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Becker’s Healthcare Podcast
Advancing Outpatient Joint Replacement Through Technology and Teamwork
00:15:26
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- [00:00]
Brian Zimmerman
Hi everyone. This is Brian Zimmerman with Beckers Healthcare. Thank you so much for tuning into the Beckers Healthcare podcast. Today we're going to talk about clinical excellence, economic value and operational Support in the ASC. Joining me for this discussion is Dr. Robert Maley. Dr. Maley is a fellowship trained, board certified orthopedic surgeon who specializes in hip and knee replacement and practices out of California, Pacific Orthopedics. Dr. Maley, thank you so much for being here today.
- [00:29]
Dr. Robert Maley
Thanks for having me.
- [00:31]
Brian Zimmerman
Let's start by, I guess, getting to know you a little bit more. Can you share a little bit more details than what I did there about your professional background and the work you're doing?
- [00:40]
Dr. Robert Maley
Yeah. So I grew up in the Bay Area and was fortunate to find a job in San Francisco. Coming out of fellowship, I did my residency at Stanford and fellowship in hip and knee replacement at Rush in Chicago. At Rush in particular, I learned a lot of newer techniques for less invasive surgery, outpatient surgery in addition to revision surgery. So coming into the Bay Area, I was really kind of eager to apply what I had learned and unfortunately to be part of a big group, there's about 15 of us. I have great partners, but total joint replacement in the outpatient setting, you know, was a new thing in San Francisco when I came into practice about 13 years ago. So yeah, I've had a very unique journey developing our program at our surgery center. I feel like I've learned a lot along the way. Our group service is San Francisco and Marin county, so we see a lot of patients from the Bay Area. We see very young, active, athletic patients that have worn out their joints to the middle aged and even the older folks. So we practice both at a hospital setting as well as an ASC setting.
- [01:48]
Brian Zimmerman
Excellent. Appreciate the background. And I'm sitting in front of a microphone here in Chicago, so certainly have a bias for your education, what you did and what you learned at Rush. So appreciate that, that piece of the background as well. You have a reputation, a penchant, I'd say, I guess, for pioneering new technologies within the ASC space. With so many new technologies hitting the market, how do you decipher which ones you want to trial?
- [02:18]
Dr. Robert Maley
That's a great question. Whenever something's presented to you, you have to take into account what could be helpful and what might just be noise. During my journey of trying to transition cases to the outpatient setting, I was trying to look and see what we actually really needed. Our surgery center, which is prec Video Surgery center in San Francisco, is a multi specialty center. So you have, you know, general surgeons, ent, orthopedic surgeons, spine surgeons, all practicing at one facility. So when we started our total joint program about 10 years ago, we were looking for different efficiencies that could help us not only start the program, you know, but also save us in terms of trying to navigate bringing a whole new service line to an already busy center. So when presented with new technologies, oftentimes we're looking to. We were looking to solve a problem, and fortunately, somebody came up with one and presented it to us. And as we began our journey and as we got going, there were things that came along the way that we realized, you know, operating on younger patients with better bone quality just required the use of tools that we didn't have. And so as we started to see tools like concise come along, we were introduced to efficiencies and technologies that were greatly needed in our space. So anytime a new tech comes up, I'm eager to at least look it, evaluate it, and see if there can be something that we can apply for usage in our center.
- [03:42]
Brian Zimmerman
Yeah. And it sounds like, based on your response there, the technology has to be solving for something. Correct. There's got to be a problem present.
- [03:50]
Dr. Robert Maley
Exactly. Yeah.
- [03:52]
Brian Zimmerman
Yeah. Want to get to sort of a quote that we hear from time to time when talking to leaders in this space is, you know, if you can't measure it, then you can't manage it. How does this, I guess, relate to you? Are there any particular technologies that come to mind that you and your center are currently using to measure and manage?
