Maximizing service line efficiency, quality and profitability is a hot topic, particularly with rising patient care demands, changing reimbursement models, and estimated physician shortfalls. This webinar takes a look at three solutions beginning in the operating room and expanding to the entire patient care journey. 1st solution: A unique clinical and operational service model focused on the specialization of qualified, reimbursable clinical labor to optimize surgeon involvement and reduce OR costs. 2nd solution: Taking a holistic view of the service line through the patient care journey to produce a value stream map to understand the current state. Assisting staff with comparing this current state to the ideal future state, comparing national benchmarks and clinical best practices helps your staff innovate and co-create an individualized plan to get your service line to a higher level. 3rd solution: Utilizing dashboard metrics of the critical to success factors, to sustain and improve your service line. As a participant, you will be able to: • Identify key operational and clinical indicators of orthopedic service line efficiency • Describe how Surgical First Assists can add value in the OR • List the steps in developing and/or evaluating or building an orthopedic service line • Describe how metrics/dashboards assist in sustaining change and improvement of orthopedic service line About the Speaker: Miki Patterson, PHD ONP, Senior Director of Orthopedics in Intelligent CareDesign at Intralign Dr. Patterson is a certified orthopedic nurse practitioner and brings over 25 years of clinical experience in healthcare, consulting, direct advanced orthopedic patient care, teaching, NIH level, qualitative and quantitative research and publishing. She is a past president of the National Association of Orthopedic Nurses (NAON) and continues to be nationally recognized for leadership and advancing orthopedic care.

1. 3 Strategies for Maximizing
Service Line Efficiency,
Quality, and Profitability
Miki Patterson PhD RNFA ONP
Vince Capasso, MSF, FACHE, MBB
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2. Speakers
Miki Patterson PhD RNFA ONP
• Certified Orthopedic Nurse Practitioner
• Over 30 years of clinical experience in healthcare,
consulting, RNFA, direct advanced orthopedic patient
care, teaching, NIH level, qualitative and quantitative
research and publishing
• Past president of the National Association of
Orthopedic Nurses (NAON) and continues to be
nationally recognized for leadership and advancing
orthopedic care
• Dr Patterson has done extensive work with hospital
leadership desiring to improve their clinical quality
and process issues while teaching change
management and giving voice to clinicians and
hospital personnel.
• PhD in Nursing Research from University of
Massachusetts Medical School, a Master’s Degree
from Boston College, and her B.S. in Nursing at
Fitchburg State University
Miki Patterson, PHD ONP
Senior Director,
Intralign
Intelligent CareDesign
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3. Speakers
Vince Capasso
• Certified Six Sigma Master Black Belt and Fellow in the
American College of Healthcare Executives
• Over 30 years of Business, Process Design, Strategy
Deployment, and Balanced Scorecard experience in a
broad variety of organizations that include consulting,
government, manufacturing, service, and
healthcare. His business experience includes executive
leadership positions in Accounting, Finance, IT, and
Supply Chain functions.
• Vince has managed hundreds of complex Process
Improvement and Strategy Deployment projects. He
has taught extensively on Lean Six Sigma, Human
Centered Design, and Strategy Deployment; has
developed Lean-Six-Sigma and Change Management
courses for many global organizations, and has been
published in national journals on the subject.
• Master of Finance degree from Bentley University and
Vincent Capasso, MSF, FACHE,
Six Sigma Master Black Belt
Senior Director, Operational
Process CareDesign
a B.S. of Accounting degree from Southern New
Hampshire University 3

4. Objectives
As a participant, you will be able to:
• Identify key operational and clinical indicators of orthopedic service
line efficiency
• Describe how Surgical First Assists can add value in the OR
• List the steps in developing and/or evaluating or building an
orthopedic service line
• Describe how metrics/dashboards assist in sustaining change and
improvement of orthopedic service line
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5. Healthcare in Transition
Providers must increase efficiency and control
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When outcomes are linked to reimbursement,
providers must drive towards value based care.

