THE AMBASSADORS
BOOK REVIEW

Volume 2, Issue 2
April 1999

 

Cost Containment in Same-Day Surgery
 ©American Health Consultants, Atlanta, Georgia

Overview by David Wright BSc, MSc, PhD (london), FCACB
Senior Consultant Biochemist, Al-Adan Labs, Kuwait.

 

This book is divided into four major topics:

A. Cost containment through equipment, supplies and facilities
B. Cost containment through staff and physicians
C. Cost containment through quality control/re-engineering
D. Cost containment through surgical procedures/patient care

 

Since this book tends to be a catalogue of cost containment strategies, my general approach to this review was to look for items in each of the four sections, which were exemplary and cite them in an illustrative manner.

A. Equipment, supplies and facilities

The book begins with a general overview of the stratagem employed in the saving of money on equipment and supply purchases. Supplies bought on consignment entail no up-front cost. Little-used equipment might best be leased rather than purchased, consumables and the like can be purchased in such a way as to obtain volume discounts, and good inventory management can reveal unused items whose purchase may be hidden as part of a larger consignment and thereby allow them to be cleared or decreased in stored quantities. This frees space up, and may save the need for expansion of storage facilities. It also reveals waste.

Even the richest of health care service providers can find new equipment painfully expensive. The authors suggest that the purchase of second hand equipment should be considered if it fulfills all the requirements of the end-user, including those of quality and reliability. Many items which have been unused and unopened can be purchased at significant [up to 50%] discounts. At least one enterprising person has set himself up in America as a purveyor of quality used equipment. Refurbishing used equipment can make it acceptable to the doctor who insists that if it doesn't look new, he won't consider using it. The concomitant purchase of extended warranties also should be considered.

Of course, buying used equipment, is very much a 'caveat emptor' prospect. This should not be an intimidating procedure, provided that the purchasing authority develop policies and procedures which govern such purchases. These must include aspects such as an ironclad 'money back' warranty, availability of spare parts and liability issues.

Some new and simple equipment may reduce complications and save money and lower patient discontent at the same time. A tympanostomy ear tube coated with silver oxide may significantly cut post-operative recurrent infection rates by half.

It is also true that more expensive anaesthetic may end up costing less in the end. As a case in point, the anaesthetic propofol was looked at by Wagner [Rutgers University College of Pharmacy, Piscataway, New Jersey, USA], who "analysed the records of 350 patients who underwent same-day laparoscopic surgery... He found that although propofol cost about $7 more per patient than thiopental sodium, the overall average cost per patient actually was $273 less when shorter anaesthetic time and recovery room times were calculated."

Stephen W. Earnhart notes how simple it can be to cut overall costs in space and facilities by having a beeper system [the family is loaned a hospital beeper] which forewarns patients' families as to when they can see their loved ones. Equally important is the use of personnel to act as patient 'greeters'. Such people can ease the patient's concerns and at the same time facilitate and shorten his 'processing'.

He adds that Same-day surgery managers should be bold in demanding cost breaks from vendors. He notes, [the major vendors] "are going to have to cut their [profit] margins to keep the business they've got."

The authors ask, "When you cut cost do you add risk?'

The use of disposable versus reusable items is not always a one-sided issue. One must examine carefully all aspects of such a choice before reaching a decision. A new concept, the use of 'reposable' [multiple use and throw away] instruments, is being sold as the "low cost answer to disposables, which are expensive, or reusables which sometimes require frequent repair and maintenance"

Not all cost savings are risk-free. Areas of risk are to be found in reusing disposable items. Disinfection in place of sterilisation can be a dangerous strategy. Additionally the use of unlicensed personnel may end up being a hazardous economy, as may the use of 'cheaper' supplies, which end up costing much more because their quality is inferior.

This may be countered by the use of product evaluation forms designed to reveal disadvantages, advantages, end-user assessment etc.

The computer is another two-headed monster in cost containment. Computer-based automation is everywhere now and it is saving significant amounts in administration, operating room quality assurance and much reduced turn-around times. Properly managed it is a boon and a risk reducer. It's uncontrolled intrusion can make it just the opposite. Its many 'bugs' can make it a [usually manageable] menace.

