An expert panel from Barnes Jewish Hospital and Washington University discuss strategies to in providing patients with the optimal surgical approach, with a focus on minimally invasive and robotic surgery techniques.
Webinar sponsored by Intuitive Surgical and originally broadcast on Becker's Healthcare - Wednesday, June 9th, 2021
Welcome everyone to today's webinar strategies that enable patients access to M. I. S. Prospective from Washington university Barnes, jewish hospital. I am brian Zimmerman with Becker's hospital view on behalf of Becker's healthcare. Thank you for joining us today. So before we begin I'm going to walk through a few quick housekeeping instructions. We'll begin. Today's webinar with the presentation will have time at the end of the hour for a question and answer session. You can submit any questions you have throughout the webinar by typing them into the Q. And a box you see on your screen, you'll find a few different engagement tools on your dashboard. Please check out our resources section and also make sure you fill out our sessions survey. Today's session is being recorded. It will be available after the event. You can use the same link used to log into today's webinar to access recording. Lastly, if at any time you have trouble with the audio or video, please try refreshing your browser. You can also submit any technical questions into the Q and A box. We're here to help is my pleasure to now introduce our speakers for today. First. Dr Jackie Martin is vice president of peri operative services at Barnes, jewish Hospital in ST louis. He's joined today by Dr Michael Awad, director of robotics and Associate professor of surgery Andrew Pierce, director of supply chain and jim thomas manager. Peri operative Performance improvement and I. S. Today they will share several strategic initiatives to align stakeholders, utilize actionable data for evidence based change management and cost reductions and increased patients access to minimally invasive surgery and help achieve the quadrupling. Gentlemen, thank you for being here today. The floor is yours. I'm going to give you my perspective as a health care executive on the who, what, when, where and why around robotic surgery. Uh huh. So one robotic surgery. Our philosophy is that we want to be able to provide the optimal approach for each patient at all the time. And it sometimes on the optimal approach may be an open surgical approach. It may be a laparoscopic approach, but sometimes it will be a robotic surgical approach. The era of modern open surgery has been around for about 150 years, laproscopic surgery for about 35 years And robotic surgery for around 20 years. The opportunity exists, though to expand robotic surgery to patients and clinicians. Now. Most places will provide an open surgical approach all hours of the day and night. This is also true of laproscopic surgery, but if you think about robotic surgery, um most programs will offer that modality during prime time, which is 7:35 p.m. Monday through Friday. So there is an opportunity to expand robotic surgery. If you think about that, it's really about 28% of the week And if you look at 80% utilization of that time, we're talking about 23% of the week where robotic surgery is available for patients. Yeah. Does this align with our vision for our patients? With the vision for our clinicians and the vision for the enterprise? Probably not. So for additional perspective um This isn't just a question around intuitive robots. We are a major academic medical center. We have a number of different robotic platforms. We have robotic platforms for partial and total needs the makeup platform by striker we have robots for neurosurgery, the rows of one by zimmer and we have two different spying robots, one from medtronic, one from globus. So this idea of making technology available. Reading patients where they are is one that transcends just the intuitive davinci. It encompasses a number of different technological platforms. Mhm. So how do we make technology available and more accessible to patients and clinicians? Two important questions around this are are we fully leveraging the opportunity and the value that this technology affords if we continue to limit its access. And secondarily, if you think about this question, what are the technologies or capital investments do you have that? You restrict To less than 23% of the available time? Not many if any. Mhm. We get this question. We used to get this question more often than not and that was dr martin. We've got these robots available and I've got a patient I want to do tomorrow morning saturday morning and you won't let me use the robot on saturday. That doesn't make sense to me. So thanks. And if you really think about that, it all comes down to operational barriers. If you will we have the technology, we have a patient, we have a surgeon. So why can't we make this happen? And one of the important things to think about as we begin this journey to expanding access is to ensure that the outcomes are the same, that the safety quality and the experience is the same as we move outside of the primetime robotics bubble. In order to do that, we're going to have to make sure we have competent staff and thats nurses bedside assistance. We have good support from um central sterile processing and also for materials management. Uh huh. This really begins with creating an aligning our goals across our different levels of leadership. And again this starts with the philosophy that we want to be able to afford the best surgical approach for any particular patient at that time. And again it may be open, it may be a microscopic, but when the answer is robotic surgery, we want to make sure that we can provide robotic surgery as a critical component of our clinical service line offerings. In order to do