Running two rooms

[bedrock]

Wanted to inquire of the collective wisdom of the board about something I'm considering------running two procedure rooms (in-office) simultaneously.

Here's the situation. I'm the only pain physician in a multispecialty group and I'm very busy. I work 50hrs/week consistently, sometimes 55. There isn't quite enough business for two pain docs as I would hate to only work (and get paid) for 25hrs/week, yet, I'm a little busier than I would like and it's fairly hard to get away for vacation.

I do 2.5-3 procedure days a week in my office procedural suite, and 2 half-days in the local ASC/hospital per month.

I'm considering putting in another C-arm/procedure room in my office and running two rooms to improve efficiency, and decrease my hours so I can enjoy more free time and more vacation time.

I'm hoping two rooms would increase my procedural efficiency by at least 30% percent. I'm fairly efficient already, although my main hesitation about doing two procedure rooms is creating a factory like atmosphere for my patients. Currently, my rad tech gives patients a massage during the procedure (when she's not moving the c-arm), and I talk to patients while I work, to help relax them and make it a more pleasant experience.

We should be able to still do most of that while running two rooms, I suppose. I wanted to ask if anyone on the board has experience running two procedure rooms, in-office? Pros, cons, # of procedures to make it worthwhile?

(BTW, dropping my worst payors isn't an option because of the politics of my multispecialty group)

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[jpb26]

Good problem to have.

I did run 2 rooms at my local ASC for a while but honestly I didnt like it. It is definitely doable but I personally felt too rushed, it felt like a factory to me and if things didnt go smoothly Id wind up running way behind. I was doing 3 per hour with 1 room and 5-6 per hour with 2 rooms.

How many procedures are you doing now and how many do you think you'll be able to do with 2 rooms.

 

[lonelobo]

I do 2.5-3 procedure days a week in my office procedural suite, and 2 half-days in the local ASC/hospital per month.

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How do you see patients in clinic doing 4 days of procedures a week?

 

[bedrock]

How do you see patients in clinic doing 4 days of procedures a week?

I do 2.5-3 procedure days a week in my office procedural suite, and 2 half-days in the local ASC/hospital per month.

3 procedure days/week---max.

The most procedure time I ever do in a week is 3 procedure days, sometimes 2.5 depending on if the clinic is backing up or if I have cases to be done at ASC/hospital

 

[ParaVert]

I see no need for a second procedure room unless you are shooting for four or more procedures per hour. Are you doing a lot of procedures under sedation? Certainly you need a LOT of staff to do IV sed in the office. Many of us turn out 15+ procedures in a day (every day) while seeing E&M visits AT THE SAME TIME with only one procedure room.

Another question for you. Since you are in an office, you have 24/7 access to a C-arm. Are you scheduling procedure days in your office that you do not schedule for E&M visits also? I have heard of some guys doing that. To me, it only makes sense if you don't have a C-arm and you need a facility. I would really encourage you to do procedures and E&M at the same time. You are productive every minute of your day.

 

[lobelsteve]

I see no need for a second procedure room unless you are shooting for four or more procedures per hour. Are you doing a lot of procedures under sedation? Certainly you need a LOT of staff to do IV sed in the office. Many of us turn out 15+ procedures in a day (every day) while seeing E&M visits AT THE SAME TIME with only one procedure room.

Another question for you. Since you are in an office, you have 24/7 access to a C-arm. Are you scheduling procedure days in your office that you do not schedule for E&M visits also? I have heard of some guys doing that. To me, it only makes sense if you don't have a C-arm and you need a facility. I would really encourage you to do procedures and E&M at the same time. You are productive every minute of your day.

Agree. 2nd room = lots more overhead. And if any complications or unexpected events occur you are 2x as likely to have the schedule screwed. And it will happen.

 

[PMR 4 MSK]

Morerapid turnover of the room is likely a better solution. It would be far cheaper to hire 1-2 people to help turn the room over faster than to buy another fluoro, another set of vital monitors, other equiptment, etc. In the 5 mminutes it would take them to get the room ready for the next pt, you are dictating and seeing the next pt prior to procedure.

 

[Tenesma]

first i'd optimize turn over/efficiceny for 1 room before going 2 rooms...

i had some colleagues who ran 2 rooms - and they made it work, BUT they also had the RN prep and drape the patient, the fluoro tech would be positioned and the RN would actually raise the local anesthesia wheal... so he would come in, put gloves on, do the injection (all meds drawn up), and then walk to next room where everything was waiting for him...

if something came up in the flow though, he was screwed...

so work on getting to 4-5 proc/hour w/ one room first. then re-think...

