Supply Chain can fuel doctor-patient relationships, organizational health

Depending on the healthcare organization, and professional and personal attitudes, physicians and surgeons can be a boon or bane to supply chain operations.

Those physicians and surgeons who cooperate and collaborate with Supply Chain executives and professionals see the Big Picture in how products and services, selected via evidence-based and outcomes-oriented value management, impact healthcare organizations and patients.

Those who cop to diva proportions and a superiority complex can be cast as persona non grata in the fiscal chess match between financial operations and clinical responsibility.

Some doctors can be demanding, difficult and even disrespectful.

Other doctors simply “get it.” They recognize and understand the part Supply Chain plays in the health of an organization where they practice medicine and serve their patients. These doctors also recognize and understand the valuable and valued role they play in the supply chain process to accomplish their shared mission.

These enlightened physicians and surgeons are the types Healthcare Purchasing News stepped up to identify and salute with its annual P.U.R.E. award that debuted last year. P.U.R.E. signifies Physicians Understanding, Respecting and Engaging Supply Chain professionals. HPN bestows its P.U.R.E. award on those physicians and surgeons who have made solid contributions to supply chain operations – activities, practices and thinking. HPN designed it to further solidify and strengthen the clinical bonds between physicians and supply chain professionals.

Last year HPN selected four physicians to receive the inaugural P.U.R.E. award; this year three join their ranks, selected from noteworthy nominations submitted to HPN.

HPN’s 2017 Supply Chain-Focused physicians are Stephen Trigg, M.D., Physician Liaison and Consultant, Mayo Clinic’s Department of Orthopedics, Jacksonville, FL; Michael Suk, M.D., JD, MPH, FACS, Chief Physician Officer (CPO), Geisinger System Services and Chairman, Musculoskeletal Institute, Geisinger Health System, Danville, PA; and Michael Worsey, M.D., Board-certified colorectal surgeon on staff at Scripps Memorial Hospital, La Jolla, CA, and Medical Director of Value Analysis for the Scripps Health System.

Trigg has partnered with Supply Chain Management and the clinical practice for more than 10 years. He chairs the Supplies and Technology Team (STT) to evaluate new technology. STTs are physician-led committees whose membership includes professionals from Supply Chain Management, clinical departments, Contracting, Revenue Cycle and Finance that work together to reduce waste through standardization while supporting innovation. All three Mayo sites – Rochester, MN, Jacksonville, FL and Phoenix/Scottsdale, AZ – now use Trigg’s STT process enterprise-wide. Trigg also provides physician leadership for a project called Challenge and Beyond, which has generated more than $22 million in expense reduction and revenue enhancement during an 18 month span.

As CPO and a practicing clinical trauma surgeon, Suk serves as the “key bridge between the clinical enterprise and the health system’s operating infrastructure “ where he works to fuse strategic planning and master facility planning while working closely with Supply Chain, Pharmacy and IT, and integrating them into clinical processes. During the last year, Suk had led an aggressive OR transformation process that includes preference card management, and supply and pharmaceutical flow throughout the pre-, intra- and post-op processes for patients. He also is co-leading a value analysis process redesign for the organization, even as he leads the orthopedics value analysis team at the institute, engaging Supply Chain for advanced planning efforts. Suk has identified surgeons to help Supply Chain develop and use supply data standards and supports the development of a centralized warehouse process at Geisinger.

Worsey worked to establish an effective value analysis process for Scripps by aligning closely with Supply Chain as well as surgery leadership, the Chief Medical Officer, chiefs of staff and service/care line physician leaders at every hospital. He challenged his peers when their new product requests competed with similar products already on the shelves. Rarely engaged in the supply chain process, requesting physicians weren’t aware of the stock on-hand and showed little interest in financially oriented discussions, which led to requests for more than 5,000 products annually and unused inventory – much of which amounted to expired product – valued at more than $7 million. As a result, Worsey standardized the 27 committees handling physician product requests down to one requiring physicians to make their requests via a nurse in Supply Chain, explaining the problem they’re trying to solve, the importance of the product, and whether it’s urgently needed or for a particular case. The committee of clinicians conducts a review on whether the requested product warrants adoption based on clinical evidence or demonstrated ability to improve patient outcomes.

