Managing the Business of Surgery

To maximize profitability in an operating room, a multitude of factors must come together at the right time and place. Surgery schedules have to be set and met. Patients and staff need to be present and equipment and supplies on hand. Surgeon preferences must be available and clear. And charges for everything from sutures to expensive implants have to be documented and captured so they can be billed.

If the surgeon, anesthesiologist or patient is late, the surgery can’t start on time, which cuts into the number of surgeries and gross revenue. If supplies are not available from materials management, it doesn’t matter if everyone is on time. If charges aren’t captured and fall through the cracks, the profit margin sinks.

Manually manipulating all the processes of scheduling, materials management and charge capture makes orchestrating the elements cumbersome at best. At worst, it reduces the bottom line in an area that should be a moneymaker. To make sure it was optimizing its profitability, The Mary Imogene Bassett Hospital in Cooperstown, N.Y. swapped its crude paper process for an automated perioperative system. The result: a 71 percent increase in starting surgeries on time, 42 percent more surgeries performed and a 30 percent boost in revenue.

Problem
Late in 1998, The Mary Imogene Bassett Hospital in Cooperstown, N.Y.—the genesis of the Bassett Healthcare system—had six operating rooms handling more than 5,300 surgeries. All surgery scheduling, surgeon preferences, clinical documentation, materials management and charge capture was manual and paper-based. Surgeons’ preferences were written in pencil on 5 by 7 index cards, with up to nine surgeons’ information on a single card.

Circulating nurses marked room, implant and supply usage on paper, which was batched and forwarded to finance for manual entry of charges. For implants, nurses also would record the information for reordering and maintaining par levels as well as keeping a federally required log. This process led to used items not being documented, and therefore not charged to the patient, resulting in lost revenue for the hospital. In the case of implants, which can be very expensive, it incurred expenses without revenue, resulting in below par consignment inventory.

Our scheduling system consisted of a scheduler hand writing the surgery schedule, then manually entering the information into a “homegrown” computer database and printing the schedule. Only 48 percent of surgeries started on time due to surgeons, anesthesiologists and patients arriving late; supplies not being on hand from the materials management department; and C-Arms not being available from the radiology department, nor technicians to run them.

Sources:
Kathleen Brooks
OR Director
Judith Henrici
Systems Manager, Perioperative Services
Bassett Healthcare
Cooperstown, N.Y.
www.bassett.org

Product/Company
Perioperative Solutions
Surgical Information Systems
Alpharetta, Ga.
www.orsoftware.com

Solution
In the fall of 1998, we secured funding and formed a six-member committee consisting of an OR director, a surgeon, a scheduler, two nurses and a clinical analyst from the information systems department to find a perioperative system solution that would automate the scheduling of surgeries, surgeon preferences, materials management, clinical documentation and charge capture. Our research was made easier because we capitalized on the efforts of a previous research group that had lost their funding for a new perioperative system. We chose Surgical Information Systems (SIS) in Alpharetta, Ga. when we saw their software in action at Medical Center East in Birmingham, Ala. It had everything we were looking for: It was Windows-based, provided clinical documentation from preadmission assessment to postop, and generated reports we could use to guide business and clinical decisions. The scheduling module interfaces well with our IDX registration system, eliminating keystrokes and ensuring accurate transmission of patient data.

Implementation/Training
We signed the contract with SIS in February 1999 and began buying hardware and building the lists that would populate our first module—scheduling. In April, we bought a server and 47 PCs. Previously, we had only two PCs in surgical services—one for the nursing clerk and one for the director of OR to check e-mail. Before we began implementing the software in the summer of 1999, we trained 60 to 70 nurses, tailoring the training to nurses’ needs. New college graduates required only a few hours of training, but some of our older nurses who had never even touched a computer before required a couple of weeks of training. We even allowed staff who had never used a computer to play solitaire on breaks to become familiar with using a mouse. Staff only learned specific modules they would use.

We implemented the software in stages that matched the flow of the patient through surgery. We started with the scheduling module in August 1999, then preadmit assessment in September. The preop and postop clinical documentation modules went live in November because they involved the same nurses and the same physical area in the hospital. In February 2000, we went live with 1,000 electronic preference cards and intraop clinical documentation. We delayed going live on the postanesthesia care unit (PACU) module until May 2000 to transition temporary traveling nurses out of the organization and hire full-time, permanent nurses and train them.

Three years later, in 2003, we implemented StatCom, an electronic board that shows at a glance by color coding where patients are in surgical services. For example, purple indicates the patient is in PACU, lime green indicates postop.

In 2004, we interfaced Rules Based Charging with the hospital’s patient accounting system to increase charge capture and improve billing accuracy.

Results
Today, The Mary Imogene Bassett Hospital is a 180-bed teaching hospital and one of four acute care hospitals and 21 community health centers in central N.Y. that comprise Bassett Healthcare. Our perioperative services department has nearly doubled in size from six ORs in 1998 to 10 operating rooms. We have more than 100 users of the perioperative information system in use at Bassett Healthcare and expect to perform 7,500 surgeries in 2005.

Since automating, we can set benchmarks and measure improvements using information provided by the system, such as details on first case delays, average length of cases and number of case hours. We can make adjustments if the system shows us delays are due to staff issues, or if we are scheduling too many different services in one room, which causes slow turnover due to the need to tear down and rebuild the set-up too often. We have streamlined processes and are starting cases on time 85 percent of the time, compared to 48 percent of the time in 1998.

Prior to SIS, everything was anecdotal. Now, when a case is delayed, we simply click a box on the documentation screen to indicate the reason for the delay.

We can review a weekly report of the data, and take care of process issues immediately.

In the last year and a half since we introduced automated charge capture of supplies, we have experienced a 30 percent jump in our revenue stream. On a single report written from SIS data, we can see a wide range of discrepancies, including supplies used within a case but not charged to the patient. In addition, we now record implant usage at the point of care. The SIS system allows us to create for the business manager a request-for-purchase document from the data recorded in the operating room. Once the document is reviewed, it is sent to materials management for reorder, eliminating potential communications breakdowns that might lead to incomplete reordering of supplies.

The system also has allowed us to justify staff increases. We knew we needed to increase staff, but our COO wanted highly quantified data, including very detailed reports proving improved efficiency, before he would approve the additional staffing. Since introducing the perioperative system and graphing the growth in surgeries, by the spring of 2001, we had sufficient data to justify the need to add 10 additional FTEs, and immediately hired more nurses and technicians.

Our new perioperative information system also has allowed us to comply with the national patient safety goals of the Joint Commission on Accreditation of Healthcare Organizations. For example, when the goals concerning the universal protocol came out in the literature, we were not only an early adopter of taking the “time out” to verify that we had the right patient, the right procedure and the right location, but we had clear documentation of our efforts. As a result of the ease of changing the screens to allow for this documentation, we had close to a year’s worth of data when JCAHO visited us in December 2004. When they presented the results of their inspection, JCAHO representatives complemented our documentation system and our ability to prove compliance with the national patient safety goals. Best of all, they said there were no requirements for improvement in the perioperative services department.

Having the right data at our fingertips when we need it enables us to make rapid course changes when necessary and to be ahead of the curve in showing measurable results.