patients who are poor historians or those presenting with an undiagnosed co-morbidity condition. "There's a whole new class of patients with undiagnosed sleep apnea," Ms. Day says. "A detailed health history can often identify these individuals prior to admission. Many anesthesia providers will insist on sleep studies before delivery of general anesthesia. If their risk for OSA is not detected until date of service, the case must be cancelled and rescheduled after diagnostic studies have been performed."
• Inform patients of payment responsibility prior to date of surgery. Cancellations can also occur if patients do not understand their responsibility for payment prior to arriving for surgery, Ms. Day points out. This is especially important in an era of high deductibles and co-pays, when patients may not realize they have a significant fee to pay on the day of surgery. "Our patient population has more skin in the game than ever before," Ms. Day says.
• Understand when cancellations are inevitable. Certain cancellations are not a cause for concern because they are unpredictable and necessary, Ms. Day asserts. For example, if an internal or external disaster occurs and the surgery center has to implement its emergency management plan, cancellations are inevitable. Pediatric surgery centers will also experience a higher rate of cancellations because children get sick more suddenly than adults.
Learn more about Pinnacle III.
Related Articles on ASC Turnarounds:
10 Tips to Keep ASCs Profitable in Tough Economic Times
50 Statistics for ASCs With an Orthopedic Focus
10 Hospitals Building, Planning or Gaining Ownership of Ambulatory Surgery Centers