As the pandemic has continued to disrupt healthcare — including surgical services — hospital and health system leaders have employed a variety of resourceful strategies and best practices to deal with their most significant challenges.
Leaders are also working to continue improving surgical excellence while expanding the access to and use of da Vinci-assisted surgery.
We have compiled responses to some of the most pressing questions related to da Vinci-assisted surgical care asked in 2021.
Note: Responses have been edited for length and clarity.
Question: How can organizations assess performing procedures using da Vinci-assisted surgery in different sites of care, such as an ASC?
Kristen O'Connor, Market President, United Surgical Partners International, Inc.: USPI operates ambulatory surgery centers and surgical hospitals in 33 states and has worked closely with Intuitive on the outpatient da Vinci robotic front. When evaluating a da Vinci surgical program, USPI takes a "back to basics" approach. As with any new service line, this means running a pro forma and understanding the upside, the breakeven point and all critical components. USPI engages all key stakeholders including physicians, inpatient health system partners, anesthesiologists and staff.
In building this program, you start with the end in mind, focusing on patient and physician satisfaction and planning for each part of the patient visit. It must be well thought through, process mapped and considered in a different frame than the inpatient environment. When carefully managed, da Vinci surgery can be an excellent service line for ASCs.
Q: How does a hospital or health system expand access to minimally invasive care by increasing use of da Vinci technology to nights and weekends?
Andrea Pakula, MD, Medical Director of Robotic Surgery, Adventist Health, Simi Valley, Calif.: At many sites, use of da Vinci surgery often begins on a limited basis, offered on weekdays from hours such as 7 a.m. to 3 p.m. Barriers to expanded access include lack of staff training. But after generating data on the outcomes produced by da Vinci surgery, a natural evolution is to expand access, because increased access results in improved outcomes. It's a natural evolution in the adoption of minimally invasive technology. I want to be able to offer da Vinci to all patients, regardless of time of day. Using the da Vinci robots enables us to do some more of the complex procedures we see on weekends, at night, regardless of the time of day.
Q: What key measures do you look at to show the financial viability and value of da Vinci-assisted surgery?
Jeffrey Jackson, CFO, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, Ariz.: We look at data extensively. We look at length of stay, readmission rates, surgical site infections, throughput and we've started looking at not just margin per case but margin per minute. We have started looking at da Vinci surgeries compared to laparoscopic or open — and analysis shows that da Vinci surgery produces positive results. By doing procedures robotically we see improvements in length of stay and in our quality metrics. These metrics prove the value of da Vinci surgeries.
Q: What is the role of data analytics in a da Vinci-assisted surgery program?
Howard P. Kern, President & CEO, Sentara Healthcare, Norfolk, Va.: Our use of data analytics focuses on our performance in key areas that drive the value proposition for da Vinci. Examples include data on reducing mortality, reducing complications, improving length of stay, improving satisfaction and improving performance from the surgeon's perspective. These are areas we measure to validate that we're getting value out of da Vinci.
We are seeing meaningful performance differentiation on areas like length of stay, mortality and complications. Those numbers speak to the advantage not just of da Vinci and minimally invasive surgery but also the technology that da Vinci brings to the table. The da Vinci team has been a real partner in helping us with data analytics development to define metrics and benchmarks and work on process innovation.
Q: How do you make data visible and actionable?
Jonathan Velez, Chief Physician and Operations Executive, Gulf Coast Medical Center, Fort Myers, Fla.: We built a dashboard that has operational metrics, financial metrics, safety metrics, patient experience metrics and metrics on volume, length of stay and readmissions, among other measures. This dashboard provides visibility to senior leaders and to the da Vinci program steering committee about the da Vinci program's performance. It shows senior leadership what they've gotten for their investment and provides data to help drive continual improvement.
Q: Why is standardization so important? How to achieve it?