that, we've got to align with our intuitive partners, with our hospital leadership, with our clinical leaders to ensure that we all have the same vision, the same goal, the same strategy. And then we empower our teams to go ahead and execute plans in order to make this happen. So again, what we want to be able to do is leverages technology, right leverages technology and expanded its access. We want to create the right culture for safety and quality. And so how do we do this? It really goes back to again aligning our vision with our strategy, creating a team, creating a plan, executing that plan and then collecting data and doing regular look backs in our program. We were able to successfully implement a plan similar to this and grow our program and increase access across the prime time and outside of prime time. If you look at the immediate benefits of expanding access at our program, we've grown really exponentially exponentially over the last three years by incorporating these tools into our clinical operations. This has also afforded us a chance to grow outside of the normal areas of growth with robotics which have traditionally been Joanne, oncology and urology, two more general surgery and particularly over the last two years for us to grow it in the arena of transplant surgery. This shows our donor transplant robotics growth over the last three years. Um, we'll double the number this year and we've recently done our first robotic recipient kidney transplant. Lot of transplants for us have gone off hours and on weekends. And so this idea of growing access outside of the normal primetime bubble will resonate as we continue to show robotic surgical growth in general surgery. So again, our strategy is just like yours is to build an excellent primetime robotic surgery program, but then expand that program off hours and weekends. And the reason that we want to do this again so that a clinician and patient can be afforded the see optimal surgical approach at that particular time. In addition, it allows us to leverage and institutional assets for the benefit of patients, clinicians and for the enterprise. Mhm. Now, as we do that, we have to make sure that we keep in mind that we have access to technology that we have a plan to keep technology current, that it's a cost effective option and that it brings value to all of our customers and customers are patients are clinicians, are providers and the institution. And so when we think about this, the who is all customers? All patients, all clinicians the enterprise. But what is value added technology that robotic surgery brings? The wind is 24/7 just like laparoscopic and open surgery. The where is where it makes sense and the Y is because robotic surgery will be the best solution for some patients and where that is the case. We want to make sure that we're able to afford that opportunity. I'm now going to move on to my colleague, Dr Michael A wad. Uh Okay thank you Dr martin. I'm Michel Awad. I'm director of robotic surgery for A BJC health care. It is my pleasure to join the panel today I'll be talking about clinical outcomes defining patient in hospital value and focusing on two main areas. Myself as a clinician. I'm an M. I. S. Surgeon and do benign, forget surgery and about how we build the team to enable success. Many times. We focus on the upstream costs of robotic surgery, the instrument and accessory costs, the capital costs and how much time spend the operating room. But just as important if not more important than these are the downstream savings. And for me as a clinician, this admittedly is where I place a lot of my attention on the length of stay blood transfusions, complications, conversions and other clinical outcome measures. So towards that point, I'd like to share with you a little story about why I prefer robotic surgery. From a clinician perspective, I do surgery on the esophagus and the esophagus is a very hard place to access. It is well protected within the body, uh protected by the ribcage, the heart and the front of the great vessels in the back and so forth. Try trying to get there from the abdomen requires access to a very small window through the diet frame about the size of a quarter. I think of it as trying to look through a keyhole with conventional laparoscopic instruments. This is often what it feels like and then if you try to get your instrumentation through there, it sometimes feels like this. So to me, the robotic advantages highlighted in tight narrow spaces and this is why it took off first in urology and G. Y. N. But increasingly so now in general surgery, in other fields. The data, I think is what drives many of us as far as the value. So I'd like to share with you examples of how we put together data that we've collected internally and how we combine that with data, intuitive surgical provides us to determine the best outcomes for our patients. This is a manuscript we published last year in surgical endoscopy where we looked at our short term clinical outcomes in patients who underwent robotic surgery for hydro for any repairs. This was a 10-year experience that we collected through an internal database at our institution with over 1000, forget experiences. We try to make sure that both patient groups were the same. And this is another key point when looking at the data. Are you truly comparing apples to apples and not disparate patient groups? So indeed our patient groups were similar. And we looked at a number of again key clinical outcome measures in my field, One of the areas that we struggle with is how do we get the stomach out of the chest, back into the abdomen When we clarified attorneys, sometimes it's a video lengthening is done when we can't do this sufficiently. But this is an inadequate option for our patients With conventional laparoscopic procedures. This is done 