Robotic-assisted surgery offers many potential advantages, including shorter operative time, less morbidity, and faster patient recovery. But rigorous comparisons with traditional surgical methods and cost-effectiveness analyses are still limited, and the price tag of the robot (in the neighborhood of $1 million) and annual maintenance contract (roughly $150,000) may give decision makers sticker shock.
In this context, perioperative services leaders at large urban institutions and small community facilities alike must develop compelling business cases to support acquisition of robotic technology. These cases require detailed analysis of market demand, upfront and ongoing costs, attraction and retention of surgeons, facility space, productivity, efficiency, and staffing.
Compiling all of this information takes time, but it is time well spent, judging by those who have successfully added robotic procedures to their case mix.
MGH experience
Massachusetts General Hospital (MGH) in Boston, where more than 42,000 operations are performed annually, took the robotics plunge almost a decade ago, according to Ryan Brumit, MBA, program manager for perioperative services. Its business case emphasized clinical advantages, the hospital's teaching mission, and the types of procedures being done.
The technology was initially pushed forward by the urology, gynecology, and cardiac surgery services, Brumit told OR Manager. In 2007, the robotic approach was being increasingly adopted as the standard of care for radical prostatectomies. Additionally, the data available at that time on length-of-stay reductions for specific cardiac procedures done robotically (off-pump coronary artery bypass grafting and mitral valve repair) helped garner support for adoption.
"We adopted the technology in 2008 to better serve our patients and support our surgeons and surgical trainees," Brumit says. "We made the investment based on which care could best be delivered using the robot. Although our robotic program remains a cost-intensive endeavor, our surgeons continue to advocate for availability of the technology where it is most appropriate."
Ryan Brumit, MBA
The hospital began with earlier iterations of surgical robots and, in 2013, purchased a da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, California). The multipurpose robot is used by the urology, gynecology, general surgery, emergency-urgent care, thoracic, otolaryngology, and pediatrics services. "We chose a dual console model to support program growth and educational aims," Brumit notes.
Operationally, the robot is stationary, so MGH has a dedicated OR for the equipment; however, the OR block schedule is separate from the robot schedule. "Even with an average of 58 ORs running daily, we don't want a dedicated robot room to go unused because there were no robotic cases scheduled," he says.
In 2016, they added a ROSA Robot (Medtech Surgical Inc, New York) for functional neurosurgery procedures.
"As the robotic approach is still in its infancy relative to open and laparoscopic procedures, robotic cases, for the most part, are still longer and costlier than their nonrobotic alternatives," Brumit acknowledges. "However, these disadvantages have the potential to diminish over time as surgeons gain experience and as the market grows more competitive."
Stakeholders made a commitment to collecting data to help guide the growth of the robotics program, such as volume, case length, and equipment and robotic room utilization. "We have observed vast improvements in these metrics over time as a result of targeted initiatives," Brumit notes.
From the fourth quarter of Fiscal Year (FY) 2016 through the third quarter of FY 2017, utilization of the robot increased 25% and monthly volume nearly doubled. Additionally, changes to the schedule and communication about availability have given robotic surgeons a sense of increased access to the technology.
"Supply costs are higher for robotic cases, but our volume and utilization have increased considerably since we adopted the technology," Brumit says. "We prefer that the technology be utilized rather than sit idle."
Among less tangible benefits, MGH has applied lessons learned from investing in robotics to evaluation of other high-cost technologies. For example, hospital leaders now strive to get more out of existing technologies before purchasing newer ones. "In the fourth quarter of FY 2016, the consensus from our robotic surgeons was that there weren't enough opportunities to use the robot, yet our utilization was 56% at that time," Brumit notes.
Additionally, a more comprehensive financial assessment has been adopted that scrutinizes not only costs generated in the OR, but all those incurred during the entire patient stay. "This was simply a shift in the way we viewed financials, driven by changes in the landscape of the healthcare industry. It was no longer viable to maintain a focus on the fixed costs of the operating room. We expanded our view to the entire patient care experience to fully appreciate the cost benefits of robotic surgery. Furthermore, we did not want operating room costs to impede the care of patients who would benefit from a robotic approach," he explains.
"Once the technology is in-house, maximizing operational efficiency requires a continuous effort," Brumit says. "For example, when we first purchased the robot, many services were vying for time. The perception was that there was never enough time to use the robot, even though monthly utilization was sitting at 50%. By developing and maintaining an assignment schedule (service and surgeon), we have elevated perceptions as well as utilization."
Another difficulty in the early years of the robotics program was matching staff to demand, Brumit says. "A variety of service-specific nurses supported robotic cases. We found that it was difficult for some nursing teams to keep their robotic skills sharp if their service's robotic case volume was low," he explains.
In addition, robotic surgeons said it was difficult for them to complete cases efficiently without consistent, dedicated support in the OR. In response, a dedicated group of registered nurses received training for robotic cases done from 7 am to 7 pm on weekdays.
"Thus, procedure times were reduced, and additional cases could be added with confidence knowing that trained support staff were available," Brumit says.