Recently, Worsey has been leading utilization reviews with general surgeons – independent private physicians and foundation physicians at Scripps. He also led a General Surgery Summit for those practicing at Scripps to encourage transparency between physicians in areas of comparative quality and costs per procedure. During the Summit, the Supply Chain contracting team met with the surgeons about the cost of competing products and their preference cards, and corporate finance reviewed their scorecards containing data on total costs to perform surgery, lengths of stay and surgical site infections.

HPN’s wide-ranging interview explored how all three became supply chain champions and maintain a sense of unity about the people, processes, products and services that impact patient outcomes and operational stability.

HPN: Why has it taken so long for doctors to become more directly involved in supply chain issues?

Stephen Trigg, M.D., Physician Liaison and Consultant, Mayo Clinic’s Department of Orthopedics, Jacksonville, FL

First and foremost is a lack of prior education and familiarity with supply chain analytics and logistics. Most physicians don’t have any idea what is involved in supplying the products and equipment to run a healthcare institution.

Michael Suk, M.D., JD, MPH, FACS, Chief Physician Officer, Geisinger System Services and Chairman, Musculoskeletal Institute, Geisinger Health System, Danville, PA

Physicians are not as closely attuned to the institutional expense of delivering healthcare. Most doctors have an expectation that the tools necessary to deliver the best possible care will be available when needed – without top-of-mind regard to what they cost. Because there is limited cost transparency and high availability in many environments, this leads to a misperception of the expense.

Michael Worsey, M.D., Board-certified colorectal surgeon on staff at Scripps Memorial Hospital, La Jolla, CA, and Medical Director of Value Analysis for the Scripps Health System

Two reasons. Firstly, because there had not been much need. Our system had been very profitable for many years and it has only been in the last one-to-two years that reimbursement has significantly fallen requiring a hard look at costs. Secondly, physicians have had no interest in what many perceive as the thankless task of asking their colleagues to give more thought to what they use, why they use it and its cost.

TRIGG REVEALED

Unlikely source of inspiration: History, it keeps repeating itself.

Most creative thing you’ve ever done: Fathered three very talented, independent, non-medical children — two musicians and an artist/animator.

What makes you laugh: British TV humor.

Best and worst advice someone ever gave you: Best: 90 percent of success is perspiration and only 10 percent inspiration; Worst: This investment cannot fail (if it sounds too good to be true, invariably it is).

Must-have accessory: Reversing camera on my car.

Favorite thing to do on a day off: Exercise and go to the beach.

Surprising fact about you: I am the first person in my family to ever go to college.

Describe yourself with three words: Determined (some would say stubborn), fair (I did play cricket after all) and inquisitive (when one stops asking questions and trying to improve it is time to retire).

Favorite object you keep in your office: A rugby ball. It reminds me of the many friends and great experiences I had while playing for 25 years and now have as a spectator. (I just returned from two weeks in New Zealand watching the British Lions tour.)

What you would tell yourself if you traveled back in time to when you just started in healthcare: Do your very best for each and every patient, work hard, never refuse a genuine request for help and know when to ask for help. Then good things will happen — and have happened.

WORSEY: Most physicians are amenable to reason when approached in the “right manner.” If you give them a good reason to do something and make it easy to do most will do it!

What convinces, inspires, motivates you to be willing to cut costs, even if it means switching to a brand of product with which you may not be comfortable or favor for whatever reason?

TRIGG: Most physicians are data-driven striving to obtain optimum treatment outcomes for our patients. What we have learned is that with proper analysis of cost variation and outcome data often times utilization of lower-cost products and practices will result in equivalent treatment outcomes. Evidence-based medicine coupled with effective Supply Chain analysis and implementation will become strategically linked in the near future in my view.