11% of the time, which is unacceptably high with the robotic approach. We've had to do this one time out of 1000 patients. And this was a particularly challenging circumstance. But otherwise this was a significant reduction in the need to do this. So called esophageal lengthening procedure. One of the other issues which I think we don't have to convince anybody about is starting a procedure minimum basically and finishing it minimally, basically. So we also tracked how often we had to convert to an open thoracic or open abdominal approach Laparoscopically. This had to be done 7% of the time robotically still to this day. We've never had to convert to an open procedure and I think this is one of the key findings we found from our clinical outcomes database. There are many other outcomes that we've published on. Besides what I've just discussed, including operative time estimated blood loss, inter operative injury and others. And we've also looked at cost equivalency at least with instrument accessory costs. We've also looked at out long term outcomes data. Again, with the ability of having a powerful data set, We can ask these rigorous questions and find these answers. One of the things that that affects my field is the recurrence rates of high attorneys can be as high as 59% at five years. I think you can see why this too is unacceptably high. With the robotic approach we've tracked our patients longitudinal e and we found that at five years we've been able to reduce this recurrence rate from 59% down to 9%. No other intervention to date has been able to result in this market a difference. And we're really excited about being able to offer this clinical improvement to our patients in summary. On the clinical side, we're finding that the robotic approach does find us with these key downstream benefits to our patients as well as to the health care system as a whole. I mentioned this data and this is uh not just for myself but also for our system as a whole. We combine our internal data with that provided by intuitive for what's called the Market Access and custom analytics program or the MAC UP program. And this is for Barnes, jewish hospital soft tissue surgery. You can see key, financial and operational, key performance indicators, or KPs. For robotics, we're seeing a reduction in the average length of stay. The contribution margin per length of stay related readmissions is significantly lower for a robotic procedures compared to other modalities. And this is true again across soft skin and soft tissue infections. Transfusion rates are lower conversion rates, not just for Haida party repairs, but across the board is lower. And these are key, not just for clinicians, but obviously for hospital administrators as well. If you take home nothing else but this I encourage you to focus on this slide. And again, I think no one really argues that open surgery is not our goal for our patients. This is over three year time period from 2017. With the kick off of our robotic surgery integrated program We've seen that are open surgery rate has reduced from 49% to 42%. And this was due to a concomitant increase in our robotic surgery approach, with a 7% increase in in our procedures. And I think we've been very excited about this and we hope to see this continuing reduction in open surgery continue. So how do we do this? Let's talk about how we built this team to get to this, and dr martin alluded to this already, but we have a rather large and complex health care system called BJC Healthcare. Made a 15 institutions in our H. S. S. 31,000 employees is the largest employer in our state and the Greater ST Louis region. And as part of this, we found that we needed to organize ourselves. So he stood up this what's called the robotics governance committee. This is a committee that covers all of the hospitals at which we have robotic systems. This group meets on a quarterly basis and we talk about synergies across the health care system, how we can work together sharing best practices, how we can meet common challenges. Now, this is further subdivided into the various institutions have their own organizational structure. Barnes, jewish Hospital is the largest of these and inside that we have a group and a team dedicated around robotics. You've met DR martin who is our vice president of surgical services. I serve as director of robotic surgery, which is a new role created for this initiative. We have a steering committee, which I'll speak about shortly as well as an operations committee that handles the day to day, week to week robotic operations. We'll talk about some of the key members of that group, but the robotic steering committee for Barnes, jewish hospital meets regularly every month. This group meets without fail. It is a standing room only group that discusses our robotic program at BJ HR operations or clinical topics. We talk about education and training opportunities as well as our joint research initiatives. This steering committee is not only all of the clinical service lines, but we also find it important to have our intuitive surgical partners at the table during these meetings as they provide a key perspective in a direct line of communication where appropriate, our robotics coordinators. Another key member of this team, this person organizes the steering committee but also has many other roles. This role was created at the onset of the Robotic Surgery Initiative in 2017, this coordinator oversees the robotic, administrative, clinical and technical operations across our hospital campus. She serves as a liaison between administration, clinical teams and intuitive surgical. We found it important to elaborate a job description for this individual which we're happy to share. Uh huh. Another key component of this team is our first assistant program. We use R. N. First