CASiM Conference 2014 Surgical Centers of Excellence June 11, 2014
Agenda 1 Trend 2 Basic philosophy 3 Specific solutions 2
Worldwide increasing pressure on healthcare systems requires sustained changes in the supply system Average growth rate p.a. per capita health expenditure 1997-2007 10 9 TUR KOR Growing supply requirements, diminishing resources and rising costs burden on healthcare systems worldwide 8 7 6 5 4 3 2 GRC LUX GBR NZL ISL MEX OECD FIN NLD CAN BEL SWE AUS DNK USA CZE PRT FRA ESP JPN NOR ITA CHE AUT DEU POL HUN IRL SVK Health spending in OECD countries grew significantly faster than overall economy By 2030 17% of the world population will already be older than 60 years of age (11% today) In addition, new methods of treatment increase the cost pressure - the issue of affordability takes center stage 1 0 0 1 2 3 4 5 6 Average growth rate per annum of per capita GDP 1997-2007 Source: OECD: Gesundheitsdaten (2009) 3
Up to 70% savings on outpatient surgery compared to inpatient surgery Savings potential of selected outpatient procedures in Germany from the perspective of health insurances 2.500 costs for health insurers 2.000 2.286 2.171 1.500 1.000 500 0 1.667-47,5% 875 Arthroscopic Arthroskop. surgery OP an of Gelenkknorpel, articular cartilage/ Menisken menisci (I24Z) 1.511-70,4% 1.532-66,4% - 57,0% - 72,1% 650 676 730 427 Neurolyse, Entfernung Removal of von Konisation Conisation Cervix cervix uteri Submuköse Submucosal Resektion, resection, Dekompression decompression of von Osteosynthesematerial osteosynthesis uteri (N09Z) plast. plastic Rekonstruktion reconstruction, Nerven nerves (B05Z) equipment (I23A)(123A) Nasenseptum nasal septum (D38Z) DRG Inpatient Kosten treatment stationärer with 2 Behandlung days of maximum mit Verweildauer stay 2 Tage (Maximalwert) Kosten Costs of ambulanter outpatient treatment (max value) Behandlung (Maximalwert) procedure (DRG) Outpatient surgery can significantly contribute to unlocking profitability potential among the German health care system Internationally significant financial benefits through outpatient surgery have also been confirmed A study of the IAAS * indicates savings potential of 25% to 68% for outpatient surgery Source: Bundesverband für ambulantes Operieren e.v.: Gutachten Oberender und Partner (2010)
Despite existing infrastructure, the potential for outpatient surgery in developed countries has by far not yet been exhausted Rate of outpatient surgery in developed countries 100% 90% 80% 70% 60% 50% 40% 30% 20% 83,8% 83,5% 79,3% 74,0% 69,8% 69,0% 68,0% 66,7% 62,5% 62,4% 62,0% 60,7% 54,0% 44,9% 42,5% 41,0% 18,5% Bezogen In relation auf ein to definiertes a definitive Vergleichskollektiv comparison group ("Korb") Bezogen In relation auf alle to Operationen all operations 10% 0% About 83% of the comparable operations ("basket") are performed on an outpatient basis in Canada and the USA; Germany only comes up to 60.7% Considering all operations, the difference is even more pronounced: In Canada, 87% of all surgeries are performed on an outpatient basis, in Germany there are only 37% This suggests that not medical, but among other things, financial, technical or political reasons, determine whether a surgery is performed outpatient or inpatient
Medical Doctors are under intense pressure Jack-of-all trades in a white coat? Performance Goals Cost Pressure Increasing pressure to reduce costs from multiple players in the health system Time Pressure High time pressure on surgery teams reduces the time for individual training and systematic quality management Each business division of the hospital is responsible for contribution margin under increased costs pressure Medical Doctors Forensics Increase of legal action related to unsuccessful treatment and malpractice Complexity Large variety of modules from many providers of medical technology increases complexity of overall system Expectations Patients have increasing expectations with respect to flexibility, time efficiency, service and zero-tolerance for mistakes 6
Two key components to improve the health care system Quality improvements Social requirement in the health system Increased efficiency Lower costs High performance system Outpatient care Coordinated processes and tools lead to an optimal performance of systems high quality results Higher efficiency & quality of results allow for higher throughput As a result optimal sustainable profitability Profits can be reinvested - better equipment, more employees, better training + Many procedures can be executed more cost efficiently as outpatient treatments e.g. FESS outpatient 600 vs. inpatient 2000 Low saturation level of outpatient treatments in Germany an other country's Cost bearers and patients increasingly honor the advantages of outpatient treatment 7
Agenda 1 Trend 2 Basic philosophy 3 Specific Solutions 8
Surgical Process Institute Deutschland GmbH (SPI) Foundation: 2010 Headquarters: Leipzig Employees: 25 Business concept: Implement for customers Surgical centers of excellence Target group: Private clinic projects as well as public non-profit institutions Partners: Leading providers of medical technology 9
Highly standardized and integrated solutions reduce risk for carrier and doctors measure standardize test develop The Diva -Statement: Our performance can not be standardized - it is dependent on individuals. The Truth : Almost all services can be standardized and often even industrialized - and thereby become significantly better in quality. 10
Surgical centers of excellence for operations of low complexity examples low ENT Functional endoscopic sinus surgery Septoplasty process variability Gynecology Hysterectomy Tightening of the pelvic floor Orthopedics Arthroscopy of knee joint Total Endo Prothesis (knee, shoulder, hip, foot) high low high Oral and maxillofacial surgery Incision in the oral cavity Correction of the alveolar ridge number of cases 11