Doctors, nurses, technologists etc. are the end-users of materials supplied to the Same-Day Surgery Unit, and their opinions on the efficacy and cost effectiveness of the items they use are invaluable aides to cost containment. Doctors' "preference cards" can reduce physician dissatisfaction and enhance savings if they are kept up to date.

B. Staff and Physicians

Physicians can and should be encouraged to contribute to cost containment in Same-Day Surgery. The surgeon is inculcated from the beginning of his training with the idea that punctilious attention to detail and a dedication to quality assurance and dedicated service on behalf of the patient are necessary aspects of his chosen profession. When cost containment is wed to quality service, he or she is by nature one of its staunchest allies.

As professionals such as these are chosen for their ability to make decisions based on fact, they are best recruited as allies by giving them the facts.

An example of this can be found in describing the way Bruce MacFadyen MD, FACS, saw the light. Shaken by some of the bills his patients were faced with, he organised a study of the costs of laparoscopic cholecystectomy. He and his colleagues found that of the 200 minutes spent in the operating room, only 47 involved the actual surgery. The rest of the time was spent on nursing or anaesthesia activities. He is now a firm supporter of cost containment. "It is a time of enlightenment. With cost reimbursement going down, everyone's concerned."

An approach to cost containment, which almost everyone is in favour of, is the tying of results with rewards. East Memphis (TN) Surgery Centre runs a feel-good program called PRIDE [Personal Responsibility in the Delivery of Excellence]. It is a gain-sharing program that allows employees to share in up to 2% of the centre's net operating income. Clinical Administrator Sarah Johnson, RN, notes, "Money is a big motivator. Everyone feels like they have a piece of the pie. This is our facility and our money we're spending. You want the best and you want the patient to be happy, but you can do it at a much lower cost."

Cutting costs and boosting morale must go hand in hand, Stephen Earnhart suggests that there are 8 areas on which one can concentrate to cut costs and boost morale. These are:

Miscellaneous factors

Medical malpractice insurance is a major factor in costing Same-Day Surgery in America. Shopping around for competitive rates makes good sense.

The time required to clean and prepare the day case theatre for the next patient in the Children's Hospital of Philadelphia, where turnaround functions were divided [because it "seemed logical'] used to take about 23 minutes. By consolidating the turnaround team with multi-skilled workers who share the same job function, the time has been cut to 15 minutes, and no one is standing around waiting to get down to work.

In the not too distant future, most of the people in the operating room will be non-medical first assistants. This, at any rate, is how Larry R. Williams, MD, FACS, sees it. "The day is coming, when the surgeon won't be in the room with the patient, but in another city. The non-surgeons will be in the OR preparing the patient, setting up the equipment, and making sure the surgery is going well, while the surgeon will be somewhere else with the virtual reality equipment, or robot, or computer.

The Denver-based Association of Operating Room Nurses \{AORN] "defines an RN first assistant [RNFA] as one who 'collaborates with the surgeon in performing a safe operation with optimal outcomes for the patient."

The duties of an RNFA are divided into three phases, the preoperative, the intra-operative and the post operative. The authors delineate these duties. Linda Groah, RN MS, CNOR, CNAA, notes that, "we should be turning over to the unlicensed and technical people the things that don't take nursing knowledge". She suggests that nurses should avail themselves of all opportunities to broaden their knowledge into the new avenues of nursing experience.

C. Quality Control/Re-engineering

In order to abolish Same-Day Surgery chaos in the form of incomplete charts, patient cancellations and inefficient scheduling, the Peninsula Regional Medical Center in Salisbury MD set up a "quality action team which gathered data on efficiency problems and developed solutions, which led to changes in preoperative procedures and the addition of a patient assessment and education program' which has resulted in savings of more than $100,000 a year from reduced patient cancellations alone [Kathy Hoffman, MBA, Laboratory Manager and quality action team leader].

The whole team dedicated themselves to gathering data and carrying out solutions. As a result of their continuing efforts,

Refining and revamping problem areas may not be enough in today's health-care environment. Denise L. Geuder, RN, MS, CNOR feels that "re-engineering can lead to significant cost savings and added efficiencies."

