8 Steps for Smooth ASC Patient Flow

Fayette Plastic Surgery Center Clinical Director Kristin Nation and ASC Co-Owner Edward Gronka, MD, discuss eight ways their surgery center keeps a smooth patient flow.

1. Do prep work early. There are several steps surgery center staff and administrators can take before the day of surgery to make sure everything runs smoothly and efficiently. Ms. Nation reviews all the charts beforehand to ensure everything is up-to-date, signed and dated so all the patient paperwork is read for the morning of surgery.

"Every morning when we come in, we have this information so another nurse and I can mix the medications ahead of time," says Ms. Nation. "We have all cases written on the board and turnover time down to a science. Between a few people, we can have turnover time down to 15 minutes. The only way we can do that is preparing things head of time."

2. Conduct a formal pre-op visit.
Hold a formal pre-op visit before every case between the surgeon and patient to ensure everyone is on the same page. More surgery centers have begun this practice because patients are more comfortable going into their procedures afterwards.

"Their pre-op visits cut down on a lot of anxiety for the patient," says Dr. Gronka. "Everything can slow down a little bit. Sometimes patients are confused about which medications they are supposed to take before surgery, which door they come in at the center or what clothes to wear that will make it easy for the nursing staff to care for them. We go over those details in the pre-op visit and doing that on the front end makes things easier during surgery."

The pre-op visit is usually within two weeks before the surgery. The patient also signs the consent form, makes sure lab work is in order and gains medical clearance for the procedure.

"That's a critical part because a lot of delays and cancellations are caused by people showing up to the operating room with hypertension, or they didn't complete their pre-op EKG," says Dr. Gronka. "It's important to have a few weeks to get that done — sometimes we even struggle to get the medical clearance through with the two-week window."

3. Run on a lean, experienced staff.
Fayette Plastic Surgery Center includes a lean staff — two nurses, a surgical tech, anesthesiologist and the surgeon — along with the administrative staff. While the team is small, combined experience allows them to move cases through quickly and efficiently.

"One of our advantages is that we don't have excessive people on staff," says Ms. Nation. "There are not people standing around and getting in the way or creating issues that slow us down. When it comes to turning over the operating room, as soon as the patient moves out the surgical tech and one of the nurses does a breakdown. Then it's one person scrubbing to prepare for the next patient. Everyone knows what needs to be done so everything moves quickly."

Experience also makes a big difference, especially when bringing on a new staff member. "When we hire someone, we train them in the OR because everyone on our team has OR exposure," says Dr. Gronka. "They know what to do in between cases and that makes a difference."

4. Be prepared for unexpected situations.
Despite the preparation work, there are some situations the ASC team won't be able to prepare for, such as a difficult intubation. Make sure all staff members know how to handle that situation and work together to get back on track.

"We always error on the side of caution, but you must have these things in the back of your mind," says Ms. Nation. "The patient might take longer in anesthesia or have trouble waking up after the procedure."

There are some things you can detect early and adjust for accordingly, such as starting an IV for obese patients. "Starting an IV for obese patients is sometimes an issue, but if you note that in the pre-op screening and do that work upfront, things will run more smoothly," says Dr. Gronka. "Outpatient surgery centers have the advantage because they are able to bring in good candidates for outpatient surgical procedures."

5. Schedule patient arrival times instead of surgery start times.
Only one surgeon is working at Fayette Plastic Surgery Center at one time, so cases can't move more quickly than the surgeon is able. If the surgeon runs behind, the cases will start late. However, the staff at this ASC schedule "patient arrival times" based on estimated start times to give surgeons room when they are running behind.

"If the surgeon is behind, we don't have anywhere to make up that time, so we explain to patients that we are behind," says Ms. Nation. "We schedule patient arrival times so that we aren't constantly looking at the clock. We take the time to talk to patients beforehand and make sure all issues are addressed. The day runs behind sometimes, but we go with the flow."

In the past, if cases ran more quickly than expected, the next patient wasn't ready because their "start time" hadn't begun; however, now the patient arrives early at their "arrival time" and can be taken in as soon as possible.

"If the patient isn't there early, that can delay the day because you lose half an hour waiting for them to arrive," says Dr. Gronka. "The nurses always err on the side of having the patient wait a little bit longer."

6. Talk to the surgical techs about surgical times.
Schedulers and administrators should discuss new cases, or procedures using different or unique technical instrumentation, about the average time the procedure should take. Surgical techs have advanced knowledge of what will go into the case and help you ensure you're leaving the right amount of time in the OR.

"I'm usually a pretty good judge of how long surgeons will take to perform a case, but if I'm not sure our OR techs will give input on how long a procedure might take or any special equipment they might need," says Ms. Nation. "We have an average of how long each case takes and we loosely base our day on those times."

Also have an intimate knowledge of each surgeon's preferences and skill; some take longer than others with similar cases.

"We try to make the process more standardized, but every case is different and the surgeons are different," says Dr. Gronka. "When I book cases at the hospital, they schedule it for a certain period of time and if I think it will be longer I'll override that. It's better if you know your physicians and cases very well."

7. Consider recovery time for case scheduling.
Generally, surgeons perform the more complex cases early so patients have a longer time to recover. However, some surgeons prefer to start with short cases first and follow-up with the longer cases. This can be problematic for the ASC because patients may need to stay late to fully recover, and this means staff are staying late as well.

"There are implications for recovery times when you consider the order of your cases," says Dr. Gronka. "If you do long cases at the end of the day, the patient will take longer to recover and the staff must stay longer with the patients. Both patients and staff members want to leave the ASC at a decent time whenever possible."

When a case takes longer than expected, Ms. Nation makes note of that procedure and investigates to see if there was an issue or complication the team could have anticipated earlier to make things run more smoothly.

8. Work with anesthesiologists.
Anesthesiologists begin the surgical process, so if they start late everything else will start late as well. Work with your anesthesiologists or anesthesiology group to develop a good working relationship and expectations.

"Our anesthesia providers really take the time to talk to patients beforehand," says Ms. Nation. "Our day starts with anesthesia, so they set the tone for everyone else. They call the patients the day before surgery to discuss their medical history and communicate with the OR team to prepare for the procedure."

The ASC just implemented electronic medical records to hopefully increase communication, data access and efficiency at the center. "We implemented EMR hoping it would have an impact on accumulating the data we need to get patients where they are supposed to be and make the pre-chart review easier," says Dr. Gronka. "We are going through growing pains right now, but we think it will have a positive impact in the future."

More Articles on Surgery Centers:

Physician Recruitment Trends for ASCs: Q&A With Paul Eiseman of Regent Surgical Health

18 Statistics on Surgery Center Acquisition Market

5 Initiatives for a Better Patient & Physician Experience

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