SUK: Years ago, out of curiosity, I reviewed the balance sheet for a complex procedure and was able to see the direct cost of implants and disposables used, and the list of open and yet unused items in relation to the surgeon, and facility charges and collections. It became clear that my “preference items” were not reflective of the best negotiated price and the “open and unused” items were simply a form of wasted resource. I quickly became involved in implant negotiations and reshaping my preference cards. Recognizing that unit cost was not the only factor to be reconciled, I began to overlay the per-minute labor and facility costs, including anesthesia, pharmacy, storage and sterilization, and overall hospital revenue into the equation. Today, I have made this transparency and context available each surgeon at Geisinger – which has further led to important related initiatives on OR efficiency, physician satisfaction and optimization.

WORSEY: As long as a product or piece of equipment has clinical evidence to show equivalent outcomes and a cost, contracting or standardization benefit I will try it. My motivation is that, in general, most instruments or equipment are fairly similar and the most important variable is the skill of the person using it.

Why do you believe physicians are so reluctant to change product brands?

TRIGG: Once a physician is achieving good results using any particular drug, procedure or device, there is an understandable reluctance to try something else unless it is proven to be significantly more effective.

SUK: For the great majority of physicians, there is a comfort level associated with familiarity that can be related to job performance and ultimately to clinical outcomes. Recognizing this, “changing brands” should not be taken lightly. Industry and institution must make commitment to educating, training and trialing to accommodate for nuances beyond what is on paper. This requires partnership and commitment. Focusing solely on cost will lead to the perception that and institution is focused on a “cheapest is best” philosophy – which will create resistance and resentment.

WORSEY: Many physicians are resistant to change since one of the keys to success, especially in surgery, is to develop an effective and efficient way to perform a procedure and then try and do it the same way every time. Standardization, then repetition (of technique and equipment) will maximize performance of at least 90 percent of surgical procedures. However, despite this a skilled surgeon should be adaptable and resourceful.

When you hear the excuse used to justify physician preference items, “because that’s what I was trained on in med school,” or “if I don’t get this I’ll take my patients somewhere else,” what goes through your mind?

TRIGG: Narrow mindedness and unprofessional behavior never arrives at a favorable solution to any problem. It is necessary that accurate information has been presented to allow for any reasonable person to make an informed decision. Hopefully this type of behavior is a rarity.

SUK REVEALED

Unlikely source of inspiration: Spending an uninterrupted 15 minutes in a green space.

Most creative thing you’ve ever done: Writing a novel. It is a work in progress…

What makes you laugh: My children.

Best and worst advice someone ever gave you: Best advice: Always assume good intentions; Say what you want, not what you don’t want. Worst advice: “Play by the book”

Must-have accessory: My iPhone… it tells me where I need to be…

Favorite thing to do on a day off: I enjoy time with my family, landscaping my yard or playing tennis/golf.

Surprising fact about you: I was selected as a White House Fellow by President George W. Bush and served as Special Assistant to Secretary Gale A. Norton at the U.S. Department of the Interior. With her, I co-authored the article titled, “America’s Public Lands and Waters: Gateway to Better Health?” based on the belief that simple outdoor activities such as hiking, biking and camping on public lands and waters can serve as a gateway to a healthier lifestyle. The progeny of this effort can be seen almost everywhere today and remains a passion of mine through my work with the National Park Service and several other non-profit organizations.

Describe yourself with three words: Creative, confident, results-oriented.

Favorite object you keep in your office: I have a candid photo of eminent Swiss surgeons, Maurice Mueller and Hans Willenegger, who more than 50 years ago founded the Arbeitgemeinschaft Osteosynthesefragen (AO). The methodology, tools and principles they established represented a paradigm shift in the way we treat fractures throughout the world. It is fair to say that every orthopedic surgeon in the world practicing today has been taught and influenced by their work. It serves as a reminder to me of what is possible with determination and visionary thinking.

What you would tell yourself if you traveled back in time to when you just started in healthcare: I have always challenged conventional wisdom in some way throughout my career — whether it be as a liberal arts major applying to medical school; simultaneously tackling degrees in medicine, law and public health; becoming public policy advocate while being a physician; or leading a fast-growing, innovative musculoskeletal institute as a practicing orthopedic trauma surgeon while bridging the gap to institutional operations. In retrospect, I would not change a thing. I would remind myself that to be a physician leader in healthcare, it is important to actually have been a physician in healthcare.

