Where Everybody Knows Your Name

It is the classic refrain in the surgeon’s lounge. Whenever you ask a fellow surgeon how their day is going they are either waiting to start a case or waiting on turnover. I used to remember going into a day of surgery with a sense of excitement. I was going to “heal with cold steel” ( but now mainly with the robot). And while I continue to really enjoy caring for my patients surgically, my mind is also occupied by what barriers are going to be placed in my way today that I am going to have to overcome to provide this care. Is it not having an anesthesiologist to start a case on time, a lack of adequate staffing, unfamiliar staff, equipment issues- the list can be pretty long.

My clinic can sometimes be just as frustrating. Because I practice at more than one site, the differences can be striking. In one location, I have a very consistent group of medical assistants, nurses, and clerical staff. In the other location, my nurse is my lifeline but it is rare that I know the medical assistant by name because of attrition and reassignment. I really value the idea of a team and this compounds the frustration around my care.

Like many organizations, our health system is trying to contain costs for a variety of reasons. I get it and support it. The biggest bang for your buck as an administrator is controlling staffing. Personnel is our biggest expense and not filling positions can be a way to make budget. The need for margin is crucial as academic health systems see research and other dollars drying up that needs to be reconciled on the back of the clinical mission. So decreasing staff through attrition is a easy way to decrease the cost per unit of service in administrative language.

This is often spun in a way that we are trying to reduce waste in the system. The other target tends to be supply costs. Especially in the OR, disposable costs can make the difference between case margin or not so surgeons are asked to standardize care by picking one vendor, decreasing the use of more expensive supplies, and being thoughtful about using certain items.

Again, this is a good thing- we want to decrease cost and improve our value proposition. These cost containment strategies and efforts have a natural ebb and flow. The thought is given competition, the ability to grow is not infinite given the limited supply of patients. So in order to improve margin to support our missions, we all need to chip in to cut costs. But from the ground level, I definitely don’t see a decline in patients. With the countervailing efforts to improve patient access, I see more and more patients who need my clinical and surgical care and much of the discussion in the surgeons’ lounge revolves around how busy we all are.

There are several frustrating factors about these cost containment measures. First, they are reactionary. They are a response to external pressures from board members or leadership to achieve short term goals. When the pressure is off, rather than continuing the efforts to decrease waste, things tend to back slide. If we are truly trying to improve value by containing costs, then it should be a continuous effort and not dependent on short term goals.

But more frustrating is the fact that cost containment seems to occur with broad brush strokes. Organizations tend to expect all segments to reduce costs equally rather than take a surgical approach ( no pun intended) to cutting costs. Of course, it is a much harder and politically fraught task to consider which areas can be cut more than others. We tend not to like to pick winners and losers but sometimes there are opportunities to eliminate entire programs that are not working and reinvest in areas that are either higher margin or that provide more meaning to the patients we serve. While academic health systems must provide comprehensive care, there is no shame in differentiating investing in winners and containing costs in low margin areas to help the organization succeed in its missions.

There are two big buckets of waste that often get ignored but hold tremendous opportunity to both improve value and tackle burnout amongst all those who care for patients. Recently, I was talking to one of my colleagues in the surgeons lounge. He had come from private practice and was used to being very productive. When he came here, he tried to maintain that level of productivity but soon found himself in the OR late at night to the point where his family was suffering. He was then discouraged by administration from adding on cases not because of his quality of life but because of overtime costs related to staffing later in the day. His productivity for a normal 12 hour OR day was cut by about 30%.

In my mind, that is waste. If there is a differential between what can normally be accomplished but the system creates inefficiencies causing a reduction in productivity, that is clearly waste. Add up this wasted physician time amongst all the surgeons in a health system and we are talking about millions of dollars that overshadows any other cost reduction strategy that is currently in place.

While the return on investment is huge, the roadblocks to improving efficiency within a finite time period and not overburdening the clinicians and staff is a tall order. It requires developing processes that support the work of the clinician. Administrators cringe because they immediately believe this requires the investment of more resources and while modest resource investment sometimes is necessary, the greatest opportunity is to create stable teams that understand the work and can collaborate in real time to continuously improve processes and improve efficiency.

Again, managing this is difficult. Flexible staffing models allow cross-coverage that can deal with the daily staffing issues that arise but this type of team approach does not have to be for everyone. At least in the OR, my guess is that 20% of the surgeons do 80% of the surgeries. That may be an exaggeration but it is relatively easy to determine who are the busiest 10-20 surgeons in an organization. If you could trial a true team based approach that spans the episode of care for patients even in a small fraction of these busy surgeons, then you could measure three variables to see if the reallocation of resources result in a return in investment. First, does this model increase the productivity per unit of time. This is obviously a step function since decreasing the time to accomplish a set number of cases does not decrease waste in a model where staff are paid a set salary and not by time. Second, does this model improve staff and physician satisfaction and quality of life? I will discuss this more below. Finally, does this model improve the value proposition for patients? Are outcomes better? Is patient satisfaction improved? Is cost stable to improved because the team does not use extra supplies because they are knowledgeable of the care being delivered?

The second area of waste that also intersects with the second metric above is staff turnover. Some data suggests that turnover rates in hospitals are approximately 20% per year with the average cost averaged out amongst all staffing categories of $60,000 per lost employee. That is a staggering number if you consider a larger health system and a real area of opportunity.

Now people leave for a variety of reasons- career advancement, to be closer to home, family reasons, dissatisfaction, benefits, hours and the list goes on and on. I have been frustrated over the years by HR practices that prevent me from helping to retain good employees. While a discussion of reducing turnover is beyond my expertise, I do believe that creating stable cohesive teams can both improve efficiency and satisfaction amongst everyone on the team helping health systems reduce cost and improve value.

If given the opportunity, I would take another approach to containing cost that values time and people. Stability of staff beats saving money through attrition. Waste in the OR often occurs when unfamiliar teams are working together. Sure SOPs can be useful, but they don’t beat a team that knows exactly what is and is not needed for a surgery. They can also continuously improve both outcomes and reduce waste that can’t be done by a static process by inconsistent teams. I would trial this approach with a few surgeons or busy clinicians and empower people locally to make decisions that support better patient care and efficiency rather than some centralized process developed by those who do not know the work. Money spent on more oversight, project managers, outside consultants, and expansion of administrative overhead could be reallocated to those caring for patients. Metrics like those above can provide accountability coupled with PDCA cycles to improve on care delivered rather than resourcing the squeakiest wheels in the organization.

These efforts would go a long way to improving both costs and satisfaction amongst every employee grouping who cares for patients. In the immortal lyrics of the 80s sitcom Cheers, ” Sometimes you want to go where everybody knows your name; And there always glad you came; You wanna be where you can see; Troubles are all the same; You wanna be where everybody knows your name.”

Thanks for reading.

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