- [04:11]
Dr. Robert Maley
Yeah, so the. We're doing total hip and total knee replacements when we started our total joint program, you know, 10 years ago. Now we do shoulders and elbows, or I have partners that do shoulders and elbows. But in the very beginning, one of our struggles was inventory. So we were having a conflict of booking six cases, trying to manage the inventory for those cases, and the reps were bringing in, you know, six trays. You know, actually more than six sets of trays for every case, because we were at that time, this is before actus came out, so we were, you know, ordering karai, but then we would have a summit on backup. And so the inventory grew exponentially. And in San Francisco, we don't have a lot of real estate, and we were trying to manage all this inventory. So one of the original technologies that I was introduced was advanced case management. It's a partnership between docsper and JJ medtech. And one of the things that they were able to measure is. Was on the preoperative templating side, you know, to get an idea of the patient's age and the templated size so that we had a better idea of what to expect. That was the first time we were able to really, truly quantitate, you know, our needs in terms of what sizes are we going to need, what inventory do we need? That was roughly around 2018. And soon thereafter, we started using Actis. So the combination of both ACM and Actif cut back dramatically on the number of boxes of stems and cups that were sent to the center for surgical day. Fast forward to ten years later. Now we are like most centers, obsessed with time and efficiency and trying to manage the different throughputs of the center. And constantly we're looking at different types of technologies to record our day and to see where we are efficient and where we could be more efficient. Another technology that was presented by my depuse sales representative was the DEO solution. And I'm not sure if you're familiar with that one, but that's one where a cell phone is anchored in the corner of the room. And through their proprietary technology, they're able to record the workflow during a surgery. And in between turnover and what they can do is they can this video recorded and then they translate to, you know, a table that actually graphs time so you can track what different team members are doing and what the surgeon is or is not doing during a case and in between cases. So we were able to see what our overtime was, you know, what our time efficiency was from wheels in to cut to close to wheels out. And so I think that technology gave us great insight into where we could be more efficient. And they were able to identify, you know, things as granular as this one assistant tends to take a lot longer in closing the wound. So we were able to then help, you know, our teammates, you know, point out where we could be more efficient. And by doing that, you know, now you see your case numbers improve because you're able to do more cases in, you know, the same amount of time.
- [07:07]
Brian Zimmerman
That's really fascinating. Appreciate the background on the technology. Can you share a little bit? I mean, because that's just got to. I would imagine for someone who's been doing this a while, that's just got to be such a new. Unlocking some new potentials there. Can you just share, I guess, personally, what that experience has been like for you in terms of the time savings and also any tips in terms of how you communicate using this data, putting it into play? Because I imagine there could be some Hesitancy. Did that come up at all? Anything you can share there?
- [07:37]
Dr. Robert Maley
Yeah, absolutely. I think the open collaboration with everybody in your facility, whether it's a hospital or an asc, is crucial. So we, one of the first things that we did was we created a total joints team and that consisted of our administrator, our medical director, who's an anesthesiologist, myself, and then a data collections person, as well as our lead nurse on the total joint team. And we meet monthly, we have met monthly for 10 years, you know, and at each meeting try to be open and honest with our feedback on what's going right and what's going wrong with the program. We review outcomes data, we review complications, we review new technologies and see, or try to see where we could become more efficient and what we can do to optimize the program. I think that the biggest thing there is to have a team that feels that they can speak honestly, that can present constructive criticism to the anesthesiologist. You're taking too long on doing spinals or blocks to the surgeon. You're taking too long to, you know, do this. Is there something that you could do quicker? Because Dr. A does it faster than you do. So I think open communication is the key to having the honest dialogue that will improve your efficiencies along the way. But you're right, I mean, having these technologies that come up and being able to see, you know, what your day looks like, you know, on a step by step printout is very impressive.
- [09:06]
Brian Zimmerman
I imagine so. And struck by your comments there too, around like sort of, you know, really maximizing the use of the tech. Technology requires this culture of transparency that you've built over time. Thinking about that culture of transparency, it seems like your team is very well positioned to adapt new technologies. Are there anything else that you're working on in this space in terms of bringing in technologies to support different things in the asc? What else are you finding value in?
