One of the most important trends in healthcare in recent years is that ambulatory surgery centers have become the setting of choice for a wide range of outpatient procedures, due to the lower costs and positive patient experiences at these facilities.
In the field of gastroenterology, for example, a study conducted by Johns Hopkins Bloomberg School of Public Health found that on average, colonoscopies performed at hospitals cost 55% more than the same procedures performed at ASCs.
Running an ASC profitably, however, requires close attention to hidden costs. These hidden costs can contribute to operational inefficiencies, reduce margins and affect patient, physician and staff experience.
To learn how to uncover and address these hidden ASC costs, Becker's Healthcare recently spoke with Nancy Schlossberg, BSN, RN, CGRN, CER, past president of the Society of Gastroenterology Nurses and Associates (SGNA) and the American Board of Certification for Gastroenterology Nurses (ABCGN).
The four "S's" of inefficiency: scheduling, staffing, space and supplies
A helpful way to identify and work to resolve the hidden costs in an ASC is to keep in mind four "S's."
Scheduling
In an ASC, schedule gaps can be extremely expensive, especially in terms of unproductive salary dollars. As a result, the ability to compress and control the schedule is essential. Scheduling software can provide a data-driven tool to improve clinical operations by optimizing provider schedules, resources, and capacity.
Staffing
"When it comes to staffing, " says Ms. Schlossberg, “staffing is a facility’s most expensive resource. ASCs need to examine their staff mix and the associated costs. It may be possible to modify the staff mix and reduce cost per procedure without sacrificing quality of care. In endoscopy settings, for example, many organizations still require two RNs in the procedure room. However, keeping state regulations and facility policies in mind, you might consider modifying procedure room staff mix from 2 RNs to one RN and one experienced, competent tech. In Endoscopy, the importance of a well-trained competent reprocessing room tech is vital to maintaining efficient procedure room turn over by ensuring availability of endoscopes to meet scheduling demands and minimizing risks of potential endoscope contamination resulting from failure to follow all steps of original equipment manufacturer’s Instructions for Use.
Space
The best ASCs utilize space in ways that support highly efficient operational workflow. These facilities optimize the number of prep bays, procedure rooms and recovery bays to best support safe and efficient patient throughput. "Money comes from the procedure room, not the prep or the recovery bays," Ms. Schlossberg said.
Do not forget the importance of adequate reprocessing space along with competent reprocessing techs to support the daily case load. You do not want to delay cases waiting for instruments!
Supplies
Supplies can be another source of hidden costs for ASCs. To minimize inventory carrying costs, organizations must determine the right PAR levels (Periodic Auto-Replenishment; minimum and maximum quantity limits set for certain items) for different supplies. It's important for teams to continually evaluate new or alternative products that deliver high quality at a lower price. However, despite potential expense, ASCs also need to stock supplies that may be needed in emergency situations.
"You need to be ready for an emergency," Ms. Schlossberg said. "In GI and endoscopy, you might use an over-the-scope clip for closure of a perforation. Make sure you have the right equipment on hand and know how to use it. Your staff must be trained and demonstrate competence using devices that are rarely used."
At GI and endoscopy centers, the importance of having the right mix of well-functioning “workhorse” scopes can't be underestimated. "Once scopes go out for repair, you lose the use of the scope, put more wear and tear on remaining scopes and potentially delay case starts. If possible, have loaner scopes on hand. Every time you delay a case, it costs money. Staff may receive overtime pay and delays may compromise patient, physicians, and staff experience," Ms. Schlossberg said.
Good scope handling and maintenance practices can preemptively reduce repair costs. Analyzing the different types of scope repairs that are needed can shed light on scope-handling issues. Large numbers of angulation repairs, for example, may suggest that staff aren't hanging scopes correctly.
Key metrics help to identify inefficiencies that can impact operating expenses
Many of the same benchmarks used in hospital operating rooms can also be used in the ASC setting to uncover hidden costs. These benchmarks include metrics like block time utilization, staff and supply cost per case.
