Cutting costs and increasing the number of surgeries is possible

It took a trauma surgeon to find a way to cut costs, improve efficiencies and increase the number of orthopedic surgeries at a major Ontario hospital. And it wasn’t about finding cheaper sutures or tools to use, or what Dr. Abdel-Rahman Lawendy called “micro changes.” It was about changing the larger processes involved in how some of the operating rooms were run and organized. Largely, it was a matter of finding a way to shift certain surgeries to become outpatient surgeries.Dr. Lawendy spoke at the recent annual Ontario Orthopaedic Association conference. He is the medical director of the ambulatory surgical centre at London Health Sciences Centre.Read: Edmonton hospital cancels orthopedic surgeries due to lack of clinical associates to provide post-procedure careBack in 2016, many hospitals were talking about budgets but a lot of discussion was around micro changes. “Philosophically all the small changes could lead to improvement but what I think most surgical enterprises or teams found was that what they changed in the OR (operating room) didn’t actually translate to any savings for a long period,” he said.What was needed was an improvement in efficiency. He noted that in Ontario, ORs are required to be maximally staffed, regardless of the procedure. The full-time equivalent (FTE) requirements in the OR usually consists of 2.5 to 3.0 FTE nurses, plus one anesthetist, and usually two surgeons including an assist. “You can get upwards of seven FTE per hour in the OR. Without question it’s the highest resource demand on the hospital, highest cost in the hospital,” he said. Being a foot and ankle specialist, he figured that level of intensity wasn’t needed for every case.And yet, there was no way to save money in the current system other than reducing case load. “That’s what we’ve heard for a long time from hospitals, in the pre-COVID era which contradicts what we typically want to do which is more surgeries within the same funding envelope,” he said. Yet the Ontario Ministry of Health had published a goal of increasing the number of procedures.“They wanted more efficient technologies for longer hours of operation, (to) standardize best practices (and) improve patient flow,” he said.Dr. Lawendy wanted to validate a streamlined surgical process and approached the hospital’s CEO with the idea of introducing a new process. It would be done in the form of a comparative study to prove the case. And so, the idea was launched to do a study of comparing the cost and safety associated with inpatient versus outpatient ankle open reduction internal fixation (ORIF).The project wasn’t launched overnight. There was a huge amount of preparation and getting people on board with the idea, and bringing in change for an outpatient group. It meant the nursing leadership, nursing union, biomedical, medical device reprocessing, day surgery and the post-anesthesia care unit (PACU) and more all had to be consulted and agree to changes. Dr. Lawendy found he had to learn exactly what everyone’s role was, in detail, from pre- to post-surgery.“All of these processes had to be engaged in order to be able to change this process,” he said. “We want to increase timely access to care and we really wanted to standardize and optimize.” A governance structure was developed to execute the project.One item was to reduce the number of instruments on the surgeon’s tray and getting all the surgeons participating in the study to agree. This simple step reduced some of the prep time. Anesthetic would be regional. “And we decided we were going to give the nursing resources based on the surgical intensity,” he said. Surgeons assessed patients and placed them into one of three newly developed tiers, depending on the complexity of the surgery, the patient’s underlying healt, and whether or not they qualified for outpatient surgery. “The surgeons took on a lot more of the work in terms of screening the patient, and changing their practice, counseling the patients, providing a different narrative, making their clinics more available,” he said. Under the new approach, surgeons set up their own instrument tray, instead of nurses doing it. While the approach required a lot more up-front work on the part of the surgeons, they could also double their output on the exact same day, Dr. Lawendy said. But the higher throughput approach isn’t for everybody. Some surgeons preferred to stick with the standard approaches used in ORs. “We redesigned the entire process. We took control of this and we did our study,” he said. The results were impressive. For starters, the pilot study showed the number of instruments was reduced from just under 85 to 20.Impressively, “one of the biggest changes is we found we cut our turnover time, which tends to frustrate surgeons quite significantly, from about 23 minutes to just over nine minutes. When we calculated all the costs, we dropped the cost by 56% in the pilot. Which became a very dramatic case for change,” Dr. Lawendy said.Plus, instead of running three or four electives in an OR, seven or eight could be run. And part of the cost efficiencies came from needing fewer nursing resources. After the pilot, more outpatient surgeries were conducted and the approach was tweaked and improved.The change was so successful, it impressed the hospital leadership and led to the creation of the Nazem Kadri Surgical Centre. Dedicated to surgical outpatients, it was opened in early 2020 across the street from Victoria Hospital. Dr. Lawendy admitted that some of the ideas on how to do things came from visits to private clinics in the U.S. and interviews with surgeons there. “The Americans were actually very generous although these are private groups. Under 8% of surgical centres in the U.S. are owned by hospitals,” he said. But his effort is a 100% public venture and is owned by the hospital.Patients who are determined to be low-risk by their surgeon can now have foot procedures, ankle, hip and knee arthroscopies, and ACL repairs done at the centre. And by being sent there as outpatients, they aren’t taking up beds needed by patients with more complex issues in the main hospital. “Our hospital ended up running more surgeries than any of our sister hospitals comparable in size because we were using less nursing resources and we were completely outpatient,” Dr. Lawendy said.

Cutting costs and increasing the number of surgeries is possible

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