Assistance or R. N. F. S. And they provide a credential assistant at the bedside for education purposes. We are teaching institution and allows our trainees to leave the bedside and sit at the second console for our robotic cases. Which is ideal from the training perspective. But even more this person allows the nursing team to have quicker and more efficient turnovers and provides a constant set of knowledge that can be helpful to provide safe care for these patients at the bedside. We also have our schedule er in tune with a robotic surgery platform as dr martin alluded to in his presentation. Part of the key drivers of that growth have been making sure that a robotic O. R. Block days are dedicated to robotic cases. So we do not allow a mixed model in our robotic rooms. We have a very clear and transparent scheduling guidelines for how these rooms are to be used to optimize utilization. Another key member of the robotics team that you're about to meet jim thomas who's our manager peri operative information systems. We'll share with you the intricacies of how he uses our internal data to measure our growth to look at areas for further development and opportunities. And he'll talk to you about how he uses that as well. And finally, uh Andrew Pierce, who are is director of supply chain will share with you also how he uses financial data both internally and externally to look at our robotic operations and how we can do this most cost effectively. Another key part of our program is curriculum and training. I also serve as director of our simulation center and we find it incredibly important to have everyone who touches the robotic system from the nurses, the coordinators, the first assistance and the surgeons be well trained and not only the routine operation of our systems, but also emergency systems such as emergency, undocumented. Furthermore, we find it important to continue this training and to share beyond our boundaries. We do have a set up to enable training across hospitals and outside of um our normal boundaries. And the covid pandemic has really enabled this. So we use a telepresence system to allow us to train surgeons and teams that other institutions to enable to us to facilitate this care and happy to speak about this as well. Thank you for the opportunity to present and I'm happy to answer questions during the Q. And A session. All right, thank you. Dr Awad. My name is Jim thomas. I managed the performance improvement in the Information Systems team for very operative services here at our facility. I want to talk to you a little bit about how we use our quality data management to support our program. You've seen parts of the slide earlier in the presentation We started doing robotic surgery at our institution in 2007 and for 10 years we kind of cruised along on our volume and we thought we were doing really, really well at 5-600 cases a year. Um we really had simple data and the reality is we kind of had unclear results. As you've seen earlier slides in starting 2017 we put some pieces together and really showed dramatic growth in our programs. So prior to that dramatic growth this is what we had and I refer to this as simple data are robotics cases were tracked. We could count the number of robotic surgeries that we did in which rooms that we did them. This is direct manually. We had some basic case information. Case times, some overall robotics times and are really our goal at that point for utilization. It was simply to perform to robotic cases per block day per room. We thought that was pretty good metric. Um and that served as well. Up to a point. We started to see some challenges by getting additional surgeons and services on board during robotic surgery and we knew that we really didn't do better. Yeah. So part of what we put together to help support this dramatic growth was more detailed analytics. We also put together a structured program around how did we manage robotics here? Not only from a data perspective but really from overall total access. Uh you've just seen this is the structure that we put into place. Um prior to 2017, we did not have most of the roles on this chart that were assigned directly to robotics. We did not have the director of robotic surgery are the operations committee that you see all the key members there. I do want to call out one key member though. Here is our robotics coordinator. This was a role that was created in 2017 and was really instrumental to helping support the dramatic growth that we did see in our robotic robotics program. This person is responsible for the day to day management of all aspects of robotics, from working with the surgeons to make sure that they have everything that they need to credentialing process to education and really supportive all of the key team members across this. Without this robotics coordinator role, we would not have been able to see the growth that we that we had reality behind this is it really takes a team to see the type of growth that we did. Again, you've seen this slide before. Um but starting in 2017 we saw nearly 50% increase in 2018 over the prior year, 2019. Again, 40% growth even with a significant impact from COVID, we still managed to see 9% growth last year. All right, so how do we do that? Well, we put together more quality metrics instead of that tabular slide that I showed you on utilization earlier. We really drill down into creating some better visuals around many of the metrics that we knew that we needed to use to support the program. This is what we use now for a high level of our utilization. Pretty quick and easy to take a look at to see. Where are opportunities are the blue band is the total allocation Of our time for robotics for that particular service. And the red hash mark is a percentage of that allocated time that that service used performing