Culture Change: Engaging Surgeons to Decrease Costs in the Operating Room

Culture Change: Engaging Surgeons to Decrease Costs in the Operating Room Ash Mansour, M.D., RPVI, FACS Chairman & Professor of Surgery Spectrum Health Medical Group

Who We Are and How We Operate

Spectrum Health

Spectrum Health Delivery System Spectrum Health Hospital Group Spectrum Health Medical Group Priority Health Spectrum Health Physician Alliance

Spectrum Health

Spectrum Health Delivery System Spectrum Health Hospital Group Spectrum Health Medical Group 12 Hospitals 170+ Service Sites 2000+ Licensed Beds Priority Health Spectrum Health Physician Alliance

Spectrum Health

Spectrum Health Delivery System Spectrum Health Hospital Group Spectrum Health Medical Group Priority Health Spectrum Health Physician Alliance

Spectrum Health Delivery System Spectrum Health Hospital Group Spectrum Health Medical Group Priority Health Spectrum Health Physician Alliance Multi-Specialty Medical Group that aligns Spectrum Health s medical care, hospital resources and insurance system in a way that creates unique value. 1200+ Members

Spectrum Health Delivery System Spectrum Health Hospital Group Spectrum Health Medical Group Priority Health Spectrum Health Physician Alliance

Spectrum Health Delivery System Spectrum Health Hospital Group Spectrum Health Medical Group Priority Health Spectrum Health Physician Alliance Non-profit health plan Service area coverage: Michigan Employer groups Individuals 652,000 members 12,000 employers

Spectrum Health Delivery System Spectrum Health Hospital Group Spectrum Health Medical Group Priority Health Spectrum Health Physician Alliance

Spectrum Health Delivery System Spectrum Health Hospital Group Spectrum Health Medical Group Priority Health Spectrum Health Physician Alliance Collaboration between Spectrum Health and private practices. PHO, PO or IPA 75 Practices 500 Physicians

Spectrum Health & Process Improvement

Spectrum Health - Priorities

Spectrum Health Priorities Case Costing

Spectrum Health Priorities & Process Improvement Lean Thinking (Toyota Production System)

Spectrum Health Priorities & Process Improvement Lean Thinking (Toyota Production System) Philosophy complete elimination of waste

Spectrum Health Priorities & Process Improvement Lean Thinking (Toyota Production System) Philosophy complete elimination of waste Waste anything that does not contribute to the value of the quality of service to the patient

Spectrum Health Priorities & Process Improvement

Case Costing & Process Improvement

Case Costing & Process Improvement Challenge people to perform to their peak ability

Case Costing & Process Improvement Challenge people to perform to their peak ability Mutually trust one another

Case Costing & Process Improvement Challenge people to perform to their peak ability Mutually trust one another Regardless of titles, our teammates are our moral peers

Case Costing & Process Improvement Challenge people to perform to their peak ability Mutually trust one another Regardless of titles, our teammates are our moral peers Awareness and reduction of authority gradient Process improvement is everyone not just leadership making decisions

Process Improvement 8 Wastes Transportation

Process Improvement 8 Wastes Transportation Motion

Process Improvement 8 Wastes Transportation Motion People

Process Improvement 8 Wastes Transportation Motion People Waiting Time

Process Improvement 8 Wastes Transportation Motion People Waiting Time Over Processing

Process Improvement 8 Wastes Transportation Motion People Waiting Time Over Processing Over Production

Process Improvement 8 Wastes Transportation Motion People Waiting Time Over Processing Over Production Defects

Process Improvement & Case Costing Over Production

How Spectrum Health Priorities, Process Improvement Themes and Case Costing are Interdependent

Case Costing Typical OR team ST s taught to be ready for surgeons needs/wants Nurses focused on pt. Surgeons want efficiency Cost is always an issue but too often sidelined at the point of care

Surgical Services Culture Financial planning Based on the previous years data Guessing on what the next year will bring Develop initiatives based on operational goals Generally set by operational managers Developed into smart goals for clinical leaders If goals are not met then tell the story why

Culture change Clinical Leadership The clinical teams should develop their own financial goals Operational teams should assist with those goals Need physician support and engagement Spectrum Health Developed a clinical model around case costing

Clinical team owned this objective Easy Achievable No discussion needed Data teams had clear direction

Case Costing Approach: - Collaboration - Process - Success

Collaboration Planning phase included Open house product display for surgeons Prices on every product Were able to see what their partners use Total cost of cases were made transparent

