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Playing the preference card by Rick Dana Barlow


Sometimes Supply Chain can stir the pot of cus-


tom procedure tray contents at their own peril … particularly if they don’t approach their efforts with a sense of prudence, tact, and, of course, data with evidence-based conclusions. So how does Supply Chain convince or persuade


surgeons to support custom procedure tray optimi- zation, which includes standardization, as a benefit to their practice, workflow, procedural quality and patient outcomes? Perhaps it starts with a mindset. “Tray optimization isn’t intended to alter the sur-


geon’s workflow or practice,” asserted Mark Scagliarini, President, Blue.Point Supply Chain Solutions. “It’s simply finding the most cost-effective way to supply the sur- geon with the tools he needs.” But you have to involve the surgeons from the begin- ning, Scagliarini emphasized, and you can’t make it about lowering price. “Price and cost are often used synonymously, but they aren’t the same,” he contin- ued. “The goal is to increase value by lowering costs. Custom pack review isn’t about finding the lowest cost products to put in the pack. It’s about finding the most cost-effective delivery method with the least amount of waste. Further, don’t make rules without explaining the


why, he advised, and be able to justify them. “If you’re setting a $10 item cap and $300 pack cap, explain why,” he said. “Not understanding the reason behind decisions can create unneeded frustration and decrease buy-in.” Benchmarking data on the total cost of packs per procedure and trends over time can help, too. “Surgeons are typically data driven, so to get


them on board, it is imperative that you have quality and quantitative data to discuss and present to the surgeon,” noted Ned Turner, Senior Vice President of Perioperative Services, Medline Industries Inc. “Gen- eral statements such as, ‘we need to standardize,’ ‘we need to reduce supply costs’ or ‘we need to eliminate waste’ are usually ineffective and may even be counter-productive in gaining support. Instead, track a surgeon’s supply consumption on certain procedures and be able to identify specific items that were opened on the back table, but never used. Ask if they would be willing to keep those in the center core rather than open them for each use. This type of conversation not only lends itself to a pathway of custom procedure tray standardization, but also ap- plies to overall surgical supply consumption.” Douse the inflammatory issue right away, suggests Susan Williams, Director, Cardinal Health Inc.’s Cat- egory Management – Presource unit. “Dispel the myth that all variation is clinical prefer- ence in nature,” Williams said. “Supply variation comes from sources other than physician or clinician prefer- ence. Sources of variation within a procedure also include equipment, contractual and clinical practice. For example, the practice of using a cholangiogram during a lap chole can vary by facility or surgeon. An example of equipment-based standardization is the cautery pencil. Can the teams all use rocker or push- button type?” Sometimes, variation simply may be historical. “Nobody knows why four different needle counters


are used in the lap chole packs,” Williams observed. “The beauty of the data analytics tool is that the varia- tion can easily be identified almost immediately upon review of the tool. In reality, patient-specific items can be a small subset of the overall components for many procedures. Obviously, for procedures such as total joints, a relatively larger percent of overall costs are patient-specific. However, items within the [tray] typically don’t reflect the specificity of the implant. “For other procedures such as lap chole or C-


section, many supplies can be standardized across multiple patient populations,” she continued. “While many of the items in custom procedure trays are not patient-specific, standardization for these items can still be reflective of variation in clinical practice. In our experience, if the culture of the system is such that physicians are engaged in the overall business results, they are more than happy to engage in the process. It’s important to note that most of the [tray] standardization can be delegated to service team leads and/or surgical technicians that are familiar with the surgeon’s techniques. “Once the teams have designed the common


standardized pack, the results can be a catalyst for the next step to begin the conversation about the clinical variation that was identified during the pro- cess. Admittedly, these conversations may be more complex. In the meantime, reduction in variation, component saving, and supply chain efficiencies can be implemented immediately. Most importantly, using a common pack also allows surgeons to work among multiple facilities within their system without distrac- tions related to varying supplies. Some believe that consistency in clinical practice can result in increased quality,” she added.


Seamless success “Any pack optimization activity should be seamless and something that should go unnoticed by the surgeon if done correctly,” insisted Ragan Manning, Director, Resource Utilization, UAB Hospital. “Sur- geons are consulted directly if packs contain a PPI that is affected, but other than that, ongoing pack opti- mization should not be disruptive to the surgeon.” Data play a key role, particularly when it applies to


process cost versus product price, according to Man- ning. “Surgeons are more likely to respond to a request based on data than to a statement like, ‘It would be more cost effective if you could use the same stapler as the other surgeons.’ The OR is a busy, high-stress and often hectic environment,” she said. “The less time and effort that is spent managing and chasing supplies, the more time can be spent focusing on patient care. If you can collect data that establishes cost per procedure by surgeon and/or case pick time per procedure by surgeon you may be able to make a strong case for whatever the proposed change is — whether it be adding an item/pack or deleting an item/pack. “Explain the cost of ordering, stocking, maintain- ing and picking routine supplies. Discuss the impact a more comprehensive pack program has on room setup and turnover time. Discuss the impact of staff entering and exiting the surgical suite in search of supplies,” she added.


“I would show the doctor a comparison of the cost of buying each individual item for the case, compared to the savings of bundling the items into a custom tray,” acknowledged Jessie Gillespie, MHA, Surgical Instrument Coordinator, North Mississippi Health Services. “I would also show the doctor a chart of the time saved between each case by using the optimized trays. I would also emphasis the value of having everything sterile needed for the case in one tray compared to going from place to place to gather the needed items. Less time spent between the start of each case means more patients should have less wait time.” For example, North Mississippi’s neuro surgeons


use surgeon-specific trays that include a variety of products, such as bipolar, kerrisons and standard instruments, according to Kimberly Davis, Manager, Central Sterile Processing. “The physician and the OR team liked having the


convenience of opening one tray to do a case,” Davis recalled. “We had constant complaints about the bipolars and kerrisons being dull and damaged. We went to the neuro section meeting to propose remov- ing the bipolars and kerrisons from the physician trays for bipolar-specific and kerrison-specific trays. We ex- plained how we would provide containers that would allow better instrument stability, so the instruments would not damage each other by stacking metal on metal, especially the fine tips of both those types of instruments. We explained how metal-on-metal, when exposed to 270-degree heat, will damage fine-tipped instruments. “The surgeon’s agreed to trial the sets,” Davis


continued. “We were able to show that by removing the fragile instruments from the heavy instrument sets, after one month the bipolars and kerrisons were being sustained better. Physician satisfaction improved. Properly working instruments provided the physician a better procedure experience, less physical requirements by the surgeon to make the instrument work and less frustration due to improperly working instruments.” Kim Blakey, Executive Director, Sterile Processing


Department, LeeSar Regional Service Center, recom- mended picking your battles prudently. “To start, do not focus on the surgeon, convince his or her leadership,” Blakey urged. “It is crucial to any surgical services quality and standardization project to engage surgeon leadership first. Surgeons are dif- ferent from the rest of us. This is not a bad thing. It takes a unique type of individual that will go to four years of college, four years of medical school, endure five years of residency and an additional one to three years of fellowship training before they can even begin to start paying back the over $150,000 to $500,0001 in student debt he or she has amassed. They do not want to listen to the Chief Financial Officer, the OR Nurse Manager, or even the CEO of their practice. They want to talk to peers that understand where they are coming from. Engage the top leader/surgeons in the standardization/quality improvement movement for a smoother ride.”


1. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card, accessed at: https://www.aamc.org/download/152968/ data/debtfactcard.pdf


www.hpnonline.com • HEALTHCARE PURCHASING NEWS • October 2015 55


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