EXECUTIVE SUMMARY
Healthcare is undergoing another major change across the nation, creating uncertainty and disruption. However, ambulatory surgery centers (ASCs) should follow experts’ advice and focus on improving quality, cost-cutting, efficiency, and productivity.
- A first step is to improve operational efficiency.
- Realign the organization’s goals.
- Increase consistency and make smart supply decisions.
Ambulatory surgery centers (ASCs), like all other healthcare organizations, might wonder what will happen in 2017 as a new Congress and President Donald Trump promise sweeping changes to the Affordable Care Act (ACA). It’s impossible to build into budgets the possibility of disruption and change. But ASCs can avoid behaving like roosters and chickens that run straight into peril and uncertainty.
Instead, it might be time to focus on what can be controlled by working to improve the organization’s productivity and efficiency.
“I think in healthcare, situations occur out of your control, but the bottom line is looking after your patients and your facilities,” says Terri Mahoney, RN, CNOR, CASC, administrator of Bluffton Okatie Surgery Center in Bluffton, SC.
“You always look at productivity, quality, and patient safety, no matter what’s happening legislatively,” Mahoney says. (See story in this issue on how a small ASC avoids growing pains.)
“Both the regulatory environment and the insurance/payer environment keep us on our toes all the time with new regulations that require us to revamp something,” says Janie Kinsey, RN, CASC, administrator at Saint Luke’s Surgicenter–Lee’s Summit in Lee’s Summit, MO.
Surgery centers do what they can to cut costs and improve productivity to prepare for any type of regulatory or insurance environment.
“Productivity starts with participation and ownership by staff,” says Alfonso del Granado, administrator of Ashton Center for Day Surgery in Hoffman Estates, IL.
Also, there’s no point in worrying about time wasted on regulations today that might not exist tomorrow, such as standards that might no longer be required if lawmakers repeal some or all of ACA and other healthcare regulations, notes Lianne McDowell, administrator at South Portland Surgical Center in Tualatin, OR. (See story on efficiency strategies in this issue.)
The first step to improving productivity is to study metrics, trends, and to listen to employees. (See story on productivity metrics in this issue.)
Staff buy-in on changes can help improve staff satisfaction. Del Granado learned this lesson as a child growing up in South America, where he would see shopkeepers operate their businesses from 6 a.m. to 10 p.m. and, yet, seem happy and satisfied with their work. Though their hours were long, they were able to work at their own pace for themselves. This sense of ownership can be imparted to employees if they’re given some autonomy in how they perform their work, del Granado says.
“I found that staff were being micromanaged remotely and were not given any kind of decision-making authority outside the normal scope of practice,” del Granado says. “So we changed that culture a little bit, making it a number-one priority to reduce employee turnover, increase satisfaction, and decrease staffing hours.”
The strategy worked, increasing patient satisfaction from 93% to 98%, decreasing employee turnover, and increasing efficiency, he says.
“We were 23% more productive when compared with the baseline metric,” del Granado says. “Ownership sounds like a buzzword, but there’s an underlying feeling that you’re in charge of your destiny, and it definitely increases satisfaction.”
There is a downside to productivity if it’s not handled in a way that reflects what employees need and want. For instance, the productivity numbers (cases worked per hour), were very high when Kinsey started working at Saint Luke’s Surgicenter.
“Our productivity numbers looked really good,” Kinsey says. “But we were expecting maybe too much from our employees.”
Ashton Center for Day Surgery also found that very high productivity rates were hard on staff. “We pulled back on the productivity,” del Granado says.
“Even though the staff was very happy and patients were satisfied, we could see it was taking a toll on the staff,” he explains. “Some were getting a little frazzled, and there was a safety component.”
Also, when a surgery center demands too much from employees, there is the risk of a high turnover rate and burnout. This especially can be true when the productivity demands remain high even when the surgery center adds new and more complex surgeries, Kinsey notes.
“We’ve had higher acuity level patients and procedures,” Kinsey says. “We started a total joint program, an overnight stay program, [and] a hysterectomy program.”
When workflow demands become more complex, staffing levels should be re-evaluated.
“So what we did was hire adequate staff, and they began spending less time complaining about how busy we were and more time getting the work done,” Kinsey says. “We were able to do more cases with those extra people, and everyone was happier.”
Kinsey and del Granado suggest the following additional strategies for improving productivity and efficiency, while maintaining quality:
• Add operational efficiency. Each organization operates differently, but sometimes it’s necessary to re-evaluate habits and workflow to see how things can improve.
