Keep Supply Chain Shortages at Bay

The most effective tactics, technologies and efficiencies to implement in a post-pandemic world.

During the pandemic, surgical centers were forced into just-in-time ordering because of shortages of everything from PPE to medications to implants. Now that that’s in the rearview mirror, we could get back to stockpiling the supplies we need. But which ones to buy in bulk and store?

New mindset

Today’s climate calls for a smarter hybrid approach. ASCs should apply just-in-time purchasing techniques for some items and buy essential, often-used items in larger quantities when appropriate.

Remember, supply shortages are nothing new. We’re always going to have supply chain problems, whether it’s the ongoing war in Ukraine that has interrupted everything from natural gas to glass production, the next wave of COVID, the next strike, or the next hurricane that could hit where some of our go-to supplies are manufactured.

It’s always a good time to improve how you procure your supplies. Here are some concepts to keep in mind as you diversify your practices.

Build in resiliency and redundancy

The size of your surgery center, of course, will determine the magnitude of your challenges. Those affiliated with large health systems have the ability to shift supplies from one site to another and have large storage capacities. Freestanding, independent surgery centers with four or fewer operating rooms are in a more disadvantageous situation.

I absolutely recommend having more than one main supplier and working with more than one group purchasing organization (GPO). Most small surgery centers work with a single source. They might have a secondary supplier they engage in a pinch, but they don’t work with them on a regular basis. To better position themselves to get the medications, syringes, needles and other equipment they need, facilities should have relationships with multiple GPOs. Most facilities don’t even know who their rep is. They just order stuff online. Larger shops might have a dedicated materials manager, but in smaller centers a scrub tech could double as the person who does its ordering. They’re doing this on the side, and since it’s a secondary role, they’re going to follow the path of least resistance. They’re not really going to price-shop between two or three companies to try to save money. And they’re certainly not going to take the time to build a relationship with the rep.

Pick up the phone!

CHECKING IT TWICE The author insists on having everything needed for a case in the OR ahead of time.

I still can plainly recall the propofol shortage that took place years ago. It almost became an orphan drug and was very hard to get. Many facilities were forced to use alternate anesthetics. If that were to happen again, are you positioned to get propofol if it’s a mainstay of your practice?

You must have good relationships with your actual account managers, not just the reps who visit your facility, so they can give you a heads up like, “Hey doctor, we might have a supply of propofol coming this weekend. Do you want me to hold a couple cartons for you?” Having that person on the phone whom you can call, which people don’t want to do nowadays, really still makes a difference.

Getting on the phone to talk with your reps once a quarter, or once every six months at least, increases the chances you’ll receive those helpful calls from them. It’s much better than crossing your fingers and hoping that an anonymous online ordering system will come through for you when supplies are short.

I still get emails from a rep I haven’t ordered with since 2016 saying he’s still my rep and is there for me, even though he realizes I haven’t made an order in years. We should do the same thing the other way. Reaching out every now and then is important to build and maintain those relationships that are important for everyday business, and particularly vital in a supply crisis. Picking up the phone can really make a difference when it comes to getting a piece of equipment you really need.

As you alter how you purchase, make sure critical items in your packs aren’t on backorder, because that will put your entire pack on backorder. That’s why it’s important to check federal websites that give updates on medication shortages if you have medications in your packs. Working with companies that will be responsive is important, even if your packs are built one to three months in advance. They can make some quick changes if they want to keep your business.

Also, order medications and supplies first thing in the morning. That’s when most of those items arrive at warehouses. To get the jump on your counterparts, don’t wait to do your ordering at the end of the day.

Take advantage of secondary markets

I also recommend that facilities look to secondary markets for some of the items they don’t use regularly. Many companies that will buy items such as sutures or anchors used in orthopedic procedures that will expire in several months from facilities that are no longer going to use them. They buy these short-dated items for pennies on the dollar, which means you can buy them for dimes on the dollar.

So instead of buying a box of 10 anchors at $400 each when you only need two of them and eight will expire, find the secondary companies who will sell you two of them.

If you have a surgeon who comes to your center once every six months and wants a particular suture for a plastics case, you don’t need to buy 10 of those when they cost $300 apiece.

You’ll have them sitting on the shelf wasting space and tying up money. When they expire, you’ve lost that money.

