In this article, Carlos Guanche, MD, managing partner of the Southern California Orthopaedic Institute in Van Nuys, Calif., discusses seven simple surgeon practices that can affect a healthcare organization’s bottom line.
1. Improper patient positioning
Certain orthopedic cases, such as arthroscopy and open shoulder surgery, depend highly on the proper positioning of a patient to ensure that the surgeon has a clear view of the site of surgery. “If the patient isn’t positioned properly, the surgeon’s vision is not as good, and it takes more time to reposition the patient and complete the surgery,” Dr. Guanche says. “More time spent in the OR means more money spent on the case.”
At the surgery center used by physicians at SCOI, Dr. Guanche says an average procedure takes around 60 minutes to complete and the cost for OR time is around $1,000. “Margins aren’t the best right now [in the current market], and once costs such as anchors and shavers are considered, most surgeons clear around less than $250 per case,” he says.
Repositioning a patient can take around 30 minutes, and the additional time in the operating room can cost a surgeon what profit he or she could make on the case, if not leaving the surgeon in the red. It is important for healthcare organizations to determine what causes improper positioning.
“Many surgeons dictate between cases, so they let their OR personnel, such as a fellow or a resident, position the next patient,” Dr. Guanche says. “Whereas the surgeon may think they are saving time, there is a steep learning curve when it comes to the amount of training and confidence fellows and residents have. This could lead to improper positioning unless the surgeon is confident in the skills of his or her staff.”
Dr. Guanche suggests that if surgeons let their staffs position patients, they should make sure to check the positioning prior to patient being prepped for surgery. By checking prior to prep, the surgeon can make adjustments as needed without having wasted supplies on prep.
2. Injuries to patients
One consequence of poor patient positioning can be injuries to the patient, which are increasingly not covered by insurance. A surgeon’s presence in the operating room prior to surgery can help eliminate these errors.
“The surgeon is the captain of the ship and should make sure that everything is done to his or her satisfaction prior to starting surgery,” Dr. Guanche says. “In the end, it will be the physician, along with the center, who writes the check if anything goes wrong, and it is not defendable if the surgeon is unaware of any potential problems.”
For example, Dr. Guanche performs shoulder surgery in the lateral position, so it is important to ensure that other arm not undergoing surgery is padded prior to starting surgery in order to eliminate a chance of nerve palsy. “It’s hard to explain to a patient why their left arm is numb when the surgery was performed on the right arm,” he says.
Investing in technology, such as new patient positioning systems, may be worthwhile for an organization as it can help ensure consistent, predictable positioning. “The postioner we use has good padding, which can help eliminate injuries if the person positioning the patient is overly aggressive. By using the same system, it creates a controlled environment, and you are not dependent on who you have to help you, whether it is a small woman or a large man,” Dr. Guanche says.
At the same time, by using a consistent process, Dr. Guanche says surgeons may be able to save an hour a day to an hour per case.
3. Wrong site surgery
According to data from a 2006 study published in the Archives of Surgery and a 2007 study published in the Annuals of Surgery, wrong site surgery occurs an estimated 5-10 times daily in the United States. As of July 6, 2009, CMS no longer covers surgeries that are performed on the wrong site or wrong patient or covers the wrong surgery.
It is therefore increasingly important that surgeons take the time to ensure prior to surgery that the right extremity is marked and prepped for surgery. This should also be identified and verified by the patient.
“I typically mark my patients in the pre-op visit,” Dr. Guanche says. “I sign the part and place a waterproof dressing over it. Patients sometimes will look at you strangely and ask what you are doing, but I’ve found that once you explain it to the patient, most get it right away.”
Dr. Guanche notes that this is another area where many surgeons may try to cut corners and mark the patient just prior to surgery. However, if the surgeon is running late, the patient may already be put to sleep in preparation for surgery, rendering it impossible to have the patient identify the correct extremity or surgery.
“[With so many resources available prior to surgery,] it is unforgivable if you perform surgery on the wrong site,” Dr. Guanche says.
