Insights > Business Best Practices
Print this Page
Download a PDFDirect Access to High-Quality Care
By: Cindy Givens, RN, BSN, Administrator,
Surgery Center at Tanasbourne, Hillsboro, Oregon
At the Surgery Center at Tanasbourne (SCTB), a multi-specialty ASC in Hillsboro, Oregon, our entire team is focused on two core goals:
- Delivering high-quality care
- Providing a great patient experience.
Because we believe in our center, we are passionate when it comes to breaking down obstacles to achieving those two goals. The truth is, we want more patients to come to our center, especially if there is an unmet clinical need. This was the spirit behind our Direct Access Colonoscopy Program, an innovative new program we created to help increase compliance rates for colonoscopy patients in our community.
Early returns have been excellent. The program has been a big success for all involved parties – for the patients, who are receiving important care more quickly; for the physicians who are able to deliver that care in a comfortable, convenient setting; and for our business, which benefits from the increased volume.
Overcoming Obstacles
Speaking of obstacles and barriers to care, colonoscopies have consistently low compliance rates – as low as 25-30% by some estimates. Though not urgent, colonoscopies are important in reducing the risk of serious disease. Colon cancer is 90% preventable with early screening.
For rather obvious reasons, most patients aren’t in a hurry to submit to a colonoscopy. Female patients in particular are likely to put off the procedure, especially since there are so few female colonoscopists.
Physical discomfort and embarrassment are not the only reasons for low compliance. Inefficient scheduling is another common culprit. When it’s the responsibility of patients to schedule their own screenings, it’s easy for them to forget about it or put it way down on the to-do list. Overworked staff at primary care physicians’ offices aren’t the right people to handle it either. Their focus does not generally emphasize organizing follow-up care. Beyond scheduling, the prospect of a hospital visit discourages patients. We have all heard it before: many people today find hospitals to be intimidating places that are difficult navigate.
In developing our Direct Access program, we were guided by Christopher Carter, MD, a GI physician who participated in a similar and successful program at a gastroenterology/endoscopy practice, where he is a partner. Several other owners played critical roles. Christine Corbin, MD, a GYN surgeon and SCTB’s Medical Director, worked closely with the primary care physicians within the Providence Health and Services’ network and the local community to streamline the referral process. Providence is a part owner of SCTB.
Colo-rectal surgeons Joseph Frankhouse, MD, and Megan Cavanaugh, MD, ensured we could handle the increased volume of cases. That Dr. Cavanaugh is the only female board-certified colo-rectal surgeon in the state of Oregon gives us a huge advantage in attracting patients. To say the least, many of our female patients appreciate the option of choosing a woman physician for this procedure.
Female patients appreciate the option of choosing a woman physician for this procedure.
Dr. Carter, who is deeply committed to improving colonoscopy compliance rates, helped his SCTB co-owners recognize how well suited our ASC is to addressing these core issues. Primarily, our surgery center is designed for patients’ convenience. It’s very easy to find, located near major thoroughfares, and offers plenty of free parking. Patients can get in and out quickly – an important consideration in our busy lives.
Secondly, and more importantly, we have staff who are trained and motivated to handle the scheduling challenges and overcome patient reluctance. It’s our mission to deliver the surgical and procedural care that’s necessary.
It’s our mission to deliver the care that’s necessary.
How Direct Access Works
Working with our scheduling staff, we defined a process to streamline the scheduling process. The key is direct referrals to the surgery center, and our close working relationship with PCPs in the community gives us an advantage. Once we receive a referral (usually on the same day a patient visits the PCP), our staff contacts the patient within 48 hours to conduct an initial phone interview. If the case is appropriate for an outpatient environment, we offer a convenient time slot in the very near future, typically within seven to 14 days. The colonoscopists have set aside block time for Direct Access cases, which SCTB is responsible to fill. The proactive outreach has proven to be a strong motivator for patients, many of whom react with an attitude of “might as well get it over with it.” Plus, there is no need for the PCP or patient to take the extra step to call the GI.
During that first call, we enter data directly into our center’s systems. At the conclusion of the first contact, we direct patients to our Web site to complete an online registration form. Our site also features extensive background documents and detailed pre-procedure instructions, particularly about diet on the days leading up to the day of treatment.