SUK: Medical school and residency training represents early steps in lifelong learning. No single vendor or group of vendors should have a monopoly on that. With regard to the statement, “if I don’t get this I’ll take my patients somewhere else” – for me the answer is simple…go “somewhere else.”

WORSEY: “You are not in medical school or residency anymore.” If you are not amenable to a well-reasoned and sensible discussion regarding preference items that takes into consideration clinical effectiveness, cost and standardization, then maybe we are better off if you take your patients elsewhere, too.

Just how influential are/were those sales rep perks anyway and how does this emerging “repless” model compare?

TRIGG: A good salesman with or without perks can have an influence on the decision to buy or adopt anything in the marketplace be it a pharmaceutical or the purchase of an automobile. Reps have to earn a living and are always looking for ways to influence a physician to adopt what they are marketing. Given the recent trends toward a “repless” sales model the largest companies are now bypassing the physicians altogether and are marketing directly to the patients with television commercials and print ads. Some of these medications and therapies are still in clinic trials or are among the most profitable drugs in the pharmaceutical company portfolio. Patients are demanding their physicians prescribe them because they saw the ad on TV. New world…

SUK: A “repless” model is an interesting concept but one that has significant execution challenges. In many cases, a device rep is the single consistent presence in the operating room environment on at any hour of any given day, and with time they become a critical member of the team. Replacing that resource is more than simply teaching staff the mechanics of a device system. It requires a true hospital commitment to OR teaming, flawless supply chain execution and a suitable backup system in case things go wrong. I am somewhat skeptical of the “savings” attributed to this model beyond the short-term – without a true partnership based on cost transparency and open dialogue, surgeons will lack the intrinsic motivation to achieve institutional long-term success.

WORSEY: The influence of sales reps and their “perks” varies enormously. Some are genuinely helpful and want you to have the best outcome for your patients with the use of their product being of secondary importance. Some want you to use their product at all cost and are willing to be dishonest and try and bribe you to do so. The “repless” model does have some potential advantages, but I think that mandatory physician disclosure of any financial interest in a product is a more important issue

Will you describe some of the challenges that physicians have in working with Supply Chain?

TRIGG: Different worlds really. Physicians have historically been left out of Supply Chain management and logistics, and Supply Chain was not involved in direct patient care equipment and pharmaceutical decision making. Given the economic reality of the rising cost of healthcare factored against declining reimbursements we have to come together and develop collaborative work groups that draw upon the expertise of everyone. Being involved with developing of this collaborative approach has been for me one of my most professionally important accomplishments.

SUK: Because surgeons and physicians take the long view of clinical journey – what happens in the operating room or interventional suite has a downstream effect on patient satisfaction and outcome that is not necessarily visible to Supply Chain leadership. It is for that reason that doctors can be particular and occasionally obstinate in ensuring they have the tools to perform their very best. Supply Chain analysts may not have the same context and direct perspective and can appear insulated from accountability. This is why it is critical to involve clinical perspectives in the dialogue.

WORSEY: Firstly, physicians receive little, if any, formal training in the financial aspects of medical care and have no idea as to the cost of most things they use. Secondly, administrative roles are very different to clinical practice, with a different culture, viewpoints and perspectives. Finally, it can be difficult to reconcile the sometimes “entrenched” view in supply chain that it is an obligation to provide a physician with whatever they want regardless of cost and evidence of clinical superiority.

Where do you see the physician’s/surgeon’s relationship with Supply Chain heading long-term?

SUK: In the long-term, both sides of the enterprise ledger will be a shared responsibility. This is evident in today’s alternate payment and shared risk models of care delivery that have begun to take hold. With increasing integration and commitment to value-based models – enhancing patient outcomes while saving costs will undoubtedly drive physicians and Supply Chain closer together.

WORSEY: The physician must become be an essential part of a clinically integrated and efficient supply chain. Only someone still in active clinical practice can give the bedside or operating room perspective of what product selection and product standardization really means to patient care. Likewise, only an actively practicing physician has the credibility to approach colleagues and have difficult discussions regarding resource/supplies utilization, outcomes and cost.

How do you see Supply Chain’s professional relationship changing with physicians and surgeons when it comes to evaluating “new” technology and technology horizon scanning?

