How to align surgeons to increase productivity and curtail outmigration

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Since surgical departments typically drive the majority of a hospital's revenue, it's imperative for hospitals to attract the best surgeons and create a robust perioperative services line.

This content is sponsored by Surgical Directions

The better a hospital's surgical department, the more likely payers and providers alike will be to refer patients to that hospital, according to Alecia Torrance, MBA, MSN(c), BSN, CNOR, senior vice president of clinical operations and chief nursing executive for Surgical Directions. To attract the best surgeons, hospital executives must understand the surgeon mindset.

"A surgeon's time is extremely valuable," says Ms. Torrance. "If a surgeon is working in an inefficient operating room where a lot of time is wasted and they can't get on the schedule, you better believe they will want to go somewhere else that has overcome those efficiency obstacles."

Ambulatory surgical centers are among hospitals' biggest competitors when it comes to retaining good surgeons, according to Ms. Torrance. ASCs tend to have less bureaucracy and more efficiency, and they also have an advantage with many insurers. Some payers only reimburse certain procedures if they are performed in an outpatient facility, such as an ASC.

In response to this trend, some hospitals are acquiring surgeon practices, but this isn't the only way to reduce surgeon outmigration, according to Ms. Torrance. By making the perioperative service line of a hospital as efficient as that of an ASC, the surgical department can boost productivity, improve surgeon satisfaction and curb outmigration.

Attracting Top Surgeons

Most ORs have block scheduling, not unlike a reservation, for surgeons. The problem with this type of schedule is new surgeons fresh out of a training don't automatically have a block, so they tend to go to multiple facilities to build their case volume. According to Ms. Torrance, making it easier for young surgeons to get on the schedule and build their case volume in one facility is just one way to attract these specialists.

Additionally, the minimum threshold to maintain a given surgeon block should be no less than 75 percent and no more than 80 percent. Surgeons without consistent block utilization should lose some or all of their block time based upon historical utilization metrics that are provided to them monthly through surgeon specific scorecards.

Hospitals can also tap into surgeons' referral sources to attract great talent and increase case volumes and prevent outmigration.

"Typically, a patient must go to a primary care physician, internist or general practitioner to be referred to see a surgeon, and these parties tend to have clear referral patterns," says Ms. Torrance. "Surgeons hold these referral sources in high esteem. If the source is based at a specific hospital, a surgeon may be more willing to work at the same facility to avoid alienating their referral source."

In other words, hospitals should not focus exclusively on attracting surgeons, but they should also dedicate energy and resources to working with their primary care physicians, internists and general practitioners, who can then use their own rapport with surgeons to attract and retain talent.

Limiting Outmigration

Once hospitals have attracted the best surgeons, it's crucial to make efforts to keep them. For this, aligned incentives are absolutely necessary.

"There are some new programs in the industry to help align incentives, including bundled payment initiatives," says Ms. Torrance. "With bundled payments, there is one payment for a patient's entire episode of care, and it's split between multiple entities."

Bundled payments encourage hospitals and surgeons to limit the amount of care they provide by optimizing the patient prior to the day of an elective surgery. By addressing patients' comorbidities and preparing them for their procedure, hospitals can improve outcomes and reduce the risk of costly readmissions.  

Gain-sharing programs that allow surgeons to share in the profits of reducing the cost of care also limits outmigration and boosts surgeons income.

It's also important that hospitals remember surgeons rarely book their own procedures — that task is frequently left to office personnel.

"A trick I learned really early on in my years running a surgery department is that office schedulers want intuitively to schedule their surgeon at whatever hospital is easiest to call and complete the task," says Ms. Torrance. "So if you can make your scheduling system better than your competitor's by creating simplified scheduling pathways and reducing the amount of work and time that an office representative has to take to schedule procedures, or be put on hold, you can win their loyalty."

While appealing to a surgeon's office scheduler is a useful tactic to limit outmigration, ultimately, the best way to keep a surgeon satisfied at your hospital is to keep their surgery schedule full.

Boosting Productivity

Since time is money in the OR, all hospitals want to support their surgeons' productivity. And, when surgeons are measurably productive, their level of engagement and commitment to an organization will rise. According to Ms. Torrance, there are six ways to increase surgeon productivity.

1. Increase access to the surgical schedule.

One way to give surgeons, particularly young surgeons, more time on the OR schedule is to designate 80 percent of the OR as blocks and have the remaining 20 percent of the rooms operate on a first-come, first-serve basis. Leaving 20 percent of the rooms open allows younger surgeons who don't yet have a block to grow their volume, expand their referral sources and, eventually, earn a block themselves.