 

[SSdoc33]

i actually have access to use 2 rooms, but i choose not to. i find that what slows you down is not the actual procedure, but all the crap and paperwork outside of it. i am WAY faster than the girls in recovery can handle, despite my constant nagging and begging for increased efficiency.

i am at about a 4/hour clip, and i dont really see that changing, regardless of if i increase to 2 rooms or try to increase efficiency.

if you are seriously contemplating this, then all E&Ms would need to be done prior to the injection. no direct referrals for injections, no switching up the game plan. you see all of the patients you are going to inject first, then bring em back a separate day to inject. otherwise, you spend too much time actually talking to the patient (god forbid), and not enough time injecting.

i can see advantages to doing an E&M the same day, and only doing injections during your "injection time". in the end, i bet the billing would be about the same.

also, id never inject anything i didnt personally see get drawn up. maybe im paranoid, but you want something done right, you gotta do it yourself.

 

[lobelsteve]

first i'd optimize turn over/efficiceny for 1 room before going 2 rooms...

i had some colleagues who ran 2 rooms - and they made it work, BUT they also had the RN prep and drape the patient, the fluoro tech would be positioned and the RN would actually raise the local anesthesia wheal... so he would come in, put gloves on, do the injection (all meds drawn up), and then walk to next room where everything was waiting for him...

if something came up in the flow though, he was screwed...

so work on getting to 4-5 proc/hour w/ one room first. then re-think...

That's ******ed. The image is never right until I adjust it. The prep is never right unless I do it. The wheal in the wrong spot probably made him just let it hurt or not get to the intended target properly. Just stupid. I would never allow anyone in my family to suffer as a patient in the "mill" type practice. It's a setup for disaster. An worse, lack of improvement.

 

[Aether2000]

One solution would be to stack the patients on top of each other, and use one 24" needle through and through. Seriously though, I have considered the same thing...I have a two fluoro tables and two fluoro rooms....I have a second C-arm that is not currently working because it is older than dirt...may be the original 1955 Philips C-arm....
Let us know how this works out for you.

 

[Pain Applicant1]

Morerapid turnover of the room is likely a better solution. It would be far cheaper to hire 1-2 people to help turn the room over faster than to buy another fluoro, another set of vital monitors, other equiptment, etc. In the 5 mminutes it would take them to get the room ready for the next pt, you are dictating and seeing the next pt prior to procedure.

Why is it cheaper? The 1-2 extra people would need to be paid for every day of work that they work for you while the fluoro unit would not cost anything after it is all paid off. While the up front cost would be higher, eventually the unit would be less expensive, wouldn't it?

 

[bedrock]

It was helpful to hear everyone's comments, thanks-

I think I'll go with Tenesma and PMR's suggestion to optimize current flow and I'll do a trial hire of one more staff member to help with turnover, and if that isn't enough, I might reconsider two rooms.

I consistently do 4/procedures per hour now, but if I could get that to 5/hr, that would shave hours off every workweek.

I'm sure I could increase that to 6 procedures an hour by running two rooms, but that would cost me a lot more than just the one extra staff member I'd need for 5 procedures/hr.

if you are seriously contemplating this, then all E&Ms would need to be done prior to the injection. no direct referrals for injections, no switching up the game plan. you see all of the patients you are going to inject first, then bring em back a separate day to inject. otherwise, you spend too much time actually talking to the patient (god forbid), and not enough time injecting.

i can see advantages to doing an E&M the same day, and only doing injections during your "injection time". in the end, i bet the billing would be about the same.

Currently I completely separate E&M and procedure time which I prefer for several reasons
1-I'm much more efficient that way when I'm not changing gears between office and procedures. Also when you have a run of clinic patients on blood thinners it doesn't kill the schedule because their procedures have to be postponed.
2-all neuroaxial procedures must have driver, which covers me legally, and makes my procedure no-show rates extremely low
3- I get paid more for the procedures done on a separate day
4-Anxious patients get script for valium during E&Ms. By separating E&Ms these patients already got script, took their valium before their procedure and are relaxed when I get to procedure room.

also, id never inject anything i didnt personally see get drawn up. maybe i'm paranoid, but you want something done right, you gotta do it yourself.

I'm still debating this one. Outside of disco/SCS I'd be okay with my trusted experienced rad tech doing the prep with our big chlorprep sticks (which are hard for a reasonably intelligent person to screw up).

I'm not sure if I could ever trust someone else to draw up the meds I'd be injecting into a patient though.

 

[bedrock]

Why is it cheaper? The 1-2 extra people would need to be paid for every day of work that they work for you while the fluoro unit would not cost anything after it is all paid off. While the up front cost would be higher, eventually the unit would be less expensive, wouldn't it?

This is the question I still can't completely answer, and I hope that someone out there has those numbers.
My concern is that you wouldn't be twice as fast by running two rooms, only 20-30% more efficient unless you really do just run a mill, and skimp on safety, accuracy, and ensuring a reasonable patient experience.

 

[PMR 4 MSK]

Why is it cheaper? The 1-2 extra people would need to be paid for every day of work that they work for you while the fluoro unit would not cost anything after it is all paid off. While the up front cost would be higher, eventually the unit would be less expensive, wouldn't it?

