"In my view, time management is one of the single most important things for ASCs," says Larry Teuber, MD, chief medical officer and president of Medical Facilities Corporation and founder and physician executive of Black Hills Surgery Center. "When I look at the efficiency of the facility, I look at what it costs to perform operations. The cost of a facility includes drugs and supplies, implants, payroll and general overhead. One of the largest wastes is payroll, meaning that surgical start times, turnover times and surgeon tardiness are probably one of the most expensive costs in the center, and the hardest to track."
Dr. Teuber discusses how surgery centers can make sure physicians start on time and maintain their schedules throughout the day.
1. Define "start time." Different specialists within the surgery center often have a different interpretation of what start times are. Anesthesiologists will have a different idea than perioperative nurses and OR technicians about when the actual "start time" begins. Dr. Teuber recommends defining start times; his group defined "start time" as the moment when the surgeon walks into the pre-op room and sees the patient.
"The fact is, everything depends on the surgeon coming to talk to the patient, sign the extremity, autograph pre-op consent and make sure the patient is ready to go," says Dr. Teuber. "There is a huge amount of wasted time if you think of the number of people who are lined up waiting for surgery — pre-op nurses, anesthesiologists, circulators, surgical assistants, postoperative specialists and recovery specialists — all dependent on when the surgeon is present in the morning. The costs on payroll are huge even if the surgeon is 15 minutes late."
Once the "start time" is defined, preoperative staff can prepare the patient before that time and everyone else will manage their schedule based on the surgeon entering the patient's room on time.
2. Shorten turnover times. Facilities must have a realistic vision of their turnover times and always work to make that time shorter. If there isn't enough time planned between patients to turnover the room, the next case will start late and both patient and physician time will be wasted. This also means staff will stay longer and place a burden on the payroll.
"The single most expensive waste in the facility comes from wasting time, and waste means inefficiency," says Dr. Teuber. There will be some unforeseeable delays, such as difficult intubations, problems during induction, problems because the patient is obese or technical challenges during surgery that could make the procedure run over schedule.
When delays are unpredictable, the center can roll with the punches; however, when delays occur due to physician tardiness or inappropriately scheduled OR times, there are ways the surgery center can eliminate them.
3. Track procedure times and make sure surgeons follow them. When surgeons schedule cases for an hour, but they are constantly taking one hour and 40 minutes to perform their cases, you must be prepared for delays.
"Continually track the time it takes surgeons to perform procedures," says Dr. Teuber. "Typically it takes a certain length of time and if the surgeon schedules it for less, that's inefficient. Surgeons will seldom schedule their cases for longer than it typically takes, but you have to make sure the schedule reflects the actual time it takes them to do the procedure."
For example, if an ACL repair usually takes 45 minutes, surgeons might schedule a case for 30 minutes because they are optimistic. Most surgeons predict they will need less time for a procedure because they don't foresee complications; however, statistics say complications occur.
4. Schedule cases efficiently. When cases have a low chance of running long or over schedule, it makes sense to schedule them earlier in the morning; cases that are less predictable should be scheduled later in the day so fewer cases run the risk of starting late.
"Procedures like knee surgery and carpal tunnel release can be done at the beginning of the day," says Dr. Teuber. "Spinal fusions, revision joint replacements and other spinal procedures should be scheduled at the end of the day."
5. Monitor when surgeons are late and modify the schedule. When surgeons are chronically late for their start times, schedule their cases for later in the day. If they are usually 15 minutes late for a 7:30am start time because they have a hard time getting out of bed earlier, the scheduler can move their start times from 7:30am to 8:00am.
"It's terribly inconsiderate for surgeons to be habitually late," says Dr. Teuber. "We monitor that and if we have a surgeon who's habitually late, we move back their start times. In a partnership, you should respect your partners, staff, patients and patients' families."
6. Assess penalties to chronically late surgeons. If moving the start times doesn't fix the problem, the center could fine surgeons for the wasted time. "If tardiness becomes a continual problem, we assess surgeons a fine for being late," says Dr. Teuber. "When a surgeon is late, the patient and families blame the facility, not the surgeon, so it reflects poorly on us. Surgeons could be late for several reasons during the day, such as their clinic running late or they were working at the hospital, but we have to deal with it."
Dr. Teuber's team compiles every minute chronically late surgeons waste and converts those numbers into financial statements. For example, if every 15 minutes of wasted time costs the center $525 — and adding up all the late time for three months equals 15 hours — the surgeon has wasted $31,000, or around $10,000 per month, just by being late.
"When you show people the economics of the situation, it starts to make sense," says Dr. Teuber. "Then the other partners in the group start wondering why one surgeon is always late and costing the center so much money. We present this information to the partners and they want to make sure everyone runs on schedule."
Sometimes the transition from the hospital to a surgery center setting is difficult because surgery centers are built for efficiency while hospitals are bigger organizations where it takes longer to move through the processes. Make this transition smoother by imparting a strong culture of efficiency in the ASC.
7. Reinvent the culture like a well-run business. If surgeons are used to hospitals where things run on a slower and less efficient clock, you'll need to reinvent their attitudes for the outpatient surgery center setting. "The most important thing is to understand and define what is efficiency and inefficiency," says Dr. Teuber. "Efficiency is really the amount of input it takes for an output. Inefficiency means something isn't as good, for a reason."
Consider how much time is spent in the operating room and how much waiting time is necessary. In a hospital, in the big economic picture, there is very little material waste but huge amounts of money are spent on implants and wasted time. In a surgery center, the goal is to cut the time between cases as much as possible.
"The staff has to make sure everything is done so the surgeon isn't waiting on them," says Dr. Teuber. "Everything must be ready and everyone must be in position when the surgeon comes in — on time — ready to operate."
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7 Steps for Keeping Physicians On Time at ASCsWritten by Laura Miller | April 12, 2012
There are several ways to maintain efficiency at surgery centers, but ASCs can't be efficient unless surgeons have good time management skills.
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