- [09:35]
Dr. Robert Maley
I mean, several things. So I don't want to get into the weeds of some of the other stuff that we do in orthopedics because, you know, we have partners that are great in total shoulders and spine and whatnot. So focusing mostly on hip and knee anytime a new tech comes in. Especially being in San Francisco where technology is very common and patients, you know, have a. Patients are well read, they are well informed, they understand what's in the marketplace and what the marketplace has to offer. So I think us being willing to at least evaluate something to see if it's going to be a Potential benefit to our practice, our center, our patients, is very important. And I think our most recent focus has been our expansion. I mentioned that we were, you know, multi specialty center. We had five, we have five operating rooms. But we found that as our total joint program grew, we were running out of space. So we opened up two brand new ors on another floor in our surgery center. So our current, you know, project is trying to manage, manage this in trying to truly become a high efficiency center for total joint replacement. So one of the most recent projects that we're taking on is tracking, you know, tracking where people are in the workflow of a day of surgery. So where the patient is, how much time they're spending in pre op, how much time they're in the operating room, how much time they're in PACU before discharge. Same thing goes for anesthesia and the surgeon and the surgical team and then our turnover teams. That's our current focus.
- [11:09]
Brian Zimmerman
Excellent. I appreciate that background. You've shared so many really tangible details about how you're operating with this technology in your practice. But zooming out here, and I don't know if this is news to you, you're probably aware, but you do have a reputation as a thought leader in this industry. So curious to close out here. I would love to just, I guess, hear your reactions to that. How do you take that? What ways, I guess do you try to lean into that, get back to community or share your expertise with other colleagues?
- [11:41]
Dr. Robert Maley
I mean, I'm very flattered by that statement. You know, you come into practice and you think you're trying to basically stand on the shoulders of the giants. So that trained you, right, and trying to, you know, apply what they have taught you and then bring it into practice. And outpatient surgery is not new. We learned from Dr. Berger, you know, how to, how to successfully do a total joint replacement and send a patient home the same day. You know, but it was coming into practice, into an area that was not doing that, that was eye opening because again, I have fantastic partners that are excellent surgeons. But patients were staying in the hospital for two to three days and then being sent to Skilled Nursing 60% of the time. And so trying to change that needle, that's where it was a bit of a struggle in the beginning. And I think being one of the first ones at our center to do outpatient joints with the support of the administrator and our hospital partner was critical because that really enabled and empowered me to try to look for the things that can help us move our needle. And to be honest, we started off small and if you look at our 10 year track record, you'll see that it's an exponential improvement in terms of numbers of cases done per year. And it's because at each point over the years we were able to become better. We were able to A, prove that it worked, B, show that it was safe, and then work with industry and our industry partners on the different technologies. I mean, I can tell you 2018 was a major inflection point in the number of cases that we were able to do. We had three technologies that came in, you know, all at once. We had ACM that was helping us plan and stock our inventory. We, you know, adapted concise during that time and envelop HypNav in the ASC patients. As you were probably well aware, these are going to be your younger patients for the most part, you know, that are going to have increased expectations, higher demands, better bone quality. So being able to template and to accurately execute your plan without, you know, destroying your body, trying to broach the femur and pack the socket, you know, became very important for us. You know, now as the programs have matured, you know, we lean on technology once again. We're using the Vellus robot for total knee replacements. We're seeing our CU scores jump up five points compared to where they were prior to the use of the robot. It is driving patients to us. We don't advertise that we have a robot. We don't try to sell anything on that. Right. We just try to execute the appropriate surgical plan for a patient and provide them the best outcome. If we can do that, then patients are going to be your microphone. They're going to drive patients to you because their outcomes are better. So I think it's been an evolution to your point. It's been 10 years that we've been doing it specifically there. And I'd like to think we were on the front end of the curve. And maybe that's why I get to have these conversations with people like you where we're talking about the different things of eic. I've been on the journey, I've seen the complications, I've seen the struggles that can happen and can occur. And you know, I, I do like to talk about it, I do like to share the experience with others because, you know, I'd rather see somebody be able to improve their learning curve, you know, in a much quicker fashion than have to go through all the trials and tribulations that we went through. You know, I think sharing knowledge is how we all learn and how we all get better.
- [14:59]
Brian Zimmerman
Dr. Mali, I think that that's a wonderful place to end appreciate the the generosity with your time and coming on the podcast to to share your wisdom and insights with. I truly appreciate it.
- [15:11]
Dr. Robert Maley
Great. Thank you for having me.
- [15:13]
Brian Zimmerman
Also want to thank our podcast sponsor, J and J Medtech. You can tune to more podcasts from Becker's Healthcare by visiting our podcast page at beckerspodcast. Com.