You don't need an RN, you need people who can clean and set up. CNA-type skill. $10 - 12/hr people. And they don't need to be working that room full time, just while you are in there. There are other things they can do the rest of the time, or just work part time.

A 2nd room will cost upwards of $150K. I'd rather go with making what I have more efficient that adding capital.

 

[Tenesma]

I don't think you need to hire somebody - I think you need to just optimize what you already got...

for example, you don't want to do E/M and procedures on same day if you want to optimize your procedure flow.
- you want staff who buy into the concept of optimizing flow.
- you want templated sheets where as much as possible is done in the holding room/recovery area.
- you want a fluoro tech who helps out w/ clean up, changing pillows (i have a cart with about 20 pillows - the tech takes down the sheets, and throws new sheet/pillows onto fluoro table (and when there is down-time while I am doing procedure she will get the next sheet/pillows ready for next case)
- my RN dials the phone/dictation system and puts it on hold, so when i am done w/ procedure I just dictate "L4 TFESI" and I am done w/ dictation
- the procedures are booked in a way to optimize timing/positioning, etc - for example, the 94 yo w/ compression fractures who takes 20 minutes just to get off the table is the last patient of the procedure morning - the cervicals are done in series, so that i don't have to spend time w/ RN/tech moving table back and forth, etc...

there are a gazillion things you can do...

my 1st RN had the best idea: She set up a video-camera and video-taped the procedure room for a 2 hour period - we then watched it with all the staff:
you'd be amazed at how they all were able to pick out all kinds of duplication, redundancies, wasted opportunities... one of their best recommendations is for RN to open procedure room door by a hair - that click signals the MA to get the next patient all set to go, while the other MA comes into the room and helps get the patient out of the procedure suite (right into a wheelchair - because we can wheel them faster into the recovery area)... another little thing, the patient gets their own BP cuff (we don't take it off between holding area, procedure and recovery room)... all of these little things add up, and are easily remedied...

you'd be surprised how much time can be wasted - in fact, we have become so efficient that my RN will pull up my EHR for me to review/edit/sign a chart between each patient, so I can get extra work done while they are turning over patients.

 

[mille125]

I don't think you need to hire somebody - I think you need to just optimize what you already got...

for example, you don't want to do E/M and procedures on same day if you want to optimize your procedure flow.
- you want staff who buy into the concept of optimizing flow.
- you want templated sheets where as much as possible is done in the holding room/recovery area.
- you want a fluoro tech who helps out w/ clean up, changing pillows (i have a cart with about 20 pillows - the tech takes down the sheets, and throws new sheet/pillows onto fluoro table (and when there is down-time while I am doing procedure she will get the next sheet/pillows ready for next case)
- my RN dials the phone/dictation system and puts it on hold, so when i am done w/ procedure I just dictate "L4 TFESI" and I am done w/ dictation
- the procedures are booked in a way to optimize timing/positioning, etc - for example, the 94 yo w/ compression fractures who takes 20 minutes just to get off the table is the last patient of the procedure morning - the cervicals are done in series, so that i don't have to spend time w/ RN/tech moving table back and forth, etc...

there are a gazillion things you can do...

my 1st RN had the best idea: She set up a video-camera and video-taped the procedure room for a 2 hour period - we then watched it with all the staff:
you'd be amazed at how they all were able to pick out all kinds of duplication, redundancies, wasted opportunities... one of their best recommendations is for RN to open procedure room door by a hair - that click signals the MA to get the next patient all set to go, while the other MA comes into the room and helps get the patient out of the procedure suite (right into a wheelchair - because we can wheel them faster into the recovery area)... another little thing, the patient gets their own BP cuff (we don't take it off between holding area, procedure and recovery room)... all of these little things add up, and are easily remedied...

you'd be surprised how much time can be wasted - in fact, we have become so efficient that my RN will pull up my EHR for me to review/edit/sign a chart between each patient, so I can get extra work done while they are turning over patients.

wow...lucky and pampered guy you are....i still think that you need a plane

 

[ParaVert]

I've tried it both ways. For me, E&M and procedures simultaneously is awesome. I have two parallel schedules. One is for the procedure room, the other is for the exam rooms. I walk out of the procedure room, go straight into an exam room. Knock out a followup. Get paged for next procedure. Finish sticking. Next procedure is RF under sedation. I go see a new patient while the staff get the procedure ready. Get paged for procedure. Burn baby burn. Walk out, see another followup. I literally don't sit down for 4 hours. How can anyone be more productive when you're just doing procedures? 4 procedures per hour, each taking 2-5 minutes of doctor time including documentation. What do you do with the other 45 minutes each hour?

 

[lonelobo]

. How can anyone be more productive when you're just doing procedures? 4 procedures per hour, each taking 2-5 minutes of doctor time including documentation. What do you do with the other 45 minutes each hour?

I actually like to talk to the pt before procedure and sometimes after-patients seem to like it, if appears the doc spends a little time with them