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Ever since Geoffrey Moore published his 1991 work on the adoption cycle of new technology, "Crossing the Chasm" has become synonymous with making a significant leap forward in a given endeavor. Today we are talking about just that - making the leap from Tier II of the preference card optimization pyramid - which as we learned in our last blog post, can yield surgical supply savings of 6-12%, to the hallowed Tier III, the "Procedure Card".
How to Approach the Procedure Card...
Doesn't it make intuitive sense that for certain high-volume procedures that have generally excellent outcomes across a variety of providers, that surgeons should all agree to:
Use the same basic "stuff"
In the same basic quantities
I mean, the very fact that similar, excellent results are achieved despite a variety of techniques and a variety of supplies makes the case that no single technique or cluster of supplies affects the outcome in a significant manner... so standardization should not affect clinical outcomes, but could make a dramatic difference in the cost of care.
Cross-Industry Inspiration
When we look to other areas of our lives where standardization is king, a paramount example is the fast-food industry and its secret weapon the franchising model. Fast-food titans such as McDonald's and Starbucks understand the critical importance of standardizing every aspect of their locations ranging from their menus to how they structure their staffing. Brands of that size aren't created by accident, they found a highly replicable model for success and ran with it. I mean, yes, we aren't making hamburgers or Frappuccino's so-to-speak in healthcare, but there is soooooo much room for standardization in soooooo many areas!
Speaking of hamburgers, this reminds me of a dinner I once had with a CEO who successfully scaled a well-known and highly profitable retail urgent care clinic model. The CEO asked me what I thought his background might be. "Well, that's easy," I said, "Clearly you came from some sort of healthcare background - CEO of a healthcare system of perhaps from the payer/analytics side."
He chuckled and said, "Nope, I was the CEO of a national fast-food chain. I'm really, really good at making the same product the same way every time." His model found success not because of the uniqueness of its offerings, but in the fact that it delivered good quality care for common ailments in a consistent, low-cost manner at scale. Isn't that the very definition of "value-based care"?
Standardization in Practice
Although the model above dealt with runny noses and earaches, the majority of procedural care - quite honestly - is no different. The runny noses and earaches of procedural care can be found aplenty, and there is no reason why many aspects in which this care is delivered cannot and should not be standardized. We are focused on surgical supplies.
But you say, surgeons like what they like and as a tribe they are fiercely competitive and independent, so... this sounds really hard... has anyone been able to do this?
Yep! Let's take a look at what's been done, and what you can do.
Skarda et al. published their experience creating a uniform, mandatory procedural preference card for laparoscopic appendectomy at a high-volume pediatric hospital.
With a combination of surgical supply standardization and swapping of high-cost items for lower-cost equivalents, Skarda and his team achieved an impressive 66% supply cost reduction for non-ruptured cases and a 59% reduction for ruptured cases. The latter might be even more impressive than the former given the higher degree of intrinsic variability in complex, ruptured cases.
In another study, Gould et al. demonstrated that even with optional use, a standardized procedure card yields significant savings. Targeting opportunity around another high-volume, lower-risk surgical procedure: laparoscopic cholecystectomy, Gould and his colleagues leveraged multiple strategies in addition to the creation of a universal procedure card, including swapping of high-cost items for lower cost equivalents and optimization of Open and Hold item categories. The result - again with optional procedure card use within the surgeon cohort - was dramatic: 32% per case reduction in supply costs!
So, it is entirely possible to achieve consensus around the technical execution and supply utilization for high-volume procedures. Additional considerations beyond laparoscopic appendectomy and cholecystectomy might include cataract surgery, cesarian section, and primary (first-time) joint replacements. Just think of the aggregate impact to U.S. healthcare costs if a 30-60% per case reduction in expense were achieved for these five cases alone...
Now...what can you do?
These steps represent broad strokes, but at the same time are specific enough to get started:
Identify a high-volume procedure in your ambulatory surgery center/hospital/healthcare system as a target for standardization - your "runny noses and earaches" of procedural care - perhaps one of the above 5.
Identify surgeon champion - surgeon engagement is essential; initially, this will entail an individual or small group, but ultimately it will need to be at scale, and like Margaret Mead once wrote, "Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has."
Use technology to analyze current state of heterogeneity and engage surgeons to create the future state of standardization. More specifically, use software. Absolutely nothing scales like software. And - if you're a healthcare system, then you're not in the business of software engineering. Don't reinvent the wheel. Get help.
Expect contagion. If you do this correctly, it will work, and you will see the success spread. You will save money and your OR teams will become more efficient.
Ready to take the first step?
Not every surgical procedure can or should be standardized. However, those that can and should comprise the majority of procedural volume in the U.S. today. So get started! Cross the Chasm!
Dr. McCarty is a practicing orthopedic surgeon in Minneapolis, MN, former team physician for the Minnesota Twins, Fuqua alum, healthcare leader, and entrepreneur.