Industry Voices—Lessons learned in quality improvement from a common eye procedure

A doctor examining a patient's eyes
Healthcare organizations can learn lessons in quality improvement from a study that focused on a common eye procedure. (Image: Getty/monkeybusinessimages)

Quality improvement is an ongoing process designed to improve patient care and experience. It may also prevent complacency, improve teamwork, raise the bar on innovation and reduce inefficiencies in all areas of care. Investing in quality improvement is an investment in high-quality care and patient satisfaction, which in turn can strengthen the bottom line.

While the primary focus of healthcare providers is to deliver high-quality care to all patients, a secondary focus often includes nurturing growth and innovation. Tweaks to some of the more common areas of day-to-day operations may prove just as fruitful in driving quality improvements and overall efficiency.

Naomi Kuznets
Naomi Kuznets (AAAHC Institute)

For example, a procedure with the tongue-tying name neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy is used to treat posterior capsular opacification (PCO), which causes symptoms such as decreased vision and glare, and is the most common delayed complication of cataract surgery.

A study that tracked the long-term outcomes of cataract surgery over a 15-year period found 49% of patients had YAG laser capsulotomies.

Establish benchmarks

Such high incident rates for a common procedure underscore the importance of performing them at the highest levels of efficiency for optimal outcomes. To establish quality improvement benchmarks and identify the characteristics of top-performers in YAG procedures, the AAAHC Institute conducted its first benchmarking study to focus on this specific procedure in 2017.

The study includes an analysis of data from accredited ambulatory surgical centers and freestanding office-based surgery centers, which performed the procedure between January to June 2017. The report offers a range of performance metrics and insights on how to drive quality improvement while reducing inefficiencies.

The benchmarking study measured performance and identified best practices from 28 facilities performing a total of 602 procedures. To gauge overall efficiency, the AAAHC Institute collected patient data from check-in to discharge, as well as a follow-up call with the patient within 14 days to determine opportunities for improvement.

Best practices for short pre-procedure times

One metric collected in the benchmarking study was pre-procedure time–starting when the patient checks into the facility to the time of the initial ablation. This includes time the patient is waiting in the procedure room and the waiting room.

The benchmarking data showed pre-procedure time ranged from 13-79 minutes, with a median of 42 minutes and average of 45 minutes. The top-performing organizations with the shortest pre-procedure times reported several best practices. The organizations:

  • Streamlined the admission process so that once the patient signs HIPAA forms and completes a medication reconciliation form, anesthetic drops are administered and the patient is ready to undergo the procedure
  • Scheduled a dedicated laser nurse to focus entirely on the pre-operative needs of the patient
  • Didn’t routinely dilate patients, eliminating the need to come in early for dilation
  • Scheduled laser patients between cataract patients and had a dedicated laser room
  • Scheduled all YAG procedures on the same day (no other patients seen) and setting appointments 30 minutes apart to ensure a positive, continuous flow
  • Prescreened all patients to determine whether they are candidates for this procedure to prevent confusion on the day of the procedure
  • Marked the procedure eye on the appointment tab and prepped the charts the day before the procedure

Best practices for discharging patients in a timely manner

Discharge time metrics also offered ample opportunity for comparing best practices.

The discharge or recovery time is the time from the end of the surgery to when patient meets the criteria for discharge. Overall, discharge times ranged from 0 to 44 minutes, with a median of four minutes and an average of six minutes. Top-performing facilities with the shortest discharge times attribute their efficiency to a variety of best practices. The organizations:

  • Allowed the patient to leave immediately after the procedure, requiring no patch, post-op vital signs or post-op drops
  • Presented patients with a descriptive video in the clinic prior to the day of procedure
  • Took a quick set of vitals after the laser and escorted the patient back to the waiting room
  • Reviewed discharge instructions and medications with the patient prior to the start of the laser while waiting for the doctor’s arrival, and made sure follow-up appointments were already scheduled
  • Allowed patients without complications to be discharged as soon as final vital signs were taken and drops were administered
  • Kept drops and vital sign equipment ready by the bedside and ensured all paperwork is signed

Make it work for you

The AAAHC Institute YAG Benchmarking Study was conducted to provide surgical centers with a tool to compare their own performance against peers to improve quality of patient care and overall operations. However, even organizations not involved in this procedure or specialty can take away lessons in quality improvement.

When reviewing a benchmarking report, take time to examine the performance of peers to better identify where your organization can improve and what best practices to deploy. To set realistic goals and expectations, compare your day-to-day operations to organizations most like your own in terms of annual volume and single versus multi-specialty providers. This information is included in the report to allow organizations to identify their peers.

When developing a quality improvement program based on benchmarking results, be sure to:

  • Examine your own activities to determine if a QI study is warranted
  • If warranted, set a goal that is specific, measurable, achievable, relevant and time-bound (SMART)
  • Implement an intervention to meet your SMART goal that includes a description of the data you will collect and evidence of data collection
  • Analyze the data and compare performance against your identified SMART goal
  • Once you achieve the goal, continue to monitor the activity over-time to ensure you maintain the goal and/or determine if you can achieve further improvements
  • If you did not obtain your goal, implement additional corrective action(s) to resolve identified problems and then re-measure the activity
  • Share the findings with your governing body and throughout your organization and incorporate into educational activities, where appropriate

Allow enough time between intervention and re-measuring for measurable results or improvements to take shape. If a deficiency persists, consider and test different best practices to boost performance. It is also important to continue the quality improvement program over time to gauge the long-term impact of interventions and new strategies, as well as uncover new opportunities for improvement and/or innovation.

Naomi Kuznets, Ph.D., vice president and senior director at the AAAHC Institute, has extensive experience developing and reviewing clinical practice guidelines and performance measures, conducting and reporting on quality improvement and benchmarking studies designed for ambulatory health care, and developing educational tools to help organizations improve patient safety and quality of care.