Hi, everyone. This is Brian Zimmerman with Becker's
Healthcare. Thank you so much for tuning in
to the Becker's 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 doctor Robert
Maley.
Doctor Maley is a fellowship trained, board certified
orthopedic surgeon who specializes in hip and knee
replacement and practices out of California
Pacific Orthopedics.
Doctor Maley, thank you so much for being
here today.
Thanks for having
me. So so let's start by, I guess,
getting to know you a little bit more.
Can you can you share a little bit
more details than what I did there about
about your professional background and the work you're
doing?
Yeah. So I grew up in the Bay
Area and 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. And at Rush, in particular, I
learned a lot of then, 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, part of a big group. There's about
15 of us.
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 thirteen
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 services San Francisco and Marin County,
so we see a lot of patients from
the Bay Area. We see, you know, very
young
active athletic, you know, patients that have worn
out their joints to the middle aged and
even the the older folks. So we practice,
you know, both at a hospital setting as
well as an ASC setting.
Excellent. Appreciate the background. And I'm I'm sitting
in front of a microphone here in Chicago,
so certainly have a bias for for for
your your education that you what you what
you did and what you learned,
at Rush. So appreciate that that piece of
the background as well.
You have,
you
have, a a a reputation, a pension, I'd
say, I guess, for for pioneer 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?
That's a great question. You know, 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 Presidio Surgery Center
in San Francisco, is a multi specialty center.
So you have
general surgeons, ENT, orthopedic surgeons, spine surgeons, all
practicing at one facility.
So when we started our total joint program
about ten 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 and
presented it to us. And as as we
began our journey, as we got going, there
were things that 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, you know,
anytime a new tech comes up, you know,
I'm eager to at least look at it,
evaluate it, and see if there can be
something that we can apply for usage in
our center.
Yeah. And it sounds like based on your
response there,
the the technology has to be solving for
something. Correct? There's gotta be a problem present.
Exactly. Yeah. Yeah.
I wanna get to sort of a quote
that we hear from time to time when
talking to to leaders in this space is,
you know, if you can't measure it, then
you can't manage it. How does this, I
I guess, relate to you? Are there any
particular technologies that that come to mind that
you and your center are currently using to
to measure and manage?
Yes. So the we're doing total hip and
total knee replacements.
When we started our total joint program, you
know, ten years ago, now we do shoulders
and elbows. 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 ordering Karai, but then we'd 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 DoxSpera and J and
J Medtech.
And one of the things that they were
able to measure was on the preoperative templating
side, you know, to get an idea of,
you know, the patient's age
and the, templated
side so that we had a better idea
of what to expect.
That was the first time that we were
able to really truly
quantitate
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 Actus. So
the combination of both ACM and Actus
cut back dramatically on the number of boxes
of stems and cups that were sent, to
the center, you know, for a surgical day.
Fast forward to, you know, ten years later,
you know, now we are, like most centers,
obsessed with time and efficiency in trying to
manage, you know, 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 DePuy 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 work flow during a surgery and in
between turnover.
And what they can do is they can,
this is video recording 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
turnover time was, 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
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 in,
you know, the same amount of time.
That that that's really fascinating. Appreciate the background
on the technology. Can you share a little
bit I mean, because that's just gotta I
I would imagine for for for someone who's
been doing this a while, that's just gotta
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,
you you know, like, using this data, putting
it into play? Because I imagine there there
could be some hesitancy.
Did that come up at all? Anything you
can share there?
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 is 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
ten 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 the 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 doctor
a does it faster than you do? So
I think open communication is is the key
to
having the honest dialogues 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
what your day looks like on a step
by step printout is very impressive.
I imagine so. And struck by your comments
there too around like sort of,
you know, really maximizing the use of the
technology requires this culture of transparency that you've
built over time.
Thinking about that, that culture of transparency, it
seems like your team is
very well positioned to adapt new technologies.
Are there anything else that that that you're
working on in this space in terms of
bringing in technologies to,
to to support different things in the ASC?
Are are you what what else are you
finding value in?
I 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 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 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, a
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 and 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 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.
Excellent. I appreciate that background. You've shared so
many sort of really,
you know, tangible details about how you're 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 you're
probably aware, but, you do have a reputation
as a as a thought thought leader in
this industry.
So curious to close out here. I would
I would love to you just, I guess,
hear your reactions to that. How do you
take that? Or or what ways, I guess,
do you try to lean into that, give
back to the community,
or or share your your expertise with other
colleagues?
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 giants so that trained you, right, and
trying to apply what they have taught you
and then bring it into practice. And outpatient
surgery is not new.
We've learned from doctor Berger, you know, how
to how to successfully do a total joint
replacement and send a patient home the same
day. 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 that
are excellent surgeons. But, patients were staying in
the hospital for two to three days and
then being sent to skilled nursing sixty percent
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 ten 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
get become better. We
were able to,
A, prove that it worked, B, show that
it was safe
and then
work on
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
because we had three technologies that came in
all at once. We had ACM that was
helping us plan and stock our inventory. We
adapted Concise
during that time and envelosibnab.
And so in the ASC patients, as you
are probably well aware, these are going to
be your younger patients for the most part
that are going to have increased expectations, higher
demands, better bone quality.
And so being able to template and to
accurately execute your plan
without
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 Velas robot for total knee replacements.
We're seeing our COO 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 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 ten years and that we've
been doing it specifically there and
I'd like to think we were kind of
on the front end of the curve.
And maybe that's why I get to have
these conversations with people like you, right, where
we're talking about you know, the different things
of the AC. I've been on the journey.
I've seen the complications. I've seen the struggles
that 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.
Doctor Meili, I think that's 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 folks
today. Truly appreciate it.
Great. Thank you for having me.
Also wanna thank our podcast sponsor, J and
J MedTech. You can tune in to more
podcasts from Becker's Healthcare by visiting our podcast
page at beckerspodcast.com.