Optimize space

Part of ASCs maximizing their finite amount of space is using reliable vendors that you can count on to deliver items the evening before or the day of surgeries. I recommend having these vendors, particularly for orthopedic procedures such as shoulder surgeries that use a lot of anchors, bring these items to your facility on consignment. That way you don’t need to pay for them ahead of time. Make it the rep’s business to bring the product for the case that day. That goes for all your durable medical equipment. Don’t store that stuff. Big and bulky ice machines, slings, sleeves, crutches, pads and other items take up way too much space. It’s much more difficult for facilities to bill for these items than it is for the manufacturers, which can have a third-party do it. Make the surgeon’s office responsible for contacting the reps to know what’s needed for the next day.

Don’t fear running out of things, because now it’s the rep’s responsibility to keep in touch with the surgeon’s office to make sure you have everything you need. Use the reps as your supply sherpas. They’re very motivated to help you run your surgery center.

If you are getting after-hours deliveries of implants and other equipment for the next day’s cases, make sure someone is there to accept them. Spending a small amount of overtime to make sure someone is there costs less than the device not being there for the next morning’s surgery. Consider offering flexible scheduling for someone who wants to start late and stay late to facilitate this without overtime.

Good supply chain management goes well beyond making sure everything is ordered on time. Waiting for three hours the next day for the delivery truck to make its way to my side of town because no one was there to get the items the night before is unacceptable. Period.

An additional improvement is to move toward mobile carts to replace your fixed shelving. This switch makes it easier to take inventory and to stock each OR every day.

FINANCIAL MANAGEMENT

Prevent Stalled Cases at All Costs

PENNY-WISE Cleaning rooms helps prevent infection but rushing through them doesn’t save as much money as you might think.

Cases that start on time and end without interruption saves more money than rapid room turnovers.

Time is money, and delays in cases consume more valuable time than can be saved by even the most efficient room turnover protocol. The focus is always “turnover, turnover, turnover,” but preventing delays is far more important than shaving minutes off turnovers between cases in operating rooms. Think of it this way: If you have seven cases a day and save four minutes between each case (not counting the first one of the day), that 24 minutes won’t allow you to do another case. Yes, it’s nice to have efficient turnovers, but if you’re moving so fast that you’re sacrificing safety, you are really focusing on the wrong thing.

It’s actually the wrong focus no matter what. What hurts the most in an operating room are cases that start late or get stalled or interrupted. If you have a delay and you’re employing three or four people in the OR and three or four people in the PACU and you have a one-hour delay and you need to pay seven people to work overtime to do that same case, you’re wasting money left and right. I cringe every time my circulator leaves the room, because it means they had to get something that should have been there. Meanwhile, the entire OR team is idle and getting paid not to work.

At ASCs, you get one CPT code and one check to pay for everything, so anything that causes a delay in the OR is an abject, absolute disaster from a cost standpoint. That’s why it’s so important to incorporate not only the price and quality of the supplies you buy into your purchasing decisions, but the reliability of the deliverability of those in your supply chain as well.

Sometimes we don’t think of that. We think that if we order it, we’ll simply get it on time. In some cases, this might mean having to pay a little more for something to ensure its arrival. However, it’s money well spent, because having to move a case is OR time you have lost and will never get back. You’re paying staff; the electricity is on; and you’re not doing anything to pay for it during that time.

That’s why it’s so important to have the supplies you need on hand. Delays are the death knell to the financial well-being of a surgery center.

—Thomas W. Durick, MD

Mind your contracts

GOING MOBILE Wheeled storage carts help OR teams have a better handle on their current inventory.

Don’t simply click the order button when you’re running out of something. While your contract might have multiple tier levels that get you a lower price the more you use an item each month, the opposite is true if your deal has expired. Unknowingly ordering boxes of something that cost $50 when the contract was in effect could cost $4,000 if it expired, which could cost you $40,000 a month and not be detected for months if you don’t stay on top of it.

What the future holds

As far as analytics go, ordering is still done by decrementation of PAR levels. Some software packages will give you a barcode for each of the items you buy that will track your levels and let you know when it’s time to place an order.

One day ASCs might get to the level of warehouses of the big suppliers, which scan their deliveries and know exactly how much of everything they have. We’re not quite that sophisticated in the OR yet.

Clearly, we learned just how fragile the supply chain is during the pandemic. It will happen again, whether it’s a natural disaster or COVID 26. We need to be ready. OSM