6. Sample of Total Joint Service Line Cost
• Roughly 45% of Episode costs are incurred in the intra-operative space
• Controlling the intra-operative space is key to improving efficiency, reducing cost and
• Control begins in the Operating Room with efficient surgeon extension
• To gain Total Joint Service Line Excellence status, data transparency, process refinement,
Rehab
$5,000 (10%)
Acute
Post-Op
$5,000 (10%)
marketing and supply chain excellence are also needed
Intra-Operative
$22,500 (45%)
Implant 41%
Hospital 45%
increasing quality
Clinic/
“Pre-hab”
$15,000 (30%)
Admission/
Pre-Op
$2,500 (5%)
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Episode of care costs

7. Bending the Cost Curve
• Alignment of surgeons and
hospitals; clinical and operational
goals
• Integration of tools and
strategies to enhance
transparency and accountability
• Change management – Strength
and capability to affect lasting,
sustained change
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Innovative Vision

8. 1. Alignment
Alignment of Surgeons, Clinicians,
and Hospital with Patient Needs

9. Alignment
Why isn’t everyone
on the same page?
The right tools can
bring clarity to goals
and objectives and
create a common
purpose.
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It takes some work!

10. 3Ps of Alignment
Process
Purpose
People
Purpose
• Is Direction Clear?
• Is the message Heard & Understood?
• Are we using the right metrics?
• Do we have a Strategy Deployment Process?
Process
• Are staff and managers trained in problem solving?
• Is there a structured Process Improvement
Methodology?
• What is the level of Efficiency?
• Does the Organization utilize standard work?
People
• What is the level of Staff Satisfaction?
• Are we Patient-Centric?
• Are there Appropriate Resources?
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11. First, understand the various voices you
will hear. Each has a different perspective.
Voice of the Customer (VOC)
• Used to describe customers’ needs and their
perceptions of your services, product, or process.
Voice of the Business (VOB)
• Used to describe your business’ needs in creating
the service or product.
Voice of the Process (VOP)
• Used to describe the current state of the process;
how is the process performing. Is it capable of meeting
customer needs?
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12. Gather Voices and Affinitize the “Themes”
Rose, Bud, Thorn Exercise | Management & Staff
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Education and Staff
Equipment Development
Culture
Trust/Cohesiveness/Accountability
Teamwork
Intra Dept.
Financials
ROSE / Positive
BUD / Opportunities
THORN / Problems
C-Suite Leadership
“Revolving door”
Patients
Surgeons
IT Systems
MD Engagement
Staffing Levels
Facilities
Engagement
Efficiency
New Ventures
Teamwork
Inter Dept.
Culture
Autonomy &
Environment
New “learning”
Leadership
Staff Flexibility
Surgeons not
Engaged

13. Gather Voices and Affinitize the “Themes”
Rose, Bud, Thorn Exercise | Patients
13
The Doctor is not
always listening
Not answering call-bells
promptly
Great Nurses
ROSE / Positive
Room has a View
Surgery went Well
Food is Very Bad
Was in Pain Waited a LONG
Time
Nurse did Not Listen
Crowded and Loud
Hallways
Would Like to have
Facilities need meal time flexibility
upgrading
Lots of noise
Receptionist was
Rude
Great PT Staff
My Surgeon is
Abrupt
BUD / Opportunities
THORN / Problems

14. Summarize the “Voices” and Synchronize
with Strategy
Voice of The
Business
Voice of The
Process
Voice of The
Customer
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15. 2. Closing Operational Gaps
Understanding Gaps Between
Current State vs. Desired Future State

16. Service Line Excellence
The Drivers of Service Line Excellence
Clinical & Operational Excellence:
Pre-Op, Intra-Op, Post-Op
Service Line Integration
& Efficiency: Patient Care Journey
Supply Chain Best Practices
Infrastructure and Practices in
Place to Drive Continuous Improvement
Effective Governance
within a Just & Safe Culture
Effective Information Systems
Structure & Analytics
Optimized Financial Management
Alignment of Partners Across
the Continuum of Care
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17. 17
Clinical and
Operational
Excellence
Efficient, Safe, High
Quality Processes
Appropriate/Optimized
Staffing
Effective/Efficient
Sterile Processing
Employ Best
Clinical Practices
Patient-Centered
Care
 % of patients with medical clearance
14 days prior to surgery
 % charts with History & Physical
complete 10 days prior to surgery
 85% + On Time First Case Starts
 Time patient waits in holding area
 Frequency of same OR team operating
together
 Staffing levels are appropriate based
on predictive modeling
 Avg Turn Around Time < 21 min
 Standard process in place and
followed for OR set-up
 Defect-free transfer of patient to PACU
 Patient assessment complete and
documented within 30 minutes of
arrival in PACU and every hour
thereafter
Driver
Critical to Success
Indicator
Critical to Success
Metrics