For instance, Saint Luke’s Surgicenter directed staff to make pre-op phone calls at the end of the day. It was a low priority, Kinsey notes.
But this often resulted in last-minute calls that would reveal that a particular patient could not come in for surgery the next day. That surgery spot would be wasted.
So the center hired someone whose job was to make the pre-op calls a week or two in advance of the surgery. The caller could identify patients who might have difficulty meeting their appointments, and find a replacement for that time slot, Kinsey says.
“That decreased our last-minute cancellations and even decreased delays because we’d have updated information about patients before they got here,” she says. “The caller would look at patients’ charts and notice if their lab work was done.”
The surgery center now conducts many different assessments ahead of time.
“We get a feel for the whole patient and it’s tied into our being better prepared when patients show up for surgery,” Kinsey says.
- Realign your goals. “The goal is to not keep the staff busy, but to take care of patients efficiently, methodically, and safely with the highest degree of satisfaction,” del Granado says. “Focus on that, and you’ll find yourself realigning your priorities a little bit.”
An example of this focus is to look at the staff schedule and ask a slightly different question: “How many nurses does this patient need?” he suggests. “It’s a slight shift of perception that makes a significant difference by staffing based on the patient’s needs instead of keeping nurses occupied.”
Nurses can idle and still perform duties above average if managers do not worry about slow periods and control their schedules through micromanaging.
“Recently, I had a discussion with someone who was pointing out that this Monday I had someone sitting idle for two hours,” del Granado recalls.
“I pointed out that the person researched a clinical question during that time, but they also should look at the person’s productivity over a week, month, and quarter,” he adds. “That person might have had two hours of idle time, but also produced three times the normal output for a nurse over time.”
- Allow for staff scheduling autonomy. Within the goals of increasing patient satisfaction and decreasing employee turnover, it’s possible to allow employees to organize their days, del Granado says.
“It can seem contradictory to have staff work harder but in fewer hours, but we managed to do it,” he says. “We decreased staff hours by 42%.”
Employees were given the autonomy to take their 15-minute breaks to watch a screen or just stand by themselves in some corner. “We gave them some freedom, saying that if they could do their work more efficiently, then they could take more breaks,” del Granado says.
“If they can keep a good pace for the rest of the day, and we have set an expectation and goal for them, then we can let them figure out how to get to that goal,” he adds. “Whereas before, an employee would say, ‘Why rush? I’m going to be here for eight hours anyway.’ Well, now they can rush and take a little break.”
Employees who work according to scheduled hours still do so, but there is more flexibility for many workers. For example, the techs who open the center to prepare for the day’s surgeries can negotiate to take turns, with one tech opening the room for all others earlier in the day, and another tech to arrive later to catch more sleep, del Granado explains.
“The goal is to get it ready by 7 a.m., but we give them autonomy on how to spend their time, and this gives them the feeling that they’re in charge of their own destiny and it increases [staff] satisfaction,” del Granado adds.
• Increase consistency. “We had been inconsistent with our anesthesia providers changing every day,” Kinsey says. “There was no standard protocol for what was an acceptable patient and what wasn’t.”
So the surgery center asked the anesthesia providers to assign one person to the center so decisions would be more consistent. Everyone would know what the assigned anesthesiologist’s expectations were and what that person expected in regard to standards for surgery through the physical status classification system (PSCS), she adds.
“Now, we have the same doctor who interprets the standards the same way every time, and it makes for more consistency,” Kinsey says.
- Make smart supply changes. Sometimes a small change can make a big difference to a center’s bottom line. For example, staff at Saint Luke’s Surgicenter–Lee’s Summit ordered supplies for scheduled surgeries and shipped overnight, Kinsey says.
“They were ordering for the next day instead of the next week,” she explains. “That change seems small, but if you place 25 orders a week and spend $150 in overnight charges when you can reduce that by half, then you can save a significant amount of money.”
The solution was to plan ahead and order for the week ahead, allowing for far cheaper shipping costs. The change was painful for a few weeks, but it worked, cutting the center’s shipping costs in half, Kinsey says.
“Supply costs have gone crazy over the last few years, and it’s something we’re all facing,” she adds. “Any way you can manage those is good, and it’s smart not spending extra money on shipping.”
- Put patients first. “We put patient care first,” Kinsey says.
“For instance, some cases that do overnight care will give patients frozen meals, warmed up in the microwave, and that’s fine, widely accepted,” she says. “But we go an extra step and order from Outback Steakhouse, and that makes patients feel very well cared-for.”
In an uncertain healthcare climate, ambulatory surgery centers can focus on what can be controlled by working to improve the organization’s productivity and efficiency.
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