4. Ineffective scheduling
According to Dr. Guanche, proper scheduling of procedures is essential to saving time and money for your healthcare organization. “I typically perform six or seven cases a day. For instance, I may have four hip arthroscopies scheduled — three right and one left. I’ll schedule the three rights in a row and then do the left so I only have to turnover the room once,” he says.
This technique can work well for any type of surgery where surgeons will see procedures on the opposite sides of the body in the same day, such as shoulder surgery. Another approach, if the surgeon has two operating rooms available, is to perform all left-side procedures in one room and all right-side procedures in the other, says Dr. Guanche. By cutting down on the time required to turnover a room, a surgeon can see more patients and spend less time prepping a room for the next patient.
“It makes for an easier day and makes a huge difference in turnaround time,” Dr. Guanche says.
5. Wasting surgical supplies
Nurses or operating room staff will open supplies before the surgeon asks for them during a procedure. According to Dr. Guanche, this practice is particularly prevalent in the hospital setting. “I’ve frequently had as many as $250-$300 in opened items that I didn’t use for every case in the hospital,” he says.
In order to stop this waste in supplies in revenues, Dr. Guanche instituted a policy where OR staff does not open any supplies, other than the obvious (i.e., retractors, knives, etc.), before the surgeon explicitly asks for it. These items include shavers, anchors and dressings.
Dr. Guanche suggests presenting surgeons with an itemized “bill” after surgery to demonstrate to the surgeon and OR staff that includes what items the surgeon asked for, what items had been used and what had been opened. “By using the bill, surgeons can see how much unused, opened items are costing them,” he says.
6. Inadequate pain management
According to Dr. Guanche, pain is the main reason for readmission after surgery, and readmissions can lead to higher healthcare costs, which are under scrutiny as the ongoing healthcare reform debate continues. Surgeons should do more to improve their patients’ pain prior to surgery in order to achieve better results. In addition, limiting post-op pain will allow patients to leave the surgery center faster, thus using less surgery center time and increasing profitability.
“A good anesthesia group is key to reducing pain,” Dr. Guanche says. “We’ve seen a huge difference in patients’ pain after surgery with nerve blocks, so finding a group that can efficiently do blocks is beneficial, especially if the surgeon is not willing to wait.”
Some common nerve blocks are interscalene blocks for arthroscopy and femoral nerve blocks for ACL surgeries, according to Dr. Guanche. Other post-operative techniques, such as compression and ice, can also help ease patients’ pain.
For these types of minimally-invasive joint surgeries, risk of infection is low because a lot of fluid is located in the site, which helps to keep the area free of infection, according to Dr. Guanche.
Open outpatient surgeries, such as shoulder replacements, that are not performed via small incisions require surgeons to be more careful as they present a higher risk of pain and infection. “I tend to use longer-acting antibiotic preps, such as alcohol with dexadine and iodine for these patients,” Dr. Guanche says.
7. Buying “latest and greatest” technology because it is trendy
Surgeons may want to buy the newest surgical technology to assist because studies show that it will save time in the operating room. Although this may be true, in the long run, healthcare organizations may be paying more in order to use the new technology without realizing financial benefits.
“Surgeons often ask for equipment without looking at the bottom line,” Dr. Guanche says.
For example, ablation devices for electrocauterization have saved surgeons time in the OR, but cost around $250 for a five-second procedure. “Old fashioned” cauterization may take an extra five minutes, but costs a surgeon only around $20 per case. “It is a 95 percent cost difference for a minimal savings in time,” Dr. Guanche says. “Before purchasing expensive equipment, it is important to look at the cost benefits.”
Dr. Guanche is a managing partner with the Southern California Orthopaedic Institute and is an expert in hip and shoulder arthroscopy as well as complex shoulder reconstruction. Learn more about SCOI.
Thank you to Erin Herbst at Hill-Rom and Allen Medical Systems for arranging the interview with Dr. Guanche. Learn more about Allen Medical.
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