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.
Contact Stephanie Wasek at stephanie@beckersasc.com.
Key Statistics for Cataracts, Colonoscopy and Knee Arthroscopy
Cataract surgery
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
for cataracts.
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.
Colonoscopy
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