robotics case. Our goal is to keep that number up 75-80%. And it's really easy to call out in Syria of opportunities from a visual like this. We know that the green circles there colorectal and are unaware oncology group were Really knocking it out of the ballpark on cases they had significant growth and at the time with their block allocation was they were picking up robotics time, any place that they could, which is how you can come up with over 100% utilization. We know that in this particular months we had a couple of other services that really had opportunity. One month doesn't make a trend, but it really just highlighted a focus area to take a look at, to pay attention to the future months or to do a deeper drill down into where we were. The other thing that we tried to use our quality data for it was really to improve our outcomes from a quality standard. We understood that our turnaround times compared to our peers was significantly longer and we knew it was much longer than what we wanted it to be at our institution. We put some processes in place, starting with a pilot within our M. I. S. Program. And we established a 30 minute turnaround time for our robotics. And due to uh pieces that we had put into place with notifying the team when they're when they're turnover time was longer than we expected. And then really getting that feedback. My s was the first service to actually get their turnaround times on media and below our goal. But as you can see there from the other services that operated in that location, we did start to see a pretty significant impact and are actually numbers for last month. All of our robotics cases had a 30 minute median turnaround time. So really dramatic results there in a fairly short period of time. One of the other things that we take a look at as our case scheduling accuracy, It's difficult to manage our inter operative time if we don't know exactly how long the case is going to take to perform. So on our case scheduling request, we asked the surgeon to provide the estimated time for their cut too close portion. And then we compare that to what it actually took to perform the surgery. The yellow, green and red visual on the left hand side is just a quick snapshot of how each surgeon performed over a rolling three month period with the green portion there being the percentage of their cases that we deemed as being scheduled accurately for the procedures that were are outliers. We can show those and see if there's any pattern or inconsistency there. And we can even drill this down into individual surgeon level performance within each of those outlier procedures, detailed analytics analytics like this help us really drill down and focus on the areas that we need to continue to improve our program overall. I shall be happy to answer any questions at the end of the presentation and like to hand it over to Andrew pierce. Okay, thank you. Jim for introducing me. I'm Andrew pierce Director for supply plus and preoperative business at Barnes, jewish hospital. And I'm going to describe our strategy, tactics and outcomes, uh, for cost management, specifically supply cost transparency at our Academic medical center. While we have grown robotic volumes in pursuit of optimal clinical outcomes, health Care costs in the us are high. This is not news representing up to 18% of total GDP, which is substantially higher than our industrialized countries that we compare against. While the rate of increase has leveled off in recent years. Um we know from signals from CMS that payment increases will be modest, which continues to put emphasis on health care providers of managing the expenses in delivering that care. Uh huh. This graphic depicts our cost structure at the hospital. It's dominated by labour with supplies as a close second. Our management tactics for matching labour. Too impatient volumes are fairly well rehearsed, but our expertise in techniques for managing supply expense were underdeveloped. We benchmarked fairly highly against some of our peers and so between the hospital and school of medicine. We together set a strategy for privatizing supply cost as an area of focus um and invested in infrastructure to bend this cost curve. The task force we created between Barnes, jewish hospital and Washington School of Medicine included a department, departmental leadership assignment of faculty leaders, creation of decision venues within specialties to develop cost transparency tools, set contracting strategies, review new products and monitor outcomes rather than emphasizing standardization, We focused on a low cost approach, recognizing that the consistency that would come of that would be a welcome byproduct. The effort involved local and system investments in expertise, new strategies to be purposeful in contracting for preferred products, providing comparative data to surgeons regarding product usage, aligning inventory to future expected usage, all while creating robust and reliable processes for introducing new products and for ensuring that product is on the shelf as expected. The primary strategy we used was cost transparency, making visible the cost of the product to the physician decision makers. The table on the top right shows the cost curve. We have been a total supply dollars spent annually. I can see that for a decade. We were growing our supply costs at 8% a year, But over the past seven years we've seen that trend change to be under 2% compound annual growth rate. And it's not because we are growing volumes. The bottom left table shows the trend in supply over net revenue And we have decreased this measure by 4.7% points. Over the time you're generating a significant move to the organization and this has been funding team member pay raises and new equipment and new buildings on campus. I'm gonna show you a couple of