18. How Does The Critical-to-Success
Tool Work?
Goal Drivers Critical to Success Indicators
Big Goal
Goal Driver #1
Goal Driver #2
Goal Driver #3
Critical to Success Indicator 1
Critical to Success Indicator 2
Critical to Success Indicator 3
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19. Building the Critical-to-Success Tree
Drivers are like themes. They
frame and compartmentalize
the goal.
Goal Drivers
Increase
Ortho
Margin
Strong Surgeon
Alignment
Surgical Process
Efficiency
Best Practice Implant
Management
Standardized Processes
Patient-Centered Care
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20. Building the Critical-to-Success Tree
Goal Drivers Critical to Success Indicators
Critical to Success Indicator
(CTSI)
These are another layer of
compartmentalization. They
break down the drivers into
measurable areas.
Increase
Ortho
Margin
Strong Surgeon
Alignment
Surgical Process
Efficiency
Best Practice Implant
Management
Standardized Processes
Patient-Centered Care
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21. Building the Critical-to-Success Tree
Goal Drivers Critical to Success Indicators
Increase
Ortho
Margin
Strong Surgeon
Alignment
Surgical Process
Efficiency
Co-Management Agreement
in Place
Surgeons Are Engaged
Best Practice Processes
Hospital provides consistent
surgical teams
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22. Building the Critical-to-Success Tree
Critical to Success Indicators Critical to Success Metrics
Co-Management Agreement
in Place
Surgeons Are Engaged
Best Practice Processes
Hospital provides consistent
surgical teams
20-30% of compensation is tied to gain sharing
On Time Starts at 85% +
75%+ of Surgeons participate in shared
governance activity
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23. Timeline: Knee Replacement Observation
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Illustrating Pain Points
7:45 8:15 8:45 9:15 9:45 10:15 10:45 11:15 11:45 12:15 12:45 1:15 1:45 2:15 2:45
Pt. in Room
10:22
Tourniquet
Off
12:05
Time Out
10:26
Incision
10:56
Surgeon Exit
12:35
Dressing On
12:49
Pt. Arrives in Pre-Op
8:30
Anes. Arrives for Nerve
Patient Waits
67m
Block
8:57
Patient Waits
27m
2nd Time Out
10:53
Nerve Block
Induction
9:15
Patient
Wheeled Out
12:56

24. Spaghetti Diagram: Hip Surgery
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Metric Mapping
Key | # of In & Outs
Surgeon: 1
RN Circulator: 16
Device Rep: 9
Scrub Tech 1: 1
Scrub Tech 2: 6
Scrub Tech 3: 5
PA: 1
Anesthesia 1: 0
Anesthesia 2: 1
Other: 2
Total: 42

25. Value Stream Map : Flows and Waste
25

26. 3. Implementing Change
Using the Correct Tools and Approach
to Move the Organization to a New Reality

27. Identify “Quick Wins” First
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Quick Wins
1 Update white Boards - room and Central (time slots for discharge and rehab)
2 Discharge Education Class - Pilot
3 Night before discharge call to family for transport
4 ON-Q ordering process / Improve
5 Nursing pain management assessment/training (i.e. heel slide to check pain)
6 Room discharge clearing for cleaning: belongings, CPM, tubes, meds, etc..
7 “Room Dirty” notification process
8 Sleeper sofa/plan around overnight
9 Potential for CPM install in AM/tech - day of discharge
10 Unit TV with Ortho-specific media content
11 Consider switching rehab gym with waiting room gym
12 PACU and TJ Floor use dual monitors | PACU needs Teletracker monitor,
TJ Floor needs PICIS monitor

