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The Focused Factory Approach to Surgery
Every facility, big or small, can implement a standardized approach to how it operates.
David Cook
Publish Date: November 3, 2015   |  Tags:   Financial Management
factory approach

Many healthcare providers consider themselves artists: Each patient and treatment requires a unique, individualized approach that relies on years of training and a little bit of intuition. This isn't necessarily incorrect — but is it the best way to offer high-quality, efficient care?

That's exactly what the Mayo Clinic wanted to find out several years ago. In 2009, we realized that our cost of care delivery in multiple areas — especially in surgical services — was too high relative to the reimbursement we were receiving. Because of that, we formed a multidisciplinary team to find a way to lower the cost of care while improving quality and outcomes.

Less Van Gogh, more Henry Ford
That's when we started looking at a care model that takes a little less from Van Gogh and a little more from Henry Ford. While most healthcare organizations use a "solution shop" model to treat patients based on an individual provider's decisions, a "focused factory" approach relies on standard care pathways to treat a specific condition, specialty or procedure, ultimately improving efficiency and reducing unwarranted variation.

The focused factory idea originally came from the Harvard Business School, when economists discovered that U.S. companies offering a narrow selection of products or services were more competitive with their international counterparts. The same idea is applicable whether you're a hospital or a company making widgets — if you focus on producing a limited number of high-quality products or services, your costs decrease, your internal service lines don't compete for resources and your overall workflow improves.

In surgery, here's how it works: The facility creates a pathway that dictates each major step in a patient's care for a specific specialty or procedure. All patients that meet a certain set of criteria — which can include factors like BMI, surgical complexity and comorbidities — are treated using this pathway. These defined treatment protocols control the important aspects of the patient's perioperative experience, including case scheduling, pre-op instructions, medications, surgical tools, anesthesia, post-op ambulation, diet, discharge and more. If a patient continues to meet the criteria, it triggers a domino effect where each staffer or physician defaults to the next step of treatment as defined in the pathway.

If you're a smaller specialty ASC, you may already have a similar model in place. However, in our large, multispecialty facility, we chose to incorporate a focused factory model for specific surgeries and patients, while also making room for individualized care in more complex cases. Now, many of our surgical services use this approach, and we've seen big benefits like cost savings, decreased length of stay and better outcomes in our high-volume areas, including cardiac, joint replacement and colorectal surgeries.

OVERCOMING RESISTANCE
Selling the Focused Factory Concept

Though it sounds like a tedious process to create and implement the pathways needed for a standardized approach to surgery, the biggest challenge is getting staff and surgeons on board with the changes.

For our staff, the increased efficiency and lack of downtime in the OR meant that the overtime pay they were used to was dramatically reduced. While unhappy at first, after our employees saw that the focused factory meant their jobs were a little easier and less stressful, they quickly warmed up to the idea.

Surgeons, though, were a tougher sell. They weren't keen on losing the "freedom" they had to use resources and dictate care as they pleased. One way we tackled this resistance was to have leadership help drive change and continually provide the results and evidence supporting this approach. While mandating the changes was a crucial step, our increased efficiency — and ability to book more cases that resulted in better patient outcomes — was a big boost to surgeon adoption.

One of the biggest critiques you hear about this focused factory approach is that it only works for a cherry-picked group of patients. And that's true, especially in hospitals or larger multispecialty facilities. Show a surgeon a standard pathway, and he'll show you how that would fail on his last sick, complex case.

That's why we advocate for a hybrid approach — our smaller surgical "factories" fit within the clinic's larger solution shop model, which relies on our providers' expertise. Our simple cases can be moved quickly and efficiently through the system, while physicians can spend more time tailoring care for our more complex cases.

How you adopt a focused factory model can vary based on your needs and patient population. Whereas a small ASC may have nearly 100% of patients placed on a pathway, a hospital may only use it for 50% of its patients in a given specialty. If your physicians are hesitant about using standard care pathways, it's best to start conservatively. Set your patient criteria to include only the most-likely-to-succeed cases at first. As you start seeing results, revisit the criteria and liberalize it to fit more patients, as appropriate.