tools that we use and have been are kind of main efforts for providing visibility to the price of products. The first is a quarterly surgeon scorecard. The report shows inter operative record of items used and their acquisition costs for each surgeon to see his or her own top five procedures. By total costs for each procedure, the surgeon can see the outcomes for other surgeons who are doing those doing that procedure as well as the trends over time. The report is pushed quarterly to every attending surgeon at Barnes, jewish hospital reports unb blinded and is intended to generate dialogue between surgeons about lower cost tactics and product choices. Our robotic surgeons have been particularly engaged to monitor and improve cost per case trends, including one particular your neurology surgeon who in response to this data made changes to its product usage to reduce his prostatectomy cost per case by 11%. Another descriptive tool that we've subsequently put in place is a supply receipt for every o our case. Working with our EMR vendor, we implemented a post case in basket message to the surgeon that shows the lie on the tail of the supplies used and acquisition costs. With some historical context including surgeons, average cost and the average cost for other surgeons who have done that procedure over the past six months. The message is generated automatically within the EMR at the time the patient leaves the operating room. The purpose of the tool is to allow the surgeon to identify where products cost more than expected, as well as to increase documentation accuracy. We've seen several examples of this reports utility, including a vascular surgeon who identified a human static agent was documented as open and used but was not needed. He got together with his peers within the section and they, as a group decided to remove it from their preference card so they wouldn't arrive and be open before it was requested as needed. This resulted in a 42% decrease in the use of that product over the ensuing year related element of continuous improvement within the program. Robotic programming is documentation accuracy. We've worked with intuitive to create a flow where we access the robots, record of intra items, intra operative items used and then we compare that to the documentation in our EMR to reconcile and correct on beginning this process, we found that over half of our robotic cases had some sort of inaccuracy, Making the data visible to the inter operative team, including the surgeons via the receive. We've seen a marked improvement to now we're under 25% of cases that have some sort of correction still needed. Consequently, we continue to innovate on the process side to make it easier for the circulating nurse to document what has happened in the case correctly. Mhm. These charts to pick the supply costs for case outcomes that we've seen over time within our robotic surgery program on the left is the cost with intuitive for each case we've done with them. Uh Over over the past five years where we've seen some movement up and down within each of the years, driven largely by the onboarding of new surgeons who may have sort of a low cost bent personally as well as the introduction of new procedure types as an example. Doing more procedures that require stapling to accomplish the case will necessarily drive cost per case up. And so that's not a challenge with usage or prices. That's simply a mixed change that can increase the cost per case. But in 2021 thus far, we are essentially flat to where we were in 2016 for the cost for intuitive instruments and accessories to do a robotic case at your hospital. Uh Even more important is the chart on the right, which is the overall supply cost per case in our robotic surgery cases. So this includes but is not exclusive to the intuitive expenses. uh this measure shows that we are down significantly since 2016 in our supply cost per case, the use of descriptive data to enable surgeons to be informed about their cases, costs activate natural competitiveness and involve expense in the context and the content of education uh creates a culture of cost awareness in our LARS. That's the culture in which we see these results. In addition to the context of our cost management efforts, we have to take some specific steps to, and this is one of the major advances to achieve these outcomes. Uh this is an introduction. This reflects an introduction of a new line of instruments from intuitive that occurred in the fourth quarter of 2020 where a portion of their instruments were redesigned with longer lives. So more uses for the instrument before it was discarded. Um that increased the usage by 20-80%. We're seeing a significant reduction, 27% reduction in cost per case for these products from the old generation to the new generation And our volumes. We've projected this to be a $240,000 run rate reduction. So this this is reflected in the advances we're seeing in 2021 rates. As a concluding comparison we're pursuing rigorous cost management program at the same time that we're growing robotic surgery. On the left is the chart that DR Awad mentioned growing robotic surgery at the expense of open surgery. Um And as we work closely with our surgeons, we've been able to achieve both that growth and a reduction in supply cost per case while advancing clinical care. But I will turn it back over to DR martin to wrap us up. My colleagues and I have uh told our story of our journey to increase access to robotic surgery, the importance that we believe that this uh modality provides as part of a complete clinical service line offering. It's important to have a strategy and a vision to have a plan to execute that plan. The importance of data analytics, the importance of the finance pieces so that as we continue to grow the program, we can do it in a cost