How leading hospitals are advancing surgical excellence through robotic-assisted surgery — Top 10 questions from 2020 answered

The COVID-19 pandemic disrupted healthcare in unprecedented ways. Surgical services were among the facets hardest hit by the pandemic, with non-urgent procedures put on hold amid viral surges. Hospitals and health system leaders committed to fostering excellence in surgical services had to work to solve the immediate needs of their patients and organizations while maintaining focus on the long-term prospects for advancing surgical service lines.

In this recap, we've compiled 10 responses to some of the most pressing questions related to robotic-assisted surgical care asked in 2020.

Note: Responses have been edited for length and clarity.

Question: How do you assess the viability of a robotics program? What mechanisms have hospitals used to look at their revenue, contribution margins and profitability?

Dr. Harry Sax, Executive Vice Chair of Surgery at Cedars-Sinai Medical Center in Los Angeles: You have to have a margin to have a mission. We believe that the delivery of the highest quality healthcare is most essential, and we believe that growth is a part of that effort. We look at our contribution margins. We tend to compare them to open surgery and the conversion from open surgery to minimally invasive surgery. In addition, we have had challenges with capacity. Our hospital sometimes is full or overfull, and therefore the importance of shortening length of stay, reducing complications and reducing readmissions becomes central. The use of minimally invasive technology including the robotics platform has helped us achieve that.

Q: How do you quantify the economic impact of better-quality outcomes? How often is a robotics program assessed and what tools do you use?

Caswell Samms, SVP & CFO of Patterson, N.J.-based St. Joseph's: [At WellStar Health], we assess our robotics program on a routine basis. When you've got a hospital that's consistently over 90 percent capacity from an occupancy perspective, length of stay becomes a huge opportunity. Intensive care unit admissions are something that we try to drive down. That additional capacity leads to more volume. We want to reduce the need for blood transfusions and limit surgical site infections to prevent readmissions and improve outcomes.

Q: What should leaders be aware of as they prepare to launch a robotics surgery program?

Dr. Fran Witt, CEO of Springfield, Ga.-based Effingham Health System: I did not expect for the program to expand as fast as it did. That's a good problem to have. Since August of 2018 we have done 477 robotic cases. We initially set our proforma at maybe 130 cases a year. Here we are two years later. The other thing to think about is the recruitment of specialty physicians to grow the program — urology in a rural area or critical access environment is something that's difficult to recruit.

You've got to be willing to take risks. If you're not a risk taker, in my opinion, you won't stay in the game. You've got to be willing to take a risk and put yourself out there.

Q: There is a wealth of information out there. What are some of the biggest challenges or roadblocks you've faced and how do you get what you need? What does your access to data look like?

Matt Hasbrouck, COO of Savannah, Ga.-based Memorial Health University Medical Center at HCA Healthcare: It's been an evolution. We started our robotics program three years ago. In the beginning, it was really about working with Intuitive to gather as much data as we could from the robotic system itself.

Now, we have a robotics steering committee that meets every month. The committee is led by one of our senior physicians, a bariatric surgeon by training, and he really pushes us. He pushes us to look further into what more we can do, so we can get down to that granular level that allows us to make more informed decisions and drive better outcomes.

We look at length of stay, readmission rates and we look at the use of enhanced surgical recovery programs. Overall, we want to continue to mature our dashboard, continue to feed our enterprise data warehouse, and compare performance across service lines and surgeons. I think these comparisons are going to drive better outcomes.

Q: By using data strategically, what are some of the initiatives that have been put into place as a result? How have you used benchmarking data to identify opportunities for standardization?

John Philips, President of Methodist Dallas Medical Center: Data has really helped our health system's leadership work with all our organization's hospital presidents to strategically grow our robotics service line. For example, we had made fairly good strides with general surgery, and of course gynecology and urology. However, we did believe there was a strategic opportunity to grow the program in general oncology. Data has helped us make the decision to expand into that area. We can measure how our outcomes in gen oncology compare to others across the nation as well. Everyone probably knows that there's limited resources and a limited number of physicians in many cases, so the data has been very helpful in letting us plan strategically and launch new robotics services at our health system.

Q: Where would you recommend starting if you haven't leveraged robotics program data much in the past?

