4 Case Studies: How You Can Use Benchmarking to Improve Practice
You know you have to track quality and patient satisfaction indicators.
Your accreditation agency requires it; increasingly, your third-party
insurers may require reporting of data; and, soon, CMS will ask you to
track and report selected indicators.
But how much of your benchmarking practice is about analyzing numbers and enacting change, rather than just doing?
“Everyone knows they need to benchmark and track quality data; every January, we get an influx of calls,” says Jennifer Greene, RHIT, of Surgical Outcomes Information Exchange. “We’ve seen a shift toward more ASCs understanding the value of benchmarking, but a lot of people are still taking the data, putting it in and not knowing what to do with the results.”
It’s increasingly important: Accreditation surveyors are now looking not just to see that you have a quality improvement process, but also what the process entails and how you’re using it, says Ms. Green. In addition, embracing benchmarking is simply a good business practice.
“People get scared off by the jargon, but benchmarking is simply a matter of knowing the measurement, how it measures up, finding the problems and determining solutions,” says Ms. Green. “Time is money; you can cost-justify those things that you want to do but might not otherwise have the evidence for. Maybe you always thought Dr. A was slow, that you weren’t processing patients fast enough. When you see numbers outside the range, you can now do a QI process and determine where the system is breaking down.
“Then you can think about solutions: Do you need staff training? Do you need to fire someone? Hire someone? Sit down with a doc and have a discussion?”
Here are four case studies of centers that have been able to make practical and tangible changes thanks to benchmarking.
1. Enhancing efficiency
When Blake Woods Medical Park Surgery Center in Jackson, Mich., started using the services of a national benchmarking service, the staff found that “in a lot of respects, we were doing better than we thought,” says Margaret Acker, RN, MSN, Blake Woods’ CEO.
That’s not to say she didn’t find room for improvement. Here are several areas where Ms. Acker has been able to put benchmarking to use at her ASC.
• Extended downtime. Blake Woods started as a single-specialty ophthalmology center, and when it looked at downtime between cataract cases, it found it was slow compared with similar centers.
“At the time, we admitted one patient every 10 minutes to three pre-op bays,” says Ms. Acker. “The benchmarking tipped us off, so we did a time study, and we found that we needed to pre-op more than three patients at a time to open up more beds.”
The result: Blake Woods started using six pre-op beds at a time, admitting three to the right eye room and three for the left eye room every 10 minutes. This method decreased downtime because “we always had a patient ready,” says Ms. Acker.
• Long discharge times. “When we looked at our discharge times, they were far longer than the industry standard,” says Ms. Acker. “We thought our nurses were just being especially nice, taking time to make sure patients were ready. But on our patient satisfaction surveys (which Blake Woods also benchmarks), patients were complaining that they were at the center too long after surgery and that they forgot discharge instructions.”
So the center incorporated explanation of discharge instructions into the pre-op process and began discharging patients as soon as they were comfortable.
“We use topical anesthesia for the most part, so if they’re stable, anesthesia discharges them in the OR,” says Ms. Acker. “We get them a drink, get the IV out and reaffirm that they’re stable in the post-op area, then we send them home. Patient satisfaction scores went up immediately after we implemented this change and remain in the 99th percentile.”
• Help with adding specialties. Blake Woods recently opened a third OR and added orthopedics and general surgery, and Ms. Acker used available benchmarking information — especially with regard to supply costs — to help guide all parts of the process, from planning to setting expectations to purchasing.
“For scheduling purposes, we looked at the time frame we should expect a knee or a shoulder to take,” she says. “We looked at cost-comparison benchmarking, so when surgeons said, ‘We need this $300 anchor,’ we were able to say no. We also looked at case volumes and average reimbursements” to determine the number of cases needed for profitability and to guide negotiations with insurers.
“I think with any project you want to start or any area you want to grow, you really need to look at the data that’s out there,” says Ms. Acker. “When I want to do something, I pay for the benchmarking report; I’ve used something from every one I’ve ever received.”
2. Cost-justifying equipment purchases
“We had a facility that was finding its recovery times were five minutes longer than the national average,” says Ms. Green. “So we helped them devise a formula to understand how much that five minutes was costing — and how much trimming that excess could save them.”
Here is Ms. Green’s formula:
Charge per procedure / OR minutes per proce-
dure = OR cost per minute
Procedures per month x OR minutes = Current OR time
Procedures per month x Target OR Minutes = Target OR Time
Current OR Time – Target OR Time = Wasted Minutes
Wasted minutes / Procedures per month = Average time wasted per case
Average time wasted per case x OR cost per minute = Wasted Dollars
“This let us show not only how much they stood to save by becoming more efficient, but how much income they could add by streamlining and using formerly wasted time to perform procedures,” says Ms. Green. “One facility we work with was able to cost-justify purchasing eye stretcher chairs that the patients never leave from pre- to post-op using this formula. The chairs save time because the patients don’t have to get out of them, and the saved time meant more procedures.”
Because the chairs are a one-time cost, the facility has continued to reap the efficiency benefits long after purchase. Further, they enhance safety by preventing patient falls and protecting the skin integrity of older patients because you eliminate having to move them.