It is also important to have a governance structure in place that ensures surgeons' interests are represented, according to Ms. Torrance.

"Many hospitals have a medical executive committee and a department of surgery, but neither party has much of a voice in how the hospital is run," says Ms. Torrance. "What hospitals need is a surgical services executive committee with surgeons, anesthesia members, administration and nurses. And administrators need to agree to defer to the SSEC on matters of the OR schedule."

2. Create logical and efficient surgical scheduling systems and processes.

The Affordable Care Act has driven more hospitals to automate scheduling processes and incorporate them in the EHR. These automated systems include a surgical module to schedule procedures.

In the past, surgeries were scheduled over the phone, via email, through fax, on paper or in-person. So many different pathways increased the likelihood of mistakes, according to Ms. Torrance. An efficient, automated system helps limit surgery schedule requests to one pathway as much as possible. Automated systems use a uniform document to collect patient data, minimize the likelihood of missing or collecting incorrect data, and provide access to the complete medical record at the time of scheduling. As test results are generated, they then migrate into the EMR. It is also important to schedule not only by procedure name, but also entering the CPT code.  

"When a case is scheduled incorrectly, the OR may not have the right name of the procedure, the necessary supplies or staff to operate, and it may end up having to delay or cancel a procedure," says Ms. Torrance. "Standardizing scheduling in a typed format, as opposed to a verbal format, can nearly eliminate mistakes, making the OR more efficient and productive."

3. Improve efficiencies.

Efforts to improve OR efficiency start with the preadmission testing department. The PAT office is not frequently seen as a revenue-producing department, so many hospitals fail to dedicate adequate time, money, space and staff to this area.

The PAT department collects information on a patient's medical history, current medications and any conditions the patient may have that would affect their surgical outcomes. The department also schedules any necessary medical exams prior to the day of surgery.

According to Ms. Torrance, hospital executives need to understand that when PAT is done well, it can help increase on-time case starts, decrease turnover times, prevent case cancellations, reduce delays and improve procedure times.

"PAT needs to take place at the front end of an episode of care, not on the day of surgery," she says. "When patients are properly prepped for surgery through the PAT department, they tend to have shorter stays and fewer complications and readmissions. Looking at these metrics, the ROI for a PAT department is clear."

Hospitals can also improve efficiencies by updating surgeon preference cards for supplies and by sharing clinical metrics — such as case times — with surgeons and anesthesiologists.

4. Decrease anesthesia times in the OR.

All too often, hospitals bring patients into the operating room just to have the anesthesiologist start their preparations — placing intravenous lines and set up critical monitoring lines and injecting surgical blocks — even though many of these things can be completed an a room other than the OR. Since the clock starts ticking when the patient enters the OR, anesthesiologists who prep patients in the OR end up lengthening case times.

"Hospitals that develop block rooms or procedure rooms outside of the OR for anesthesiologists to complete their preparatory functions significantly reduce anesthesia times and boost efficiency," says Ms. Torrance.

5. Have specialty surgical teams assist procedures.

Most surgeons specialize in certain areas of medicine, be it orthopedics, neurology, OB-GYN or other subspecialties. That said, nurses that specialize in one or two specific areas on top of their general surgical knowledge are assets to the surgical team. Specialized nurses who assist with the same type of procedures every day are more likely to be able to anticipate surgeons' needs and predict any situations that might arise with a given surgery.

"Some small hospitals may not have the staff to create specialized surgical teams, but for larger hospitals and health systems with lots of resources, it just makes sense," said Ms. Torrance.

Hospitals interested in training nurses in the OR typically use the Association of periOperative Registered Nurses' 101 course, design their own intensive six-month program or create a hybrid program. With a general course and some mentoring with specialty team leaders, most nurses can become a full-fledged member of the surgical team in one year or less, and then learn to become specialists.

Because specialized surgical teams can improve case efficiency and surgeon productivity, as well as make nurses feel more knowledgeable, they can also boost surgeon satisfaction and nurse satisfaction.

6. Set a goal to have surgeons perform more than one case per day.

When a hospital implements OR improvement efforts, most aim to make measureable progress. For instance, many hospitals aim to be so efficient that they can add an extra surgical case per day per room, Ms. Torrance explains.

"The only way to know how far a hospital OR has come is to measure key performance metrics," says Ms. Torrance. "It's so important to set up key performance indicators and dashboards to capture an OR's baseline performance as well as every small step of progress. This data can help surgical departments set goals and show individual surgeons when their productivity is improving."

According to Ms. Torrance, the hospitals that are most transparent with their data for on-time starts, case times and turnover times and the like are the hospitals that will succeed in improving surgical outcomes, increasing surgeon productivity and curbing outmigration.

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