Innovation in Surgical Services
Surgical Services Innovation requires more than new clinical procedures and technologies. Behind the effective clinical innovations is a mountain of process and behavioral innovation that is required to implement the new breakthroughs. Read the following article from O.R. Manager magazine to better understand the steps required for successful Surgical Innovation.
Innovation: The path to superior OR teamwork and results
Cynthia Shaver, RN, MSN; OR Manager, Vol. 33 No. 5 May 2017
Healthcare lags behind other industries when it comes to innovation. That’s partly because new treatments must be vetted for safety and efficacy, and partly because fee-for-service reimbursement sparked little incentive for creativity and efficiency.
Under value-based purchasing, OR leaders have more opportunity to be innovative, but first they must understand what innovation is (and isn’t) and how to promote it. “Innovation is creating something completely new that doesn’t exist in the world,” says John Kenagy, MD, director of Kenagy & Associates in Longview, Washington, and a clinical professor of surgery at the University of Washington, Seattle.
Many academic hospitals now have innovation centers, such as the Center for Innovation at Mayo Clinic, Rochester, Minnesota, that provide multiple resources, ranging from 3-D printers for creating prototype products to sophisticated electronic white boards where teams can develop ideas.
These centers can be valuable resources for OR directors, says Cheryl Weisbrod, MSN, RN, nurse administrator for surgical services at Mayo. Weisbrod has tapped into the center’s expertise to develop parallel OR processing techniques. “[Staff at the center] have an out-of-the box thinking, energy, and creativity that help people look at things differently,” she says.
“Innovation can be used every day to help hospitals and patients,” says Thomas Fee, MBA, managing partner of Verity Partners, LLC in Atlanta, Georgia. “It often fundamentally changes the process you use to get the work done.”
But innovation goes beyond leading-edge technology or new devices, and you don’t have to work in an organization with a formal center to apply innovation tools and principles, he adds.
What are the tools of innovation?
Innovation isn’t the same as process or performance improvement, which focus on reducing variance in the workflow. “Performance improvement tools like Lean and Six Sigma don’t work well for innovation,” says Fee. In fact, they often cause an innovation to fail. “They focus on current processes, but with innovation, you want to throw out the current process and put a new, better one in place,” he says. “The focus is on outcomes.”
Those seeking to innovate must learn new tools, and one key tool is design thinking, which focuses on identifying customer needs and behavior. “It’s all about the end users, whether it’s the surgeons or patients, who are the central customers in an OR,” Fee says. “You need to ask them what they really need and what their expectations are, and then work back from there to come up with really creative answers that meet those expectations.” Observing, listening, and engaging customers helps determine their journey and typical behaviors.
Design thinking originated with architects, and Fee uses the example of a new OR layout to illustrate the concept. When asked to design a new OR, leaders first need to ask questions such as, “What kinds of patients are going to come into this OR? What kinds of surgery are we going to do?” He says the next step is to “forget about our old ideas of what an OR should be and come up with a brand-new layout that will better conform to what we think the future is going to look like and the future needs of our patients.”
n addition to tools, OR leaders need to consider the stages of innovation—scope, design, develop, implement, and rollout. A study of 14 innovation centers by MarketSquare, in collaboration with the Duke Innovation and Entrepreneurship Initiative, identified best practices across the stages. Fee coordinated the survey.
Scope, or “scoping” refers to identifying and selecting opportunities. Fee says the study of innovation centers showed that it’s important at this stage to create a simple, focused project proposal. The proposal sets the direction toward the goal by defining the opportunity, including risk assessment, establishing the project team, and outlining funding.
At innovation centers, projects are typically evaluated and selected by an advisory panel. Similarly, OR leaders can establish their own advisory panel, which Fee says should include those external to the organization, to provide a wider viewpoint. During scoping, leaders should focus on opportunities, rather than jumping into making a business case.
During this step the team applies design thinking. In addition to focusing on the customer, team members test their own assumptions, create solutions, and recruit those who can help them with the project. This can sometimes be done inexpensively by tapping into local colleges for expertise in areas such as technology or human behavior.
At this stage, prototypes (working solutions) are evaluated through rapid-fire, agile pilot testing (sidebar 2, p X). “You need to get to ‘show me’ as fast as you can,” Fee says. That means choosing what’s called “minimally viable” solutions, where spending is kept to a minimum. Fee notes that organizations often focus on funding too early in the process, before the decision has been made on what solution to pursue.
Leaders should tell the pilot team to use the initial solution from the design step every day for 2 weeks and to ask themselves, ‘How could I use this better? What is it I need to change about this to better meet the customer needs?’”
Then they should let the team determine what works best.
The pilot team must consider the big picture in addition to making individual changes. “Keep asking what the trade-offs are so that you can continually improve the overall outcomes,” he says. The prototype will undergo iterations based on feedback from daily debriefings. ”Your first prototype is usually not the best,” Fee says. “You have to go to the third or fourth prototype. Often by the second or third iteration, you make a radical change based on your findings of actually trying to use the innovation.”
Two weeks is about the right amount of time for a prototype pilot to avoid burnout, Fee says. After that, the team can take a break, celebrate, evaluate, and decide where to go next. The team should assess how the prototype stacks up against the desired quality, service, satisfaction, financial, and volume or utilization. Teams should consider whether they’ve reached a breakthrough. If something is lacking, another 2-week pilot is needed.
Implementation takes the chosen solution to a larger playing field. Teams build a business case that includes operational plans, such as training, and financial implications.
