Surgical Value Incubator News

Sometimes, the usual way of doing things is not the best way. Case in point: In 2018, when URMC CEO David Linehan, MD, was chair of the Department of Surgery, he and Colorectal Surgery Division Chief Larissa Temple, MD, began evaluating longtime departmental practices to seek ways to reduce costs while maintaining or improving the quality of patient care.

The earliest brainstorming sessions took place on a picnic bench at URMC among department members on the multidisciplinary quality team. In alignment with the URMC Quality Institute, the “Surgical Value Incubator” was born. Today, that innovative effort has blossomed into a full-fledged program with national accolades.

The Value Incubator is projected to save the Department of Surgery approximately $600,000 annually by implementing simple changes such as reducing the need for a standing CBC order for all patients and transitioning to a smaller, less expensive sterile surgical pack for procedures.

The work has also placed the department in the national spotlight and in a leadership role for improving value in surgical care.

The team has published articles in peer-reviewed surgical journals, presented at the ASCRS annual scientific meeting, and at the American College of Surgeons (ACS) National Quality and Safey Conference, and its Clinical Congress. Two new papers have been accepted for publication later this summer, and the ACS will highlight team’s work this fall, Temple said.

Earlier this year, the team also received the URMC Board of Excellence award.

“Using the learning healthcare framework of the Quality Institute, the Value Incubator is able to drive real clinical change and provide a platform for implementation science,” Temple said.

First Challenge: Shifting Culture

The Surgical Value Incubator brings together clinician champions (APPs, surgical trainees, and surgical faculty) and a multidisciplinary group of experts (administrators, project managers, and data analysts) to provide the best available practices in quality improvement, implementation science, finance, and informatics. The multidisciplinary composition of the Value Incubator fosters creative innovation.

The team focuses on projects to improve the five phases of surgical care: preoperative planning, perioperative, intraoperative, post operative, and discharge.

They bundled their work into three types of interventions: getting rid of things that are of no value, elevating evidence-based guidelines to decrease clinical variation, and decreasing length of stay and hospital costs.

One of the main challenges, Temple said, has been to shift culture and navigate inertia. Medicine is replete with tradition, and not everyone buys into de-implementation or changing longstanding practices, even as new evidence emerges.

For example, a surgical lab-reduction project asked physicians to think twice about ordering a daily complete blood count (CBC) for their patients. Historically, it has been common for all hospitalized surgical patients here to get daily labs, but Temple questioned the reasoning and clinical relevance.

“We didn’t want to say that you shouldn’t draw blood, but just think about it and consider whether it’s going to change clinical care,” she said. “And as a patient, being woken up to have daily blood work is a dissatisfier and can lead to unnecessary interventions.”

The goal was to reduce bloodwork by 20 percent. In a pilot study in colorectal surgery, the team exceeded the goal with a 50-percent reduction. They also looked at readmissions and length-of-stay relative to the bloodwork patients received. Overall, she estimates a cost savings so far of about $75,000 just on lab materials and running the tests—a number that could expand to $600,000 after a larger rollout planned for this year in the Department of Surgery. New, customized dashboards with statistics also serve as a reminder to “think twice” about ordering blood tests, Temple said.

Project Highlights

The team collaborated with analytics and IT experts and built an infrastructure to assess the value and return-on-investment for many projects. The team is evaluating cost-cutting measures as pilot studies before widespread implementation takes place. Examples:

• Decreasing waste in the operating room. Knowing that disposable OR supplies are not only expensive but a high source of medical waste that impacts the environment, the team asked questions such as: Are all drapes and instruments necessary? Why do some physicians use smaller sterile packs to perform minor surgical procedures in an outpatient setting, while surgeons in the hospital use larger, more expensive sterile packs for the same procedure? Plastic surgeons are piloting this project, using smaller sterile packs at the Sawgrass outpatient facility. Estimated savings: about $70,000 per year.

