Introduction:
With the shift towards value-based healthcare delivery, institutions must evaluate ways to decrease the cost of care while maintaining the quality of care provided. Traditional hospital costing methodologies do little to elucidate the true cost of care delivery. Time-driven activity-based costing (TDABC), a methodology developed by Kaplan and Anderson which utilizes a combination of time and resource cost per minute, can be used to more accurately assess overall cost of care and efficiency. In a previous study, we undertook to apply TDABC to the preoperative evaluation process of patients undergoing cataract surgery at the Jules Stein Eye Institute at UCLA. Based on our analysis, we identified opportunities for process improvement and cost reduction. One of these was the implementation of a novel triage questionnaire addressing medical conditions that would warrant further screening. By implementing this questionnaire, our aim is to increase efficiency and decrease overall costs without impacting turnover times, operating room delays, or clinical adverse events.
Methods:
A screening questionnaire was developed based on validated surveys and is in the process of being independently validated. The questions are designed to identify patients with systemic disease significant enough to provide a functional limitation that would impact their ability to undergo cataract surgery. In the pilot phase of the study, the questionnaire was administered to 20 patients. Those answering all “no” (considered a negative screen) did not undergo any further preoperative screening. Patients answering “yes” to any question then proceeded to have the standard full interview and review of records. After these patients underwent surgery, we compared findings on the preoperative evaluation with answers to our questionnaire. Case delays, cancellation rates, and unanticipated adverse events were recorded as part of the new process design along with assessment of the cost. We performed a TDABC analysis of the new screening process including the questionnaire, and compared the time and cost to that of the original process. Data on personnel, space, and equipment cost were obtained from the operations department.
Results:
Fifty percent of patients had a negative screen and had no further evaluation prior to surgery. There was no impact on turnover time and delays as compared to patients not part of the pilot study over the same time frame. [AR1] From the previous TDABC analysis, the average process time for the original preoperative evaluation process was 128 minutes at a cost of $186. With the triage questionnaire, the average process time was 64 minutes at a cost of $90. The use of the questionnaire demonstrated a 50% reduction in time and a 52% reduction in cost. There were no unanticipated adverse outcomes.
Conclusion:
We were able to demonstrate a reduction in average cost and time of the preoperative screening process using this questionnaire in place of the full interview in patients undergoing low risk surgery, without negatively impacting operating room turnover or outcomes. TDABC is a useful tool in identifying process inefficiencies and provides a basis for continued process improvements.