28. Plot projects based on Resources and ROI
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What will give you most benefit for least effort?
Roadmap of High-Impact Tactical Projects | Example
High
Med
Low
Improve Discharge Process
Streamline Surgical Flow
Reduce Case Time Late Starts
Staff Resource Planning
Low Med High
Return on Investment: Hard $ only
Resources Required
(time, effort, staff, cost)
Improve Time Out
Disposable Supply Improvement
– Outside OR Core
Cell Saver Analysis/Redesign
Antibiotic Cement Analysis/
Redesign
Maintenance and Equipment
Improvement
Surgical Set Analysis/Flow
Improve Surgical Scheduling
Disposable Supply Improvement –
OR Core
Medicare TJA Bundled Care
Data Mapping
Revenue Cycle Assessment
TDABC Model
TJA Supply Chain Implant Cost
Medicare Pricing Accuracy
Improve TJA Education

29. Week
1-3
Week
4
Week
5
Week
4-15
Week
16
Assessment
Project
Kick-Off
Roadmap
Remaining
Projects
Onsite
Remote
Coaching
Onsite
Remote
Coaching
Onsite
Remote
Coaching
Co-creation, Recommendations, & Pilots Dashboard
Implementation
100 Day Sprint Methodology
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30. Process Transformation: Project Examples
Sample Results: Peri-Op Infection Rate Reduction
Problem Result
Total Joint infection rates
were at 3% vs a national
average of .72%.
After 6 months the total joint infection
rate was 0% resulting in a projected
savings of $1.4 million per year through
avoidance of extended length of
stay/treatment and readmission.
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31. Process Transformation: Project Examples
Sample Results: Surgical Cancelation Rate Reduction
Problem Result
The cancellation rate dropped to 6% and
identified the potential to improve margin
by 1.4M with estimated margin impact for
FY 2013 of $500K.
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The surgery cancellation rate
was consistently high for
three years, at 13% at the
time of engagement.

32. Intelligent Process Transformation
Sample Results: Supply Chain Efficiency
Problem Result
The hospital was experiencing
high supply cost, increasing
OR supply chain labor cost,
stock-outs and excess
inventory.
Reduced total supply inventory by $670K.
Reduced supplies on specialty carts by
$70K and reduced labor cost of $80K.
Before Before After After
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33. “Sales reps have created this
necessity for themselves with
the surgeon, and we’re saying
it’s not as necessary as
everyone thinks it is.”
Justin Freed, Executive Director of Supply Chain at
Loma Linda University Medical Center
Source: Lee, Jaimy. "Devicemaker Sales Reps Being Replaced in the OR." Modern Healthcare 16 Aug. 2014

34. The Role of the Sales Rep
Influencing the Cost of Orthopedic Implants
• Lack of price transparency
and rep presence leads to
unnecessary up-sell
• Rep or multiple reps in OR
slows room turnover
• Clinical support provided by
the rep is not free – charged
through hefty SG&A implant
cost
The result: Loss of control, reduced
efficiency and higher supply costs.
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35. Effective Support of Operational & Clinical Efficiency
Specialized SFAs – the Smarter Alternative
Low High
Doctors assisting
Partners
Practice Employed
SFAs
Freelance SFAs
Hospital Employed
SFAs
Specialized
SFAs
Advanced Surgical Support Adds Value
in the OR
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Skill Level / Efficiency

36. Consider Advanced Surgical Support
Specialized Surgical First Assists are a Highly Skilled Group
of Surgeon Extenders
Experience Matters: University of MD St. Joseph Medical Center Case
Study / 2013 data
Procedure
Actual
procedure
time
Typical
procedure
time*
# of 2013
procedures
Minutes
freed
General Surgery 100 138 1123 42,674
Urology 205 270 117 7,605
GYN 128 138 80 800
*Estimated average surgery time without SFA is based on 2012 Medicare
data and top HCPCS codes associated with each procedure area. 36

37. Sustaining the Gains
Maintaining Accountability, Automating
Dashboards and Linking Metrics to Projects

38. Maintaining the Gains / Strategy Execution
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Use Dashboards to track key metrics
Strategy
Goals
Metrics
Projects
Responsible

39. Maintaining the Gains / Strategy Execution
Using your Critical to Success Metrics focus your data collection on the
metrics that drive success
Strategy
Goals
Metrics
Projects
Responsible
39

40. Thank You