— David J. Cook, MD

Assembly line
When adopting this approach, we targeted one surgical specialty at a time to ensure that our mini-factories fit within our hospital's larger "solution shop" care model, which uses a traditional approach to treating patients. We followed 6 key steps, regardless of the specialty we were looking at.

1. Identify patients and specialties. One of the most important steps in creating a focused factory is choosing which specialties to focus on and determining which patients can be treated using a standard pathway. In a small, single-specialty ASC, this is probably already determined. For a larger, multispecialty facility, you may want to look at your high-volume procedures with routine components, like orthopedics or cataract cases.

Once you've determined the specialty, study your current patient population and its outcomes. Identify which patients have the best outcomes and any common factors among them. Use this, plus input from your medical director and other stakeholders, to define the criteria. For example, for a patient to get on the outpatient total joint pathway, he must have at-home support, no comorbidities and a relatively routine operation planned.

2. Create the care pathway. Once you've identified the patients and specialty, it's time to look at each care component. Start by dividing up the perioperative process — for example, pre-op, the OR and post-op recovery. Then, identify the specific steps or treatments in each area.

Look at your patient outcome distribution curve for each of these steps to determine what the gold standard is currently and how many patients are meeting that goal. For example, when we looked at bladder catheter removal after cardiac surgery, we saw that the very best we were doing was removing the catheter on the afternoon of the day after surgery, which occurred in about 60% of patients. We then researched best practices and quality measurements already in place, and met with our physicians to discuss whether this was a realistic expectation. Once everyone agreed, this goal for catheter removal became part of our defined cardiac surgery pathway.

Sarah Grota, APRN, CNP, Glen Au, RN, CCRN, and Erica Wittwer, MD, PhD CHECK-UPS Sarah Grota, APRN, CNP, Glen Au, RN, CCRN, and Erica Wittwer, MD, PhD, make rounds at the Mayo Clinic in Rochester, Minn. The group makes up a part of the clinic's "focused factory" in its cardiac surgery department.

3. Communicate the care protocols. After determining these pathways, we needed to communicate these protocols with bedside providers and physicians, as well as clearly identify the patients who were to be treated using the pathway. Whether you use EMRs or paper charts, having clear communication is essential.

In our health IT system, patients who meet the threshold receive a specific mark in their charts. The system also shows the provider all of the next steps in the pathway. So, a PACU nurse can go into the system, confirm that the patient is still meeting the criteria and see protocols like when the patient can eat or the medications he should receive in recovery, which can be ordered from our pharmacy with the push of a button.

4. Let staff move through the pathway without physician input, when appropriate. In a focused factory, staff is empowered to move through the care protocol without gaining a doctor's approval before each step, since the protocol uses physician-agreed-to standards. For example, a colorectal patient recovering from surgery wants something to drink. Previously, the nurse may have had to track down the doctor to approve of this first, which could be frustrating for everyone involved.

Now, the nurse can check the patient's chart and see that he can have a drink as long as he is meeting pathway standards. If he isn't meeting the criteria, the nurse knows she must revert back to the traditional individualized care model and find the physician before moving forward.

5. Group patients with similar care together. We found that locating both our pathway and individualized, complex cases together slowed down workflow and made implementing the pathways more difficult. Consider assigning your focused-factory cases in designated pre-op, OR and PACU areas, while grouping those who don't meet the standards in a separate location. This also helps in making sense of metrics.

6. Roll it out in phases. Determining the patient criteria and best practices took us about 3 months per specialty, per care environment. After that, we spent about 3 months in early implementation, starting with the OR protocols and expanding them throughout patients' entire length of stay. During this early phase, we studied our outcomes and worked with providers to tweak the pathway as needed. Full implementation in each specialty took about a year.

Challenging, but rewarding
It doesn't matter if you're a small ASC or a large general hospital, or if you're standardizing cataracts, gastroenterology, orthopedics or cardiac surgery — the process is the same. And the benefits of adopting this care model can be significant. Within 3 months in our facility, we saw a multimillion-dollar return on our investment and could do 15% to 25% more cases with the same number of personnel and operating rooms. We reduced overall overtime costs and patients' length of stay and, most importantly, improved our patients' 30-day outcomes.

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