"Building a successful and scalable robotic program takes time and effort from a multidisciplinary team. Surgeons, nurses, and perioperative administrative staff must work together to get the most out of the technology (optimize utilization, improve case length, create and maintain an educational environment, and such)," Brumit says. "We've found it beneficial to have both a larger working group to discuss and resolve operational challenges, as well as a smaller steering committee to govern and guide the program.
"The Robot Working Group meets biannually to discuss challenges and drive strategy," he explains. "During these meetings, we present monthly and quarterly metrics relevant to the robot so that the entire community is aware of the program's strengths and opportunities. We maintain a distribution list to ensure that all members of the community are well informed regardless of their attendance.
"The Robot Executive Committee meets biannually to develop the program's direction and definition. It also provides perioperative and surgical leadership to discuss how the MGH robotic program fits into the various other robotic programs across Partners Healthcare," he says.
Lutheran Medical Center experience
Deborah
Hedrick, MA, RN, NEA-BC
Lutheran Medical Center's 259-bed community hospital in Wheat Ridge, Colorado, brought robotic surgery on board in 2010, when it opened a new OR, according to Deborah Hedrick, MA, RN, NEA-BC, director of perioperative services. Their business case was strongly driven by local competition and surgeons.
"We live in a very competitive market here in the Denver area. There are more than 20 hospitals, and we are all competing for each other's business. So we weren't ready to lose volume to another hospital," she explains. "Everyone here was getting robots, so we got the da Vinci Si Surgical System, mainly for GYN and urology procedures."
The business case for purchase of a second robot–another Si Surgical System–just 2 years later, was based on analytics provided by Intuitive Surgical and Lutheran Medical's business development team. "We looked at the market and trends in our volume, and analyses showed that within a matter of 6 months, the number of patients would exceed time available. That meant that my surgeons would go elsewhere," Hed-rick explains. "We were just booming, with a high volume of robotic hysterectomies."
A da Vinci Xi Surgical System, a new platform with greater arm mobility, was purchased in 2016. "We have a colorectal surgeon who is medical director of our colorectal cancer program, and he performs numerous cancer cases," she explains. "He needed the Xi, which enables multiquadrant procedures."
Lutheran Medical has designated rooms for robotic procedures. Rooms are scheduled on a first-come, first-served basis. "Currently we staff two RNs and a surgical technologist for each robotic case, but we plan to reduce that to one RN and one surgical technologist," Hedrick says.
All staff must complete Xi and Si robotic educational modules, which are provided by Intuitive, and all new employees must be supervised by a preceptor for a couple of cases, she adds.
Lutheran Medical has been collecting data to track return on investment. Between 2015 and 2016, the proportion of operations done robotically increased from 7% to 9%, and the actual number of cases increased from 387 to 521, according to Anna Hooker, MBA, MS, the center's perioperative business manager. That growth appeared to be attributable to a doubling of the volume in general surgery and OB-GYN. For colorectal operations, length of hospital stay is about 7 days for open and laparoscopic procedures combined, but just 4 days for Xi robotic procedures.
The impact on operative time varies. An inexperienced surgeon may need up to 6 months to become proficient, although some surgeons adapt more quickly to the new technology. "We have one general surgeon who just came out of his residency, and he's faster doing a robotic hernia repair than a laparoscopic one because he's not used to doing the latter," Hooker notes. Use of the robot translates to a shorter time in the OR, she adds.
Anna Hooker, MBA, MS
"We have had some procedures shift from laparoscopic or open to robotic, but overall, in recent years, we had growth in the volume of both robotic and nonrobotic general surgery procedures: an increase of 23% and 10%, respectively," she says. "So it's not like one is pulling from the other. They are related, and there has been growth in both."
With this growth, however, comes additional expense for items such as dedicated pans to clean the robot's instruments, as well as new imaging and other equipment needed to fit the robot.
"Investing in surgical robots is preparing us for the future as more of the residents come to us trained on robotics, so they are more comfortable, and they acclimate faster," Hedrick says.
The technology also nicely positions the hospital to offer remote consultation.
"We are working right now with a new integration system to be able to record not only pictures but videos. And there is a possibility for telemedicine, to share procedures with other physicians on a secure channel, without bringing somebody else into the operating room for observation."
Perioperative leaders building robotics business cases should tap people with in-depth market knowledge, Hedrick says. It's important to know what technology you need; for example, if your surgeons aren't interested in single-site multiquadrant surgeries, you might want to look at Xi versus Si.
"Use your robotics company representative to help develop your business plan," she advises. "They have all the data on demographics and how many robotics cases each hospital is doing. They can tell you, in your service area, which hospital patients are choosing over yours, so you can really see the volume that you are losing. Also, use your business manager or your business development specialist."
Hedrick admits that crafting a business plan isn't easy. "The ones we did took at least a couple of months to draft. There are a lot of data to compile," Hedrick notes. "But if you spend the time, there's a good chance of success. All three times I requested a robot, I've gotten it, when other hospitals in our system have been turned down. If you make a strong case in your business plan, it's hard to say no." ✥
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