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The Change Management Project, Part 2: Setting the Table

Posted in Surgeon as Entrepreneur | May 2013 | Comments (2)

Tags: Editor's Choiceorthopaedic surgeryambulatory surgery centerssurgeon entrepreneursclinical challenges

I just completed a successful day of surgery at the hospital. I completed eight cases by 4:30 p.m. This was quite an accomplishment for a center that boasts a turnover time of close to one hour. The dirty little secret is that I had three operating rooms and two complete surgical teams, including anesthesia. Nonetheless, the lead anesthesiologist was rightly proud of pulling off this feat. Funny thing is, two days prior I performed nine surgeries of similar difficulty at my one room surgery center before noon. Oh, it gets better. The operating room staff that I use in my OR is the same staff that I use at the hospital, with the exception that there are five staff in the hospital OR and only two in my surgery center.

How can this be?

What I have decided to do is embark upon the journey (or nightmare) of implementing at a hospital what we have achieved in my surgery center. There are reasons that I believe my OR is so successful. Granted, a single-specialty OR allows certain efficiencies not available at the hospital, but I have agreed to take over the orthopaedic service. Not the OB/GYN or general surgery service. I will approach this from a single-specialty mentality. I believe that this is a component of the solution. The hospital staff needs to take ownership of the product that they are producing: a safe, efficient and high quality surgical experience.

It’s About Product and Process

The choice of product has a huge impact on the cost of a procedure. The implant can consume as much as 50% of the DRG for a total joint replacement. Choice of implant (or implants) can also affect the process implemented to manage the procedure. As an example, there are five companies that control the lion’s share of joint replacements in the U.S. That is five different sets of instruments and implants that have to be managed for just total knee procedures. It is unrealistic to believe that a hospital OR staff will have a familiarity with all of these systems.

That being said, hospitals have spent decades dumbing down their OR staff. This all began when the orthopaedic device companies started sending sales reps to the OR. The sales rep provided a valuable service. They assisted the back table with the instruments and technique. They also managed inventory by bringing their products and instruments to the case. This has allowed the hospitals to allow their staff to not know specifics about cases and orthopaedic systems. This provides value to the hospital in that they can train their staff to cover a multitude of different cases, thereby allowing greater cross coverage. The problem is that this comes at a cost. The sales rep adds approximately 40% to the cost of the implant.1 The sales rep is also there to do exactly that—SELL. The presence of the sales rep increases implant usage by up to 30%. The rep also drives implant usage to the more expensive variations of the same product.

Selection of implants follows a process of careful evaluation of cost and quality. The decisions do not involve the traditional rep-to-doctor interface followed by a reluctant hospital accepting the choice in order to appease the physician. Hospitals have been discussing different strategies to change the selection of physician preference devices (PPDs). These include physician alignment, procurement and sourcing, group purchasing and supply-chain strategies. I believe that the answer lies in the alignment of the physician with the hospital. This can take many forms. Co-management, gain sharing, capitation and physician employment all achieve some level of alignment. Some are better than others and will be discussed in a future article. The other options merely represent top-down authority (procurement and supply chain) or another layer of a middleman (group purchasing) that still takes their piece of the healthcare pie.

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Antonín Cuc 05/03/2013 02:30 PM
The treatments of"necrosis femural head" by my meaning it could be perfect used nonchirurgical method for young patient with perfect bones "restricting of all locomotion with infusions to alive a small surfaces of harm hip" the reslut is controlling on MRI test. Do you agree? Many physicians prefere THR, because it is with more financial profits, but it is more dangerous for patient and worse for Health status for next life. Do you agree? What is your praxis?
Karl 05/03/2013 10:31 AM
Can you and your OR staff do a revision on your own?