"Reducing inefficiencies is all about asking the right questions," Ms. Schlossberg said. "Can you reduce those costs without lowering the quality of care?"
Patient flow is also important to evaluate using metrics such as on-time starts and room turnaround time. "It can be helpful to look at typical reasons for room delays in your center. When a patient's procedure is complete, you may also want to consider whether you have enough recovery spaces for them to go," Ms. Schlossberg said.
Navigators can reduce costly last-minute cancellations & improve the patient experience
At ASCs that perform screening colonoscopies, it's a good idea to have a dedicated navigator who also handles scheduling. The navigator proactively calls patients and can even start some of the pre-op documentation in advance.
"There is all sorts of literature about the importance of the navigator in colon cancer screening," Ms. Schlossberg said. "That goes back to scheduling. Once a patient is scheduled, is there someone they can talk to in the middle of the night if they have a bad prep? Without that, you run the risk of scheduling gaps resulting from same-day cancellations and no-shows."
While the goal at ASCs should always be to compress the schedule, teams must also set expectations upfront with patients that their procedure times may change. At GI and endoscopy ASCs, maintaining an easily accessible patient waiting list is a best practice. If a colonoscopy patient can't come in on short notice, an upper endoscopy patient can be called since it does not involve a bowel prep.
Well-trained ASC staff promote greater efficiency
Both informal and formal training for employees is beneficial. Helping ancillary staff understand how procedures are performed, for example, can pay dividends.
"You do everyone a great service if you invite them into a room and show them how a colonoscopy is performed," Ms. Schlossberg said. "Your biller might say, 'Wow, I heard you say colonoscopy with a snare polypectomy. Yet, when I look at the supplies for the case, there's no snare listed. Should there be?'"
It can also be productive to regularly schedule “Skills Day” to provide quality assurance of endoscopy training and skill retention. At various stations, provide staff with the opportunity to demonstrate their skills through a return demonstration guided by a competency checklist. Stations might include new equipment and devices and equipment such as electrosurgical generators that can pose a very high risk to patient safety. When it comes to formal training, a competency-based approach is preferred. Staff certification among nurses and techs demonstrates proficiency, as well as a personal and professional commitment to patient care. GI and endoscopy nurses can get certified through the American Board of Certification for Gastroenterology Nurses (ABCGN).
"Certification in endoscopy nursing means that a person has the equivalent of what a two-year nurse should know in GI and endoscopy," Ms. Schlossberg said. "That's very important. If you can say that your entire staff is certified, it shows patients that you really care about the quality of who is in the room assisting the physician."
Certification for the technicians who reprocess the scopes used in GI and endoscopy procedures is also highly recommended. Avoiding transmission of infectious agents demands strict adherence to published reprocessing guidelines, particularly as endoscopic units become busier, and the number of procedures performed nationwide increases. Scopes are fragile and expensive. Endoscope reprocessing is a multi-step process demanding meticulous attention to detail, time, space, and training.
GI and endoscopy techs can obtain certification from the Healthcare Sterile Processing Association (HSPA), as well as the Certification Board for Sterile Processing and Distribution (CBSPD).
"Having people dedicated to that work is so key. The individuals reprocessing scopes must be up to date on the procedures. Every manufacturer provides a checklist because every scope model and manufacturer is a little bit different. Tech certification, especially for techs who reprocess scopes, gives everyone a much better feeling."
The path forward to ensure ASC growth
To survive and thrive in today's challenging, competitive environment, ASCs must take a multi-pronged approach to optimizing safety and efficiency. This includes taking a close look at the ways that the ASC schedules patients, deploys staff, utilizes space, and uses supplies.
Ensuring staff are trained to utilize and maintain key equipment, like scopes in the GI and endoscopy space, is central to delivering high levels of safety and patient satisfaction, as well as achieving profitable operations.
This content represents the views and opinions of Nancy Schlossberg, BSN, RN, CGRN, CER and does not necessarily represent the views or opinions of Olympus.
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