Collaboration Nursing leadership commitment No product would be removed without physician support Total engagement from the team if physicians remained engaged in the work Physician commitment Would engage the whole physician group in the work Required to help negotiate product prices with contract administrators Willing to trial new items

Process 1. Set a baseline price for each procedure 2. Clinical teams discuss the most important items for these procedures 3. Develop a plan to reduce the cost by $100 for each provider Negotiate contracts (surgeon led) Change practice

1. Pull data for baseline cost analysis

2. Clinical Team discussion 3. Negotiate price

Success Met the goal Clinical outcomes unchanged (or better) Safe and open environment Culture built on open communication and trust Authority gradient is greatly reduced

Surgeon Engagement

Surgeons to Decrease Variable Costs in the Operating Room Lindsey M. Korepta MD 1, M. Ashraf Mansour MD 2, Stefano Bordoli MD 2, Robert F. Cuff MD 2, Jason D. Slaikeu MD 2, Christopher M. Chambers MD 2, Peter Y. Wong MD 2, Eanas S. Yassa MD 2 GRMEP/MSU Vascular Surgery Residency 1, Spectrum Health Hospital 2 Grand Rapids, MI

Introduction The cost of a surgical procedure can vary from case to case and surgeon to surgeon. While there are certain fixed costs associated with the operating room, surgeons can greatly influence the variable cost for each procedure.

Fixed Costs Power Light Water Salaries

Variable Costs Sheaths Catheters Wires Stents Grafts Shunts

Variable Costs Surgeons have control over many of the variable costs for each type of procedure that they perform, and often follow the techniques of their mentors and predecessors.

Purpose To assess whether the variable cost per case can be significantly decreased by informing surgeons of the price tag for the materials that they use and by comparing surgeons to one another.

Method A retrospective database was created to include the number of cases, baseline costs, and variable costs of commonly performed general, vascular, colorectal, and orthopaedic surgical procedures

Methods Cost analysis prior to intervention July 1, 2013 through June 30, 2014 Cost analysis after intervention July 1, 2014 through June 30, 2015

Method The intervention included holding a forum in which procedural supplies were pulled for each surgeon/procedure (Table 1). Variable costs were itemized and totaled. Surgeon comparisons total supply cost and differences in technique Surgeon feedback & identification of opportunities Surgeons encouraged (but not mandated) to change practice to cost-effective care.

Table 1. Total Case Number

Laparoscopic Inguinal Hernia Repair

2014 3942 cases reported 2015 3786 cases reported Results

Results Overall cost average decreased anywhere from $24 to $944 per procedure. Significant decreases observed Open & Lap Inguinal Hernia Lap Appy Lap Chole

Results Lap Appy 13 surgeons 6 surgeons with significant differences (pre & post) Lap Hernia 3 surgeons 3 surgeons with significant differences (pre & post) *Only surgeons with 10 or more procedures pre & post were included.

Median Supply Cost per Case ($) Supply Cost Data 1200 1000 * Pre Post * 800 600 400 * * 200 * p < 0.05 0 Lap Appendectomy Lap Cholecystectomy Open Inguinal Hernia Repair Lap Inguinal Hernia Repair

Median Supply Cost per Case ($) Figure 2. Pre and Post Supply Cost Data for Laparoscopic Appendectomy by Individual Surgeon 1400 1200 1000 800 600 400 200 0 Pre Post

Median Supply Cost per Case ($) Figure 3. Pre and Post Supply Cost Data for Laparoscopic Inguinal Hernia Repair by Individual Surgeon 2500 2000 1500 1000 500 0 Pre Post Green line indicates significant difference between pre and post (p < 0.05)

Median supply cost per case ($) 580 560 540 Pre Post 520 500 480 460 All Procedures * p < 0.05

Did Patient Outcomes Change?

BEFORE - General Surgery

AFTER General Surgery

AFTER - General Surgery

Conclusions By engaging surgeons and involving them in illustrations of variable cost analysis for specific procedures, we were able to decrease the overall cost for many commonly performed procedures. These savings do not have a negative impact on efficiency in the operating room or patient safety.

Conclusions Changing the culture and reducing the authority gradient are essential to engagement and overall team success.

What s Next? Celebrate Sustain Spread

Celebrate!

SUMMARY Changing the culture is hard work It is possible to engage surgeons to decrease costs in the OR This work can be spread in other areas

Questions?