effective manner. That brings value not only to clinicians and patients but also to the enterprise. Um We will move forward and entertain questions. We're not there yet, we're not complete. We're still continuing to build and grow across our system and trying to bring some of the lessons that we learned that B. J. H. To the other H. S. O. B. J. C. Thank you for your time and attention and we'll move on to questions and answers. Thank you all very much. Thank you to dr martin. Dr Iowa jim and Andrew. We'd like to now open up the Q and A. Please submit any questions through the Q. And A box that you see on your screen and if we're not able to get it in the time we have left we'll be sure to follow up with you after the program to get those addressed. So dr martin. This first question is for you. Um the attending as it can be hard to change the culture around robotics at a large academic institution. How are you able to align your teams to grow your program? Yeah, that's a great question actually. And again, when I arrived here in 2017, We had had robotics here for 10 years. And uh As it was mentioned by Jim earlier, Jim Thomas, we were doing about 500 cases a year, almost 10 years. So we had a program, we we had surgeons doing robot cases. We really didn't have an integrated robotic surgery program. So the first step was looking in the mirror and acknowledging that we did not have an integrated program. And asking the question, do we want to do better? Do we want to be better? The answer was yes. From our clinicians, it was just from our administration and it was just from our intuitive partners. And so we began there to put a plan together to move to growing and expanding access to robotic surgery. Um part of that again was the theme that I sort of tried to weave through my portion of the talk and that is we want to be able to offer offer offer robotic surgery is an option just like we were offered by Priske, opic and open surgery is an option to any patient where that is the best solution. So how do we do that? And so we we did all the things that we talked about. It was about optimizing the investment, but also we are a large academic medical center and many of our residents now. The best residents are showing up asking the question, what will my robot surgery experience be? Should I choose to come to your institution? And so we are, we will not be able and are not able to attract the best residents if we don't have robotics as part of our educational offering. And so that was also critically important. So education training, our curriculum, all these things are important at a major active medical center, not just medical outcomes. Thank you so much for for laying all that out. Dr martin Dr Iowa. This, this next question is for you. So the attending asked if groups are working in silos at an institution, how do you gain alignment on a shared vision for your program? Mhm. Great question. And you know, I think traditionally our institution has operated in silos. I think part of the challenge in overcoming that is trying to recognize that all of the sister institutions within our health care system are not the same. They have individual needs that are unique. Some of them are large tertiary care academic medical centers. Some of them are community hospitals that serve a different patient population. So I think that's one of the first steps is recognizing the diverse needs of the partners within our health care system. We also understand, though, that we do have some commonalities. We do have common ease across the HSS within our health system. We're all striving for the best patient care. We're all looking for efficiency in the operating room, best utilization of the resource and training that meets a high level of quality experience for our patients and our providers that we expect. We have common challenges. We mentioned today, some of those are ready with regard to turnover times, cost containment and others. By bringing everybody at the table, were able to discuss these issues openly in a forum that is safe and that allows people to talk about these common concerns and challenges and we work together to address them. Thank you Doctor a wad. And this next question is for you as well. And I think it builds on this theme of uh sort of understanding specific needs. So the attending asked what steps did you put in place to best support the resident or fellow experience in the O. R. Have you seen a difference in your resident competency because of these changes question. So at Barnes, jewish hospital we are a teaching institution. We have over 120 trainees that are touching the robot. That's across a multitude of specialties including G. Y. N. Urology, minimally invasive surgery, thoracic have had a billary and others. And so we do have a great need to attend to the training experience to make sure that it is both quality for them, but also safe for the patient. There are several things we've instituted to make that happen. So the first is recognizing that while there are some learning goals that are achieved at the bedside, the primary learning happens at the surgeon's console. Our institution has invested in a duel surgeon council for all of the robotic platforms that are teaching institutions that allows somewhat of a driver's ed experience where the attending surgeon, as well as the training, can switch back and forth, the attending surgeon can demonstrate safe and effective techniques and how to operate by using that system. Now, in order to enable the use of the dual console, we did have to commit to having a provided, excuse me, a credential provider at the bedside at all times. And so that begun with our R. N. F. A. Program that I alluded to earlier. Our pilot was in late 2018 with a single RFK. That pilot was a tremendous success. Not only did it enable the