SPI offers a fully integrated highly standardized solution Equipment Process organization Quality assurance Training Qualification Center of excellence Potential analysis Business plan Operator Model Certification Simulator training Referring physicians management Marketing 12
Agenda 1 Trend 2 Basic philosophy 3 Specific solutions 13
SPI offers a fully integrated solution Equipment Process organization Quality assurance Training Qualification Center of excellence Potential analysis Business plan Operator Model Certification Simulator training Referring physicians management Marketing 14
SURGPLUS The SPI approach is based on the principle of preconfiguration 15
SURGPLUS The SPI approach is based on the principle of preconfiguration 16
SURGPLUS A Cockpit for ENT surgery TYPE: SURG +ENT CREW Surgical Crew A Surgeon B 1-Technical Officer Surgery E 2-Technical Officer Surgery Anesthesia Crew C Anesthetist D Technical Officer Anesthesia CONFIGURATION 1 2 3 4 5 6 Centralized Endoscopic Surgery System (CESS) Navigation Display Primary Surgery Display Onboard Information System Navigation Foot control SRG Surgeon TOS Technical Officer Surgery ANE Anaesthesiologist TOA Technical Officer Anesthesia CESS Centralized Endoscopic Surgery System 17
SPI offers a fully integrated solution Equipment Process organization Quality assurance Training Qualification Center of excellence Potential analysis Business plan Operator Model Certification Simulator training Referring physicians management Marketing 18
Coordinated and optimized processes Basis for a high performance quality and efficiency Operational Handbook All processes are optimized for outpatient care Efficient time management is the basis for high-throughput surgery Three principal areas of work are coordinated: Booking and Service: Admission / Discharge of patients, billing, preparation of surgery time schedules Diagnosis and treatment: preliminary investigation and indication, smaller treatments Surgery: outpatient, minimal invasive ENT surgery 19
SURGPLUS Defined operating procedures Example: Functional Endoscopic Sinus Surgery Standard of centre of ecxellence Variables Option 1 Option 2 Option 3 Order of compartments Scope of sinusotomy Dealing with middle concha Hemostasis technique Type and quantity of devices Navigation Documentation... 20
SURGPLUS Surgical procedures are trained systematically Example: Functional endoscopic sinus surgery 8/39... 9/39 Medialization of concha 10/39 Partial removal of process uncinatus natus... 11/39 Partial removal of bulla ethmoidalis... 12/39 Initial approach frontal sinus 13/39 Confirmation with navigation/photo 14/39 15/39 Opening of rear ethimoid...... 21
SURGPLUS The SPM-Tutor is a training tool 22
SURGPLUS The SPM-Operator is used during surgery 23
SPI offers a fully integrated solution Equipment Process organization Quality assurance Training Qualification Center of excellence Potential analysis Business plan Operator Model Certification Simulator training Referring physicians management Marketing 24
SURGPLUS Continuous training and quality assurance is essential Versatile skills are requested Technical training Surgical training Service training Certification of the teams on cockpit Simulator training Human factors 25
SURGPLUS Module 3: Interpersonal Competence 26
SPI offers a fully integrated solution Equipment Process organization Quality assurance Training Qualification Center of excellence Potential analysis Business plan Operator Model Certification Simulator training Referring physicians management Marketing 27
SURGPLUS Module 4: The business concept needs to be clearly defined Economic efficiency - Revenue Costs Number of patients Capacity Refunding Population catchment area Incidence # OR Procedures Case-Mix UAS /DRG Competition Referrer SLOT- Zeiten times OR capacity utilization Incisionsuturing time Changing times 28
SURGPLUS Economic use of expensive OR-facilities is guaranteed Example: functional endoscopic sinus surgery OPS 5-224.63 Refund per Minute 21 19 17 15 13 sustainable optimization of perioperative times Remaining high outcome quality 2 CO < 5 %; CI < 1 %; LoF 0 % Increase in profit contribution 11 9 7 5 Costs per OR-Minute 35 40 45 50 55 60 70 80 90 100 120 Perioperative time in minutes 2 CO Critical Occurance, CI Critical Incident, FoF Loss of Function 29
Clear advantages of outpatient high performance system for patients, medical doctors and cost bearers Patients Medical doctors Cost bearers Short-term medical leave due to minimal invasive treatment Recovery at home Entire treatment is performed by one doctor Shorter waiting times Lower risk of infection by hospital bacteria Increase of patient throughput Shorter and better projectable surgeries due to standardized processes Higher degree of specialization on specific surgeries Improved surgery-terms due to optimal technical endowment Realization of cost savings compared to inpatient surgeries Reduced staffing costs (care) Optimal utilization of operating room result in decreasing downtime Decrease of rehabilitation costs 30
Requirements for integrated high-performance systems Specialization towards few selected indications rather than maximum care Ability to continuously recruit the adequate number of "matching" patients Throughput at highest quality level low process variability Equipment on highest technical level high Process-Compliance low high Specialized team number of cases Quickly reach the profit zone to recoup investments and to create a self-supporting system Tailored training concepts (Administration and surgical team) to set up, secure, and improve quality standards 31
First results for selected high performance outpatient systems Reduction of OR time : up to 40% Increase of quality : up to 400% EBIT Margin of clinic : 25% + Reduction of cost in the healthcare system : up to 25-60% Support carrier model option to generate an independent quality brand Dedicated standard model to offer an high performance ambulant solution in an clinic and reduce risk of change management 32
Thank you! 33