Labor costs for knee surgery bend downward
Benchmarking study highlights best practices
It may be a recession, but labor costs always seem to go up. That, however, is not the case for participants in the latest survey of the Accreditation Association for Ambulatory Health Care (AAAHC), based in Wilmette, IL. Labor costs per procedure for knee arthroscopy with meniscectomy are down over the previous year for organizations that participated in both surveys, says Naomi Kuznets, PhD, director of the AAAHC Institute for Quality Improvement. "It was the only surprise of the survey."
Labor costs had a wide range, too, running from around $15 per case to more than $40. The bulk of those costs — for all but one of the 18 participating organizations — was RN time. Indeed, at one organization, four registered nurses were used for each procedure. The average wage for the RNs was just more than $22 per hour. Technician time averaged out to $9.72 per hour. (To see graph detailing labor costs, click here.)
Procedure time lasted from 20 minutes to just less than 40 minutes, with a mean of 31 minutes. One significant finding of the study was that there was no statistical correlation between procedure time and the volume of cases an organization has. "This is good news for most organizations and supports performance measurement study findings that an organization does not need large volumes to be efficient; they only need to know and adopt the best practices," the report states.
Only about half of all cases started on time, according to the survey. One of the most efficient of those organizations noted that it could start on time by making sure there are a minimum of supplies and that surgeons have adequate instruments available.
Some of the organizations reported a problem making sure that all but the first case of the day started on time, something the report notes may be due to not allowing enough time for each case or inadequate turn-around time. Those organizations that do start on time note the following strategies to stay on track:
- checking if lab work is complete and acceptable;
- pre-certification of insurance approval;
- ensuring the proper equipment and supplies are available;
- pre-operative education by appointment, phone, or written communication;
- having the operating room crew ready at least 15 minutes prior to start time;
- standardizing setup and equipment.
Make the most of pre-surgical time
Making sure things are in order prior to the start of a procedure can assist organizations in keeping to schedule. One of the best performers in this category had pre-procedure time at just more than 40 minutes — less than half the time of the worst-performing surgery centers. That organization uses practices such as:
- reviewing pre-operative information and making pre-operative phone calls well before patient arrival so that if testing or further consultation is necessary, the patient is ready on time.
- patients are brought to the operating room (OR) directly;
- personnel are not afraid to perform duties outside their usual area of expertise — garbage, mopping, and cleaning can be done by anyone;
- the instrument tech returns to help with turnover;
- the scrub nurse remains in the room during turnover and begins the clean up;
- anesthesia staff interview the patient while OR staff turn over the room;
- prior to the end of the previous case, supplies and instruments for the next case are placed on a clean prep table and left outside the OR by the instrument processing tech. As soon as the room is clean, the table is wheeled into the room.
Discharge time can be made more efficient by making use of regional anesthesia and minimal narcotics. One organization noted that it was able to perform well because patients were well prepared for their operation and were less nervous as a result. If anesthesia staff can anticipate a case’s wrap-up, they also can reduce anesthesia so patients are awake and alert when the surgery is completed. Giving discharge instructions to the patient prior to the procedure also helps move the patient through the facility quickly.
Median discharge time was 93.5 minutes, and overall facility time was a mean of 223 minutes.
One of the most efficient practices was the Center for Special Surgery in Wall, NJ. It had the second best discharge time in the study at 60 minutes. "It’s a question of having the right anesthesia in the right amounts," says nurse administrator Marsha Silberman, RN. "We have a great system in place and we do a tremendous amount of preoperative teaching, which makes discharge easier for patient and family."
Silberman agrees that there are dangers in aiming for an ever-lower discharge time. The trick is making sure you improve as much as you can while keeping a constant vigil on patient outcomes. Having anesthesiologists who are geared toward ambulatory tracking and use their agents accordingly helps, as does having experienced surgeons who are able "to go in and out with less trauma," she notes.
Extrapolate the results
One of the nice things about this survey — and others that AAAHC does — is that it gives practices the ability to take some of the good ideas espoused by other top performers and implement them throughout an organization. In that way, says Silberman, what works for one organization in knees may prove a boon to another in cataract surgery. "You review the studies and find new ideas," she says. "You try things, maybe it works, maybe it doesn’t. But there are lots of ideas out there."
Despite being a better performing surgery center, Silberman says there is no sitting back on her laurels. "I don’t think you can ever stop improving. There are so many facets to an ambulatory surgical center that there is always something you can do to improve."
And the positive data have an added benefit of validating the previous efforts Silberman and her staff have made.
Kuznets says that it was gratifying to see that the organizations that participated in both AAAHC knee studies had improved in at least one area. "There was a great improvement in prep and operation time overall," she notes. "And others found that they could get patients out faster if they checked on the patients more frequently. It all comes down to time being money."
Another area of improvement overall was a narrowing in the prices for equipment. "It looks like they have to be very vocal in negotiating prices and keeping up on what competitive prices are," Kuznets says. "That will allow them to improve further."
In the last study, draping costs varied from less than $10 to more than $50; shaver blade costs varied from less than $50 to more than $100; and arthro wand costs varied from $20 to almost $100. This year, while drapes still ranged from less than $10 to $70, the bulk of the participants had drape costs ranging from about $15 to $30. Median shaver blade cost was $58, with most facilities hovering around the $50 mark. Arthro wand costs were a median of $148. Again, most organizations paid about $150 each. (To see graph detailing supply costs, click here.)
"The thing is that some organizations are more aware than others, and some have obvious opportunities," says Kuznets.
"We know that these are the issues our members are interested in," she says. "One of the better performers was worried that she was moving patients through too quickly and that the patients felt hustled out the door. They took the information from the report and then looked at patient satisfaction. But the patients were doing so well that they didn’t see it in a negative light. That’s what this kind of data can teach you."
Silberman says doing a good job is a matter of learning to put systems together for a specific patient population. "We are focused on the limited amount of time we will have the patient, and we streamline everything according to the patient’s need. It affords us great satisfaction to know that what we are doing, when compared to others nationally, bears up so well."
The AAAHC now is readying its next reports: a return to the cataract study and tumescent liposuction. A second study on colonoscopy also is pending.
[For more information, contact:
- Naomi Kuznets, PhD, Director, AAAHC Institute for Quality Improvement, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091-2992. Telephone: (847) 853-6079.
- Marsha Silberman, RN, CNOR, CAPA, Nurse Administrator, Center for Special Surgery, 1902 Highway 35, Wall, NJ 07719. Telephone: (732) 974-3727.]
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