Meanwhile, our staff also preps up the chart with the physical and medical history available from the PCP. Once we have the full information set prepared, we fax it back to the scheduled colonoscopist. Next we fax back a confirmation to the referring PCP to ensure they are fully aware of the screening schedule. We feel it is critical that we close the loop and keep good communication with our referring PCPs.
On procedure day, the many benefits of outpatient surgery centers are manifested. Patients are typically at the center no more than three or four hours, and recovery times are reduced. Patients miss 1 or 1.5 days of work at the most. Inpatient procedures usually require much longer recuperation periods. Our infection and complication rates are zero, thanks to our superior clinical staff, attention to detail and careful patient screening and selection. As you can see, it all adds up.
Strong Results
Our program has been a success. To date, we have received 196 referrals and seen 130 patients, for a 66% compliance rate. While there is always room for improvement, that percentage represents a major increase over local rates.
Of the patients we did not see, 10% did not return our phone calls, while 5 % did not schedule for financial reasons. Another 5% were not interested. Lastly, 12% did not meet medical criteria or were sent to the physician for an appointment prior to the colonoscopy at our facility.
The addition of 15- 20 cases per month, on top of the existing volume, is a boon to the business. Our patient satisfaction rates are excellent, too. On a scale of 1-5, we average 4.8 for any given month. One of our own clinical managers participated in Direct Access as a "guinea pig." Her feedback is fairly typical. She said us it was a very positive experience – "just a breeze" were her exact words. We love feedback like that.
The results: higher compliance rates, 15 extra cases per month and outstanding patient satisfaction.
The Bottom Line: Getting to Win-Win
After a bumpy financial beginning, the surgery center is operating well at all levels. Patient satisfaction is high, the clinical outcomes are very good, and profitability has been achieved. The hospital made some financial sacrifices to make this business work, but maintaining healthy relationships with our surgeons is critical to our long-term success, even if the value of those relationships can’t always be quantified as line items on a balance sheet.
There are considerable economic benefits for patients, too. There is no copay and thanks to our very favorable fee structure we save most patients significant money on their deductibles and out-of-pocket expenses. Compared to the local hospital where patients can expect to pay up to $1,500, we offer savings of roughly 50%. Needless to say, health plans like the lower rates, too, as well as the increased compliance.
Our physicians are happy, primarily because they are delivering needed care to patients in an environment they believe in. They also like to see a full procedure schedule at the surgery center.
Enabling Success
Direct Access has worked very well for SCTB, and I think there are a few clear reasons why. First and foremost, colonoscopies play to the strengths of outpatient surgery centers. Many relatively healthy people need the procedure. There is no need for anesthesiologist, and polyp removals can be done on the spot.
However, I would encourage leaders at other surgery centers considering similar programs to bear in mind a few key ingredients for success. We have benefitted from strong surgeon-owner commitment. Overall ASC success and the effectiveness of programs like Direct Access are highly dependent on having engaged owners who are committed to the success of the venture and acting as strong team players. Direct Access simply would not have worked without the efforts of Drs. Carter, Cavanaugh, Corbin and Frankhouse, not to mention the support of the other investors. In fact, Drs. Cavanaugh and Frankhouse were motivated to invest in SCTB to some degree because they saw the appeal of Direct Access.
There are also some important operational modifications. One very important factor was that all surgeons agreed on standard protocols for the procedure and to regular block times. We have set aside time in our procedure rooms on a weekly basis – six or seven appointments in the morning on regular days. The colonoscopists have their own standard blocks, with dedicated time for Direct Access cases within that time. In other words, we can get treatments scheduled quickly, which is key to improving compliance. We also invested in making sure we had the right clinical and support staff, who are trained in the unique needs of the colonoscopists and their patients. The point is, a lot of planning went into designing and launching our program.
The Bottom Line
Because we view the Direct Access program as a true win-win for our patients and surgeons, we are very excited to expand the program as we move forward. Looking ahead, we are exploring ways to drive more colonoscopies to our center and improve compliance rates. While some patients will always be reluctant to schedule colonoscopies, it’s gratifying for us to have helped solve this significant clinical issue.