Play #2 – Eliminating Variability in Instruments/Disposables
Variety may be the spice of life in ordinary day-to-day circumstances, but in the Operating Room, it can be a recipe for reduced profitability, inefficiency, and low quality. We frequently encounter Chiefs of Surgery and leaders of Surgical Services who struggle with the question of variability, particularly how much of it to allow and where to allow it.
Practitioners in other industries – the auto and computer industries are prime examples – have long understood that standardization begets higher quality and profitability and have done their best to eliminate variability. However, this principle is hotly contested in healthcare.
Healthcare practitioners know that most surgical costs are incurred in the OR and that the a surgeon’s greatest influence over both cost and outcomes lies in the intraoperative period of care. Yet this knowledge doesn’t make striking the right balance between standardization and individual freedom to practice – a balance that is often central to an institution’s value proposition – any easier. When we ask practitioners interested in reducing instrument and disposable variability: Why it is that there’s not more standardization, we typically get the following responses. Do these resonate with your experience?
- It’s hard to say NO! to doctors, we don’t know how to get started.
- We are not sure it will improve efficiency or quality in the OR.
- We are not sure the returns from standardization are worth the effort.
In the remainder of this post, we’ll examine each of these responses by posing them as questions and providing some answers. We will start with the last response, and work backwards, because the OR is the largest profit and cost center of any health system (60% of the profit and 50% of the cost).
Is standardization of instruments/disposables worth the effort?
The answer is YES, not only does it lower costs and create operational efficiency, it does so without any negative impact on outcomes, and hypothetically (to be proven) a positive one. Two cases illustrate this well:
- Thyroidectomy – Disposable Standardization Yields $1,274/Procedure
Our co-founder, Dr. Langerman, assessed the average disposable costs of Thyroidectomy procedures across five different surgeons at a single facility. The range of disposable costs was $298 at the low end to $1,572 at the high end, a $1,274 difference from low to high. Cumulatively, this variability in disposables represented a $400,000 annual savings opportunity for just one procedure at that institution. Imagine the potential multiplied by a factor of 10 or 15, as the practice optimized its other procedures with high volumes of disposables!
- Eliminating Equipment Variation in Laparoscopic Cholecystectomy Standardization Yields $2,497/Procedure
The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) performed a study of the variation in equipment use across 36 surgeons. The study revealed that equipment costs at the low end were $258 and at the high end they were $2,755. That’s a savings of $2,497 per procedure, for those operating at the high end of cost. Cumulatively, for a surgeon operating at the high end, that’s a savings of just under $1mm per year based on a volume of 28 case/month.
Will standardization improve efficiency and quality?
At ExplORer, we love this question, because we sit at the intersection of surgical workflows, decisions, and instrument/disposable choices, as pre-operative and realtime support solution. The answer is, YES!
Here’s how: with fewer variations, and a process to get to a standardized path, set up is faster, intraoperative delays and disruptions are eliminated, and the team can focus on the patient, not trying to remember which retractor Dr. X wants. Efficiency and quality soar when choices are minimized during a procedure so that they can focus on decisions that truly matter for the benefit of the patient. Imagine that you are a scrub nurse in the typical community hospital. You work with 15-20 surgeons performing 30-40 different procedures, each with 15-40 instruments. Add to this variability in your teammates, that adds up to a lot of permutations to learn and manage, and try to adapt to.
The quality of surgical experience for you and the patient will improve exponentially with standardization – of not only, instruments and disposables, but also, procedural steps – and pre-operative and real-time workflow navigation from a product like ExplORer.
Where do we start, and should we say “no” to doctors?
We empathize with how hard it is to manage the change process in healthcare, especially when it comes to making changes in surgery, the revenue and profit stream of hospitals, and with surgeons the owners of those patient relationships. We’ve found that saying NO rarely works, and that there are three keys to enabling change and sustaining momentum across the standardization process, including: pick a few sub-specialties and enlist the surgical team, gather data and educate, and implement tools and process to lock in change.
Pick a Few Sub-specialties and Enlist the Team
In picking sub-specialties, we find it helps to prioritize those with innovative leadership both at the surgeon and nursing level. A small cadre of two to three innovative surgeons and scrub nurses are critical to gaining momentum and sustaining change. Once you have innovative leaders in mind, it’s time to select a set of procedures that are performed at significant volume, that are moderately complicated, and include a higher quotient of instruments and supplies. Ensuring that procedures you select have these three characteristics will maximize your potential to create value.
Gather Data and Educate Surgeons and Nurses
Data gathering and education are paramount in convincing nurses and doctors that change is necessary and worth the effort. This process of show and tell works best when doctors and nurses are engaged in the data collection process and the data comes from their procedures. These efforts need not be complicated multi-month endeavors; in fact, analysis of data from current systems, such as charge sheets, can be performed to illustrate opportunities for improvement, like cost differences in procedures across a group of doctors. Gitelis and Ujiki found at Northshore University Health that educating doctors on the cost of disposables used in laparoscopic cholecystectomies lead to a 10% savings in disposable costs and an annual savings of $27,000. Similarly, our own experience documenting waste shows that teams can utilize ExplORer more effectively to collect and analyze data, eliminating the need for consultants and observers.
Implement Tools and Processes to Lock in Change
Tools and processes are key inputs to locking in change. Imagine you identified $27,000 to $500,000 in savings opportunities but each time you entered the OR to perform a procedure your standard items were not all in the room and the nurses and techs working with you did not know your procedure well enough to know exactly what standard items you would use and when. Unfortunately, this is an all too common problem. In fact, we’ve found that 85% of waste in the OR occurs because nurse and techs have gaps in their knowledge of procedures, particularly with regard to instruments and disposables that are to be used. Unfortunately, preference cards and the other tools available in the OR are insufficient. They don’t start with a view of the procedural steps and how to enable them with a step-wise sequence of instruments and supplies to be utilized. There’s no shared experience, no harmonizing force that creates a quality shared experience. So, it’s little surprise that efforts at standardization fail in a short period of time. In today’s high turnover environment where 20-40% of your surgical team members are replaced every year it’s hard to achieve sustained results without enabling technology.
What’s needed is easy to use tools that enable rapid review of, and engagement in, a procedure by the entire team before and during surgery. Absent persistent practice together – something that occurs in only 45% of cases based on our experience – teams need a playbook, like ExplORer, that builds and sustains knowledge and supports standardization.
Here’s to finding the right balance in standardization, that aligns with your strategy. Please contact us if we can help.
Posted by: Thomas G. Knight, Chief Operating Officer
About ExplORer Surgical
ExplORer Surgical is an interactive surgical playbook that reduces disruptions and wasted disposables by improving surgical team communication. ExplORer Surgical also provides real-time performance and scheduling data to OR administrators to enhance quality of care and efficiency. Surgical teams use the software to coordinate their activities while managing their tools and supplies in a way never before possible. The result is optimal teamwork, increased efficiency, and high performance.
Gitelis M, Vigneswaran Y, Ujiki M, et al. Educating surgeons on intraoperative disposable supply costs during laparoscopic cholecystectomy: a Regional health System’s experience. Am J Surg. 2015;209:488e492.