JP: What I've learned over time is don't stray from what all of us in healthcare already know — it's all about the patient. Focus on quality outcomes in robotics just like you do elsewhere. That has to be your true north and define your culture. Also, find a surgeon champion. A lot of times it starts with one person, that one surgeon who is passionate about improved quality of care. Then lastly, partner with Intuitive. I think the way that they partner with hospitals is excellent. Truly, partner with Intuitive and they'll help your program grow.

Q: What financial misconceptions have you proved to be inaccurate through building up your robotics program?

Dr. Jackie Martin, Vice President of Surgical Services at Barnes-Jewish Hospital in St. Louis: Technology is always expensive. Surgeons always want the latest and greatest things. Our job as administrators and partners is to figure out where the real value is.

If you're just starting out with a robotics program and you're not looking at your data and analytics, it's hard to identify that real value. Once you have the data, you can look at your KPIs, things like SSIs, length of stay and blood transfusions.

You can't simply look at your initial acquisition cost as the determining factor as to whether or not you should have robotics. And if you're going to be a providing leading edge care in your area, you've got to have a complete service line of offerings.

Q: 24/7 or expanded hours access seems to be critical focus and strategy for many. How are you working towards making this a reality? Do your surgeons have unrestricted access to the technology?

JM: The first thing to do is to build a stable program during prime time, which is 7:30 to 5:00 p.m., Monday through Friday. We've been able to do that. The next thing to do is settle on a philosophy. Our philosophy is that each patient should get the best approach regardless of time of day or day of the week. And if you think about it, we offer open surgery and laparoscopic surgery 24/7, and yet we have this other technology that initially was restricted based upon programmatic barriers. So, we got a small group together and developed a plan and executed that plan. We started on weekends. And we're expanding to weekday hours. Now everybody's expected to be able to support robotic cases 24/7.

Q: When it comes to reinvestment strategies, what's your starting point for an incremental system? What parameters do you meet before you start considering next steps?

Jeff Buehrle, CFO of Arizona rural hospitals for Phoenix-based Banner Health: I've been working on incremental growth for many, many years. When you look at one facility that might do 275 cases versus another facility that's doing 550, you really have to dive in and find out what the difference is. And when you really look at the utilization of the OR during peak times and really see what's happening, well, the facility that has 275 cases, their case hours might be between five and seven hours because it's an oncology program, so you're not going to be able to fit four or five additional cases into a day. You have to really look at your own data and understand it.

Make sure you understand your volumes by type and identify where your peak times and non-peak times are. We also need to understand the needs of our surgeons and where capacity exists.

Q: How do you maintain growth and profitability within your inpatient robotic program while also creating an outpatient robotics strategy?

Terri Freguletti, Vice President of Perioperative Services at Hackensack (N.J.) Medical Center: We have good demand for our inpatient program, so moving some cases to outpatient actually helps us to grow our inpatient strategy because we need the flexibility to have more robotic time for our inpatients. We were fortunate to have that as the motivator.

When we moved the cases to outpatient, we expected to see not-so-great profit and loss statements because there was this illusion that the robotic cases moving to outpatient were our loss leaders. We were very happy after the first six months when we started running P and Ls and we found out that when we laid out length of stay, cost, complication rates, readmissions and blood loss, we were actually quite surprised to find out that robotics was the least expensive way for us to be doing some of these cases. I encourage people to look at the numbers between doing a case open, robotic and laparoscopic and look at length of stay as part of that mix.

When we moved the robotic surgery to the ASC, we realized we put surgical sets together with less instrumentation. We were able to reduce some of the carrying costs of the instrumentation, and we were able to turn the cases over faster and get them in and out quicker. We were able to get more cases in at less cost per case and then backfill that with higher-acuity cases in our inpatient operating rooms. That's how the profit and loss went for us.

We're looking at what surgeries we can move to minimally invasive platforms – particularly robotics. Our surgical footprint can't continue to take up 40 percent of our beds with the medical bed need created by COVID-19. We have to rethink how we do surgery and how we can get patients in and out of the facility faster to free up beds.

We've also looked at some of our ERAS protocols and tried to see where we could shave off some days in length of stay in order to keep the flow of patients in and out of the hospital quicker to lessen the risk of exposure but to also to make sure that there's space to care for COVID patients.

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