She proved this by re-engineering the Same-Day Surgery services at St. Francis Hospital in Tulsa, Oklahoma when this part of the hospital's services was relocated to another building. In her efforts, she focussed on customers, competition and change. Once again making it a team effort materially assisted their efforts. They switched to the 'just-in-time' inventory, and the indispensable attitude of flexibility on the part of staff generally. Geuder created a task force of surgeons, anesthesiologists, nurse managers and staff nurses.

She notes, "When you begin re-engineering, you look at your biggest problems and your most significant opportunities."

She separated the inpatient and ambulatory screening processes, realising that complex prescreening tests aren't necessary for most ambulatory patients. Services were centred around the patient [patient-focussed care]. "Even more importantly, the Same-Day Surgery center created a new concept of case management that relies heavily on cross-training and less on hierarchy."

"The center of the future is low cost, patient-friendly." The Minimally Invasive Care Center at Abbott Northwestern Hospital exemplifies this concept.

At first staff resisted the necessary change in their mind-set, but this dissipated within a year, and staff morale, efficiency and patient care improved. The key to their success was a "fundamental change in methods". Everyone on the staff became a patient, dressed in patient gowns and discovered;

D. Surgical procedures/patient care

Driscoll Children's Hospital in Corpus Christi, Texas, observed that 37% of patients with tonsillectomies experienced nausea and vomiting. After they changed over to the use of ondansetron, this rate fell precipitously to 7%. Managing post-operative nausea meant not only less discomfort to the patient, but also faster discharge. Day surgery nurse manager, Bette Nelson, noted, "{Controlling nausea and vomiting] is not only important for the comfort of the patient, but it helps them later on."

Critical path cost control for high tech, high volume surgery.

'Critical paths' are the key to reducing costs by changing, standardising and co-ordinating practice patterns. They are stratagems devised to reduce costs [trimming what is unnecessary to safe, quality care] while maintaining patient satisfaction and holding or improving quality of outcomes.

Judy Adder-Keller, MSN, RN, CS, director of medical and surgical nursing and case management at Gwinnett Hospital System in Lawrenceville, Georgia, looked at laparoscopic cholecystectomies. She noted that some doctors administered antibiotics before the procedure, while others did not. Outcomes did not differ between the two groups. She observed that, the pre-operative use of antibiotics "are not part of the critical path".

"We wanted to maintain quality care, but our costs were not controlled, so we developed a critical path."

Patrice Spath, ART, a consultant in health care quality and resource management with Brown, Spath and Associates in Forest park, Oregon, suggests the following steps for developing a critical path:

Estimating procedure costs

Vangle Paschall, RN, CNOR, laser endoscopic co-ordinator for Promina Gwinnett Hospital System in Lawrenceville, Georgia writes, "When you look at cost-effectiveness, you need to look at all the costs, not just charges to the patient."

She offers the following cost analysis of laparoscopic appendectomy done at her facility.

  1. Look at some 'best practices" to establish a baseline for your own comparisons. Study a minimum of 50 cases
  2. Set your own criteria; compare like with like.
  3. Gather the data from the accounting department; compute the surgical cost.
  4. Compare costs for the open and laparoscopic surgery.
  5. Compare length of stay costs.
  6. Add up total surgical costs and length of stay costs and compare all the data.

In her situation, she determined that laparoscopic appendectomy was $299 cheaper than was open appendectomy.

The "Best Practices Program"

The United States Surgical Corporation offers a free "Best Practices Program" "designed to help hospitals identify their costs for a given procedure, find ways to reduce them and generate more revenue from them".

The program works step by step as follows:

More comprehensive notes in the text further explain the program.

Conclusion

In summary, then, the book is a primer on the techniques of cost containment, specifically with respect to Same-Day Surgery, but with application throughout modern medical practice. It is a harbinger of the future in cost effective, high quality medicine. We could all profit from an acquaintance with what it contains.

(This book review is being published simultaneously in the Kuwait Medical Journal, March 1999, vol.31 Issue 1. The KMJ email is kmj@kma.org.kw )


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