resident to leave the bedside and sit at the other council, but there was unintended beneficial side effects such as faster turnover times and more consistent care and so forth. As a result, the second year we expanded to four RFC and the following year we've expanded to eight. So the R. O. I. Has been very clear for that. In addition, we have robust and formal curriculum for our trainees that span all service lines. Regardless of specialty, we do have a procedure and specialty specific curricula for advanced training use that occurs both inside the operating room and outside. I do direct our surgical simulation center, where we're fortunate to have a full fledge robotic system which provides that hands on training. And finally we take a team based approach to training, recognizing that the surgeon does not operate in isolation. So we bring our operative teams down to the simulation center where we can have a safe space and our anesthesia providers or surgery providers or nursing providers work together just as they would not operating. Thank you for tackling both of those doctor I want and sharing, sharing those great results. Um jim this question came through for you. So the attending asked B. J. C. Has had very rapid growth of their robotics program. What do you see as your biggest upcoming challenges as you continue to build a world class robotics program? Thank you for that question is very, very timely. And it's actually one of the things that we've been considering and talking about Artsakh Committee um with the rapid growth that we have seen one of the biggest challenges. And really how do we accommodate continued growth right now? It feels like we're in a post pandemic recovery period. We're on track for 2021 to do 20% more cases than we saw even last year. Uh to accommodate that growth. It would be great if we could just go out and pick up another robotics platform. Even if capital is freely available. The process to work with our state to get an additional platform is very cumbersome and timely. So just bring another robot on site is not really an option to increase capacity. So we have to look at other ways to manage increases in volume. Part of that has already been discussed. We've investigated our weekend program as well as extending our monday through friday hours to make sure that we've got the right resources we need them and when we need them. The other thing that we've done is we're taking a more critical review of our actual utilization. We know some services have moved into new arenas and new procedures that they're performing robotically. We continue to look at their utilization is assigned on our block model. We know that some services are underutilized and we actively work with those services and those individuals to make sure that they have the volume on the robotics to support the amount of block hours that they have. Um and when not we reallocate that time to services that do show growth. Thank you. Jim appreciate you tackling that question and we're coming close on time. So this will likely be the last the last question. Andrew it's for you. The question says, how did you implement the extended use program smoothly at your institution. I really appreciate that question because it does require a fair amount of operational and clinical planning with intuitive and the teams to ensure that cases are supported. As it made this transition, we place the regularly used instruments into instrument trays and sterilize them together and our intent was not to discard any instruments before we had fully used them. And so the trick was that we were going to come to the end of the use of these items individually as they reach their maximum number of fires or uses. Um And so we had to have our inventory pre deployed and ready to be pulled as we can. You got to the end of the use of any of the individual items. Um And so we had that ready and we're comfortable that we would be able to transition the inventory from one to the next. Uh from a logistics perspective, the real trick was within our electronic medical record and what the inter operative nurse was going to documents. We actually sort of time the transition of what was loaded onto our preference cards and ready in the EMR to document or when we thought we would first use any of the products. And then what we did was made a switch of all of these new catalog numbers to deactivate the old and activate the new and begin to document the new version of these items that were very similar to to the existing ones. We knew that the consequent charged to the patients was going to be lower with the new instrument life, extended life. And so we were comfortable that we would be sort of solving with an early conversion that resulted in lower charges to our patients As we sort of worked out the old inventory from our trays and adopted the new one. So it was a fairly complicated conversion, but one that we were excited to pull off because of the advantage of both the sort of minor advances and the effectiveness of the instruments as well as of course the price advantage to the organization. Thank you so much for for tackling that. Andrew and thanks to all of you. It's been wonderful and this is his all the time we have for today. I just want to thank once again thank DR martin DR I wa jim and Andrew for that excellent presentation and discussion. So a big thank you as well to intuitive for sponsoring today's webinar as a reminder. If we did not address your question today, we will be sure to follow up with you directly after today's webinar concludes for more information on today's content. Please check out the additional resources on your weapon or console and don't forget to fill out our webinar survey. Thank you for joining us today. We hope you have a wonderful afternoon and a great rest of your day.