Again, starting smaller before expanding is key. For example, Dignity Health in San Francisco, California, uses a practice called “Run, Run, Jump” when implementing new technology. The first pilot requires technology partners to test feasibility in an area where the likelihood for success is high. The second pilot test takes the solution to a very different setting where there is no product champion. If both pilots succeed, the organization commits to full implementation. During this phase, word of mouth from users is effective in building wider support.
This strategy could easily be applied in the OR even when making internal changes. For example, an OR director could start a new process within one service line before expanding it to others.
During this phase, the solution is scaled up to the entire organization (or entire OR). In addition to training, social media can be helpful in sharing success stories and reinforcing positive behavior. “You need to keep things moving because innovation is perishable,” Fee says of the entire process. “Project teams can lose momentum.” Ideally, a working solution should be developed within 90 days.
Innovation in surgery
The five stages of innovation can be grouped conceptually into desirability (what do customers need or want?), feasibility (what can we build or create?), and viability (what can we profitably deliver?).
Here is an example of an innovative surgical product that illustrates the stages.
Scope: The identified opportunity was finding a way for a urologist to inject with a syringe without experiencing the frustration of having to remove his eyes from the cystoscope during a procedure.
Design: A team including an engineering student, surgeon, and OR staff designed a syringe that gave an audible click each time one unit was administered.
Develop: Within 2 months, a prototype was developed in the laboratory setting.
Implement: The prototype was piloted for 3 months.
Rollout: The product will be commercialized.
Keep in mind, however, that innovation also applies to ideas or approaches, not just products.
Innovation methodologies aren’t just for innovations developed within an organization. “If you adopt innovation from the outside, regardless of how much training the vendor provides or case studies [sales representatives] show you, you still need to do a ‘shake-down cruise’ like you would do for a new sailboat,” Fee says.
That means once again having a team use the innovation for a few weeks to work out the bugs before implementing it more widely, Fee says. “If you look back at almost every innovation you’ve implemented in the OR, after about a week or so, people said it was too hard and they wanted to go back to the old way,” Fee says.
Piloting on a smaller scale helps minimize those negative feelings. For example, when implementing electronic health records, it’s not enough just to have a vendor provide education about the different screens. Staff must understand how their processes need to change to accommodate the new technology; otherwise, they may try to take shortcuts or other workarounds.
Fee also suggests a pilot approach for adopting new workflows such as enhanced recovery after surgery. “You can take a doctor and one team and have them work on it for a few weeks or months to prototype it before expanding it to other specialties,” Fee says. “With most innovations [from outside the organization], you have to change your process and techniques to make the innovation work.”
Embedding the concept
Innovation should be part of an organization’s culture, but Fee says most hospitals view it as an external tool set for specific projects.
At companies such as GE or 3M, which have an innovation culture, he says, “Everyone in the organization is trained in innovation; they have clear expectations as to their role and how quickly it will take to get from the idea to the initial design.” Dr Kenagy says the key to embedding innovation into the culture is moving from a “make/standardize/sell” organization, common in both business and healthcare, to a “sense/respond/adapt” organization by using Adaptive Design (OR Manager, August 2015, pp 4, 5; www.kenagyassociates.com).“It’s well documented that organizations can get to a sense/respond/adapt model, but management needs to be engaged at the start in leading this,” Dr Kenagy says.
To permeate the organization with innovation, leaders must consider how people make decisions. “The human brain is very good at improving on past success patterns, but for most of us, our brains are naturally designed to be quite uncomfortable with something we don’t know about,” Dr Kenagy says. This poses a challenge given that innovation doesn’t exist in the present form.
To foster a new way of thinking, Dr Kenagy suggests that leaders “create low-risk, high-reward opportunities for people to think and act differently,” he says. “They can start experiencing sense and respond, which leads to progress through adaptation and learning.” Experiencing progress toward a meaningful purpose is a very powerful way to change thinking. Even leaders based in an organization not adept at innovation can use the same principles to sense, respond, adapt, and learn.
Education is also required to embed innovation. For organizations that lack their own innovation centers, Fee suggests reaching out to those that have them and asking for a mentor or coach. Lists of innovation centers are available at http://www.beckershospitalreview.com/healthcare-information-technology/40-hospitals-with-innovation-centers.html and http://www.aha.org/advocacy-issues/initiatives/innovation.shtml.
Other resources include You Tube videos on design thinking and healthcare innovation, such as https://www.lynda.com/Creativity-tutorials/What-design-thinking/433738/462408-4.html, and books such as Innovation Navigation: How To Get From Idea To Reality In 90 Days, by Kurt Baumberger.
“The key thing of innovation is its focus on the outcome, not on the process,” Fee says. “Innovation gives people the freedom to make slight customizations [of a solution] to fit the work style of the team that’s using it; there’s room for creativity.”
At Mayo, Weisbrod notes that leaders must keep innovation front and center of management and staff, telling them, “Just because we are doing it this way today, doesn’t mean we need to keep doing it that way.” She adds, “We’re always thinking of how we can improve the surgical suite and are looking for ideas on listservs and at meetings.”
Weisbrod also says it’s important to give permission to fail. “It’s OK that we try something and it doesn’t work,” she says. In some cases, part of the idea is feasible and can be used “as is” or woven into another project.
Fee concludes with benefits that will resonate with most OR leaders: “Innovation is very exciting and a lot of fun.”
Cynthia Saver, MS, RN, is president of CLS Development, Inc, Columbia, Maryland, which provides editorial services to healthcare publications.
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