Mr. Kern: We believe the key to our success is having the ability to repeatedly and reliably deliver high-quality outcomes and excellent customer experiences. To do that, you have to have standardization; unwanted variation is the enemy of quality and service excellence. Standardization has been a core part of what we've done and how we've done it.
Standardization of policies, processes and technologies is particularly important for health systems that have da Vinci surgery at multiple sites, and for sites with numerous surgeons performing da Vinci surgery. We have developed system-based policies to provide consistency and we constantly look for best practices and then standardize these practices across the system. We have institutionalized the notion of standardization.
Q: What barriers does culture present? How do you change the culture?
David Beffa, MD, General Surgeon/Acute Care Surgeon, Sutter Health Medical Center, Sacramento, Calif.: Overcoming barriers and changing the culture can be hard, as the culture within an institution can make it difficult to make changes. Changing the culture and removing barriers requires buy-in from executive leadership, physician champions, education, outcomes data and busting myths.
When we first started our da Vinci journey, we were seeing amazing outcomes, but could only utilize a robot Monday through Friday during typical hours with regular block time. A problem with acute care surgery is that some of the sickest patients come in after hours, 24/7. So, we were seeing great outcomes in the limited time we used the robotics. But we were offering one standard of care during the week and another on the weekend. That two-tier dilemma presented ethical issues and drove us to expand after-hours access, because we knew the outcomes were better. We wanted to be able to offer the same standard of care, regardless of time or day. This was the wakeup call and the driving force to overcome our cultural barriers.
Q: Why do many organizations approach da Vinci-assisted surgery as a service line? What are advantages?
Mr. Kern, Mr. Jackson: While some health systems view da Vinci surgery as a "tool," many systems manage da Vinci surgery as a "service line." They have a vision for this service line, with service line strategies, standardized processes and policies across the entire system.
At Sentara, early on, da Vinci was managed hospital by hospital and even surgeon by surgeon. Today, Sentara has a service line model where the surgeons, management and clinical staff come together to look at the needs in the community and the demand models. Working together as a cohesive service line team means developing a vision and plans.
At Dignity Health, by managing da Vinci surgery as a service line the system's leaders can ask, "Are we doing the right cases to maximize the return on our investment?" The service line approach has advantages in entering into value-based agreements with commercial plans, where Dignity Health can incorporate da Vinci surgery where appropriate. Managing as a service line puts greater focus on metrics that matter to plans. As a result of its service line approach, Dignity Health sees improvements in its length of stay and quality metrics.
Q: With cost being a barrier to adoption of da Vinci surgery, what is the best way to overcome this barrier?
Gary Guthart, PhD, CEO, Intuitive: The key financial metric to health systems is the total cost of a complete episode of care. This includes the total cost for all materials, staff, capital equipment and recurring issues that come up from complications. Often when the question of costs arises, the conversation focuses on just one aspect of costs, such as material costs or the cost of capital equipment. Someone might focus on how much the scalpel costs. But that is not the dominant cost. A sophisticated and comprehensive cost analysis is required to look at the total cost for the entire episode of care. When this analysis is done, incorporating the costs of total OR time and the costs of complications, organizations can make informed, data-driven decisions. This "total cost" analysis usually finds that well-run da Vinci programs result in lower total costs than open surgical programs. This helps overcome concerns about the costs of da Vinci-assisted surgery.
Per Mr. Kern (Sentara Healthcare), analysis has found that with da Vinci, costs are on the order of 15 to 20 percent lower. This is due to shorter length of stay and lower operating room costs.
Q: How has training on da Vinci-assisted surgery changed since the pandemic began?
Dr. Guthart: Early on during the pandemic, Intuitive saw the need to pivot in how training was done. It was clear that getting on a plane or driving great distances wasn't going to work. Our team started working closely with customers to conduct training online and to use tools such as virtual reality. Intuitive also forward deployed training resources into local regions to have an increased physical proximity. The increased digital presence and increased local presence has resulted in increased access to training and improved convenience for customers.
To learn more, visit Intuitive's Content Hub.