TRIGG: One of the surprising things I have learned from my Supply Chain colleagues is how adept they are in a whole range of applied analytics and logistics. Surgeons are trained to want what they want when they want it as we have to plan for every contingency. An ongoing meeting of the minds which analyzes the critical needs to take care of the patient without incurring expensive over supply or redundant technology leads to a much tighter and more efficient operation at a lower cost.

SUK: When executed correctly, the relationship between physicians and surgeons will grow closer with Supply Chain as it pertains to new technology and innovation. This is not only true because of the need for a balanced approach to clinical and non-clinical imperatives, but also because emerging technologies can pave the way to higher value. What we must be mindful of is too great a focus on bringing in the new without sunsetting similar, outdated materials. Supply Chain, through its inventory accounting, can be an important checkrein in this regard.

WORSEY: There is a “tidal wave” of new technology and new products, and physicians have to be involved in the initial clinical review and evaluation. Ideally, each specialty and sub-specialty would designate a physician to work with Supply Chain to evaluate products in their field and determine if there is a clinical advantage over existing products. If a clinical advantage is determined, then Supply Chain would evaluate cost and contracting issues. These evaluations, along with consideration for standardization opportunities, would then be used to determine whether a new product/technology is added or not. There is the case of “new and unique” technology as opposed to incremental improvement over existing technology. [In this case] there is really no clinical track record nor anything to compare, which is a little more difficult. Each hospital or system should determine if they have leaders in their fields who would be “early adopters/evaluators” for these products and a process for subsequent evaluation.

What benefits can physicians gain by working so closely with Supply Chain in the area of identifying and evaluating new products, services and technology?

SUK: Physicians can understand the financial or otherwise implications that are attendant with a new product or service and further align objectives. A shared governance approach that spans clinical request to clinical evidence review all the way through enforcement of decisions can be beneficial to all and avoid unnecessary conflicts.

WORSEY: When a physician evaluates new products/technology it requires them to take a good long hard look at the clinical problem, existing products/technology and conduct a thorough clinical review of available literature. All too often we have a narrow focus and little time to keep up with current and future developments.

What benefits can Supply Chain gain by working so closely with physicians in the area of identifying and evaluating new products, services and technology?

SUK: Having a clinical voice involved in Supply Chain provides an essential barometer on changing technology, techniques and clinical care pathways. How that is managed is critical ensuring a balance of financial metrics and clinical justifications.

WORSEY: Supply Chain gains from the clinical expertise of physicians who are the end users and can give a perspective not available in the literature. Additionally, the development of a solid working relationship with physicians allows each to see the other’s perspective and then more easily come to a mutually agreeable consensus.

How might having a physician or surgeon on the Supply Chain staff – or even leading the department – change the dynamic?

TRIGG: From first-hand experience developing a collaborative team of physicians and Supply Chain staff has efficiently streamlined the entire process of the point to point episode of patient care. Once we also added Revenue, Finance and Pharmacy colleagues to our group we had a team that could effectively analyze the entirety of the cost of care in real time. Knowing this has important predictive implications for future institutional planning of growth, infrastructure, and advancing the science of healthcare.

SUK: Having a dyad leadership structure between physicians and administrators is an ideal model to foster forward progress, promote an alignment of goals and communicate management decisions. The physician or surgeon has the ability to bring a credible clinical balance to the financial pressures associated with cost containment. And when done the right way – new technology can be balanced with the retirement of older technology, and physician preference items can be openly adjudicated. A clinician should have the willingness and ability to translate clinical advantages to the financial context while at the same time support the financial contextual drivers that may lead to hard decisions.

WORSEY: As the Medical Director of Value Analysis/Supply Chain I have, with the help and support of administration, assisted in streamlining and standardizing the previously fragmented and very heterogeneous management of supply chain throughout the hospitals in our system. Additionally, having a physician leader makes Supply Chain interaction with other physicians much more productive, since physicians do not respond well when being told – or even asked – what to do by administrators. Morale has improved in Supply Chain as having physician support, encouragement and backup makes interaction with other physicians less stressful. They can always refer a difficult physician to me!