“You can adapt the formula to determine the charge per minute of the entire procedure, through discharge,” adds Ms. Green. “Then, when you look at complication rates, you can figure out how much a complication costs you. If patients are staying two to four hours instead of 30 minutes, you can see how that would eat up all your profit on the case; you might even have to do more cases in order to make up for the hit from that one complication.”
3. Making patients more comfortable
In addition to tracking various clinical indicators, Digestive Health Specialists—Puyallup keeps close watch on patient satisfaction scores.
“If we see complaints consistently, we take them to the standards of practice committee to develop a plan of action to correct the issue,” says Chalene Wilson, RN, the center’s director of nursing. An example: “One of the things we ask on our patient satisfaction surveys is whether patients had any swelling, redness or tenderness at their IV sites. A lot were coming back with reports of these symptoms.”
To address this, a product rep from the supply company in-serviced the staff on proper technique.
“Our phlebitis rates decreased quickly,” says Ms. Wilson. Rarely do we have an IV site problem. The in-service was an easy fix for something that had been a discomfort for patients, but that we might not have spotted otherwise.”
4. Meeting best-practice standards
Sometimes, when quality tracking reveals inefficiencies, you may find that you aren’t fully utilizing national best practices. Central Bucks Specialists in Doylestown, Pa., for example, was suffering from inconsistent room turnover that caused scheduling problems and resultant frustration on all sides.
“When we tried to get to the bottom of the problem we got myriad answers,” says Zvi Weinman, MBA, the administrator of Central Bucks, which performs 8,000 GI procedures annually. “The staff thought it was caused by the physicians, the physicians thought it was caused by the staff, and occasionally, everyone thought it was caused by the anesthesiologists.”
Mr. Weinman was able to have hard data in hand that allowed him to analyze the problem objectively by tracking quality indicators: arrival to patient in room; patient in room to time-out; time-out to scope in; scope in to scope-out; scope-out to recovery start; recovery start to discharge; and polypectomy rate. Two areas stood out.
• Time-out to scope-in time. Five of six practicing physicians, were averaging within minutes of one another; the sixth was averaging close to 20 minutes longer than the others per procedure. The discrepancy was due to his conscious sedation practice: Rather than giving a big bolus up front, he was doing a little at a time, and onset of the anesthetic took markedly longer as a result. When the surgeon was able to see the difference his conscious sedation practices were having on his procedure times, and that what his peers were doing wasn’t affecting outcomes adversely, he changed practice.
• Scope-in time to scope-out time. Four of six
doctors averaged within minutes of one another for scope time. One took markedly longer, and another was significantly shorter. It was not a matter of quality, but rather a matter of practice preference. For the physician who took longer, Central Bucks started scheduling his procedures for an extra 15 minutes each, and built it into the schedule, eliminating backups for his patients. And the faster physician was able to slow his scope withdrawal to ensure greater consistency and better adhere to identified GI best practices.
Key Statistics for Cataracts, Colonoscopy and Knee Arthroscopy
Here are selected national averages for cataract surgery times and an interesting practice statistic, courtesy of Surgical Outcomes Information Exchange. The numbers represent the average for 27,000 cases submitted to SOIX from 2006 to March 2008.
• OR time — 25 to 30 minutes
• Recovery time — 25 to 30 minutes
• Surgical time — 15 to 20 minutes
• 76 percent of facilities use MAC anesthesia
The 2007 AAAHC Institute report “Cataract Extraction with Lens Insertion” offers data from 70 organizations that perform more than 131,000 cataract surgeries each year. Here are some of the data from the report, the latest of seven conducted since 1999 on cataract and lens operations:
• Intraoperative anesthetic techniques included topical (42 percent), peribulbar block (24 percent), retrobulbar block (26 percent).
• Individuals insured by Medicare were less likely to receive high-tech replacement lenses that also correct presbyopia (15 percent) compared to non-Medicare eligible patients who received the corrective reading lens (28 percent).
• Two weeks after surgery, 95 percent of patients said their vision had changed for the better. Ninety-nine percent said they would recommend the procedure to friends or family members with cataracts.
The AAAHC Institute report gathered data from 107 organizations that perform nearly 500,000 colonoscopies each year. Here are some findings from the report, also the seventh in the series of colonoscopy best practices studies conducted by the AAAHC Institute:
• In 94 percent of cases, a time was given for visualization of the cecum.
• In 80 percent (1,871) of the cases, the time from cecum visualization to the end of the procedure was six minutes or more.
• The average time from the visualization of the cecum to the end of the procedure (by organization) ranged from four to 18 minutes, with a median of nine minutes.
Knee arthroscopy with meniscectomy
This AAAHC Institute study gathered data from 31 organizations performing more than 17,800 procedures a year participated. Among the findings:
• Forty-five percent of procedures were performed due to traumatic injury and 55 percent due to degenerative disease.
• Average discharge time ranged from about 94 minutes for patients receiving epidural/spinal anesthesia to 66 minutes with local anesthesia and IV sedation.
• All but 35 patients (5 percent) indicated they had begun walking within seven days of the procedure.
— Stephanie Wasek
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