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Streamlining the cataract clinic

Lean principles are essential to meeting increased demand for cataract surgery

Roibeard O’hEineachain

Posted: Monday, January 6, 2020

The coming decades will see a massive increase in the demand for cataract surgery, but a streamlined approach integrating electronic patient management systems with both health system administration and modern diagnostic technology may lighten the burden, according to speakers at a symposium at the Annual Conference of the Irish College of Ophthalmologists in Galway, Ireland.

Cataract surgery accounted for 82% of all ophthalmic procedures between 1991-2001 and the requirement for cataract surgery is projected to more than double over the next 20 years, said Paul Mullaney FRCOphth, Sligo General Hospital, Sligo, Ireland.

“We are going to be inundated with the coming tsunami and we will need more resources, but we have to be sure that we are using the resources maximally and that’s where lean principles come in,” said Dr Mullaney, whose ophthalmology team won the prestigious Irish Health Service Executive’s National Health Service Excellence award in 2016.

THE MEANING OF LEAN
He outlined a number of measures that have improved performance at his clinic. The process begins prior to referral, whether by optometrists or medical ophthalmologists, when patients should undergo measurement of refraction and IOP and fundus examination. Once a patient has been referred for cataract surgery their details are entered into an electronic patient record (EPR) housed on a hospital server linked to peripheral clinics and optometric centres.

During the preoperative assessment period patients are listed for surgery based on severity of symptoms and clinical findings. They then receive information including a brief explanation of procedure and major possible complications such as endophthalmitis, surgical mishap and, where relevant, retinal detachment.

He emphasised that patients should not be cleared to progress to surgery until all relevant issues determined during clinic assessment are resolved. But once a patient is cleared they should be ready for surgery – there should be no cancellations on the day of surgery.

He noted that newer technologies are becoming available that can greatly enhance efficiency in cataract surgery. They include surgical microscopes that enable surgeons, while they operate, to see machine settings, anatomical landmarks and other important data, all provided from the wirelessly connected EPR. Although they are expensive, the very newest devices can be leased at a much lower cost through managed service contracts. An additional advantage is that, in the event of a machine breaking down, the company is obliged to replace it with a newer model.

“The culture you need to promote is one of getting the maximum out of your resources safely and effectively and also finding ways to improve that service. You need organisational support with all hospital departments, The department has to sell itself constantly internally and externally with maximised outcomes bringing in revenue,” Dr Mullaney added.

GETTING THE RIGHT ETHOS
A professional ethos and a focused approach in the cataract clinic environment are key to efficient and effective surgery, according to Paul Barrington Chell FRCS, Ophthalmologica Consulting, formerly clinical director of Head and Neck Surgery at Worcestershire Royal Hospital, Worcester, UK, a unit recognised for efficient surgery.

“It’s about setting an ethos where everything is going to be clean and sterile and friendly and the receptionist looks up when you walk through the door. If you get the ethos right and you get the staff right everything will go well for the patients,” Dr Chell noted.

Nurses in a cataract clinic must be multi-skilled and able to take on the whole range of preoperative, surgical and postoperative tasks involved in assisting the patient’s journey from their entry to the clinic to their discharge. Furthermore, all team members should be involved in planning of services. Teams must understand social versus business language, he stressed.

It is also important to take human factors into consideration. Performing too few surgeries will result in the surgical team not having enough regular practice, yet performing too many surgeries can also reduce performance levels, through sheer fatigue and other factors affecting concentration and alertness, Dr Chell said.

Paul Mullaney: Paul.mullaney@hse.ie
Paul Barrington Chell: paul.chell@virgin.net