• Chest tube management. After reviewing data for patients who came through the Emergency Department with a collapsed lung, the trauma team conducted a pilot study and found that chest tubes could be removed sooner without harm—and that could lead to fewer patient days in the hospital. Cost savings are estimated to be about $200,000 per year, plus the benefits of fewer chest x-rays, freeing up nurses who must manage these patients, and more hospital beds in a system continually at capacity. This project was officially launched in February.

• Intrathecal morphine (Duramorph). A URMC Surgery resident published a retrospective review showing that patients who received intrathecal morphine had a lower need for systemic opioids and a reduced length of stay. Additionally, the ICU Pharmacy Team found no significant increase in respiratory failure when using intrathecal morphine compared to systemic opioids. Since ICU beds are a scarce resource, the team aims to increase access to intrathecal morphine (with continuous floor monitoring), which is expected to free up ICU beds and reduce the use of systemic opioids. This project is currently in the pilot phase at Wilmot Cancer Institute (WCC5), and cost savings are expected.

• Surgical dashboards and cost cards. Is the cost of operating on a colon, for example, different among surgeons? By tracking this and reporting the information back to the surgeons relative to their colleagues, costs have dropped. Analytics also can determine if the use of certain surgical instruments saves time and costs without compromising quality of care. To this end, user-friendly, customized dashboards are for use across Strong by hospital unit instead of by surgical team.

“We started out with projects we thought would be successful,” Temple said. “You can see how even with these slight changes we are saving money and either maintaining and/or improving patient outcomes. I am excited about it all, but what I’m most excited about is decreasing care variation, less waste, and having doctors being engaged in improving the value. I get surgeons emailing me every month with ideas for new projects.”

Temple credits Derek Wakeman, MD, who serves as co-director of the Value Incubator, for bringing a deep understanding of healthcare quality and operational efficiency toward innovation and improvement. Marija Cvetanovska, MS, serves as the senior project manager overseeing complex projects from conception to dissemination, ensuring seamless project initiation, implementation, and sustaining momentum. She drives initiatives that contribute to significant cost savings and improvements in patient care outcomes. In addition, the following core members of the Value Incubator team includes Elizabeth Levatino, manager of Department of Surgery quality and safety; research residents Peter Juviler, MD, and Yatee Dave, MD; and all Value Incubator members:

• Surgical Faculty: Lisa Cannon, Michael Nabozny, Michal Lada, Carolyn Jones, Tosh Prasad, Patrick Reavey, David Darcy, Michael Vella, Karina Newhall, Eva Galka, Nicole Wilson, Jacob Moalem, Michael Stoner, Mark Gestring
• Surgical Residents: Matthew Byrne, Ariana Goodman, Nicholas Searcy, Alexa Melucci, Bailey Hilty, Logan Todhunter
• APPs: Alicia Frelier, Kari Schenck
• Nursing: Stacey Esposito, Michele Snell, Ivelisse Vicente, Haley Markham, Teresa Angona, Katharine Leven, Amy Davey
• Administrators: Pam Urban, Al LaVigueur, Angela Iacchetta
• Quality Institute: Irena Boyce, John Bramley, Patrick Ward
• Operations Excellence: Carrie Steiner
• Pharmacy: Stephen Rappaport
• Medical Students: Mariah Erlick (Class of ’23), Noah Tsao (Class of ’26), Sarah Wegman (Class of ’26)

In photo

First row: Derek Wakeman, Marija Cvetanovska, Lisa Cannon, Yatee Dave, Pam Urban, Al LaVigueur, Noah Tsao, Sarah Wegman, Elizabeth Levatino
Second row: Mike Nabozny, John Bramley, Larissa Temple, Mike Lada, Paritosh Prasad, Patrick Reavey, David Darcy, Matthew Byrne, Peter Juvile. 

Published on 8/9/2024 12:00:00 AM  in URMC Today, Top Stories