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Hi, everyone. This is Brian Zimmerman with Becker's

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Healthcare. Thank you so much for tuning in

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to the Becker's Healthcare podcast.

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Today, we're going to talk about clinical excellence,

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economic value, and operational support in the ASC.

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Joining me for this discussion is doctor Robert

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Maley.

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Doctor Maley is a fellowship trained, board certified

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orthopedic surgeon who specializes in hip and knee

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replacement and practices out of California

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Pacific Orthopedics.

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Doctor Maley, thank you so much for being

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here today.

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Thanks for having

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me. So so let's start by, I guess,

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getting to know you a little bit more.

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Can you can you share a little bit

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more details than what I did there about

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about your professional background and the work you're

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doing?

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Yeah. So I grew up in the Bay

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Area and was fortunate to find a job

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in San Francisco

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coming out of fellowship. I did my residency

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at Stanford and,

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fellowship in hip and knee replacement at Rush

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in Chicago. And at Rush, in particular, I

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learned a lot of then, newer techniques for

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less invasive surgery,

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outpatient surgery, in addition to revision surgery. So

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coming into the Bay Area, I was really

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kind of eager to apply what I had

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learned

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and,

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unfortunately, part of a

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big group. There's about 15 of us.

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Great partners,

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but total joint replacement in the outpatient setting,

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you know, was a new thing in San

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Francisco when I came into practice about thirteen

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years ago.

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So, yeah, I've had a very unique journey,

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developing our program at our surgery center. I

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feel like I've learned a lot along the

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way.

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Our group services San Francisco and Marin County,

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so we see a lot of patients from

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the Bay Area. We see, you know, very

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young

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active athletic, you know, patients that have worn

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out their joints to the middle aged and

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even the the older folks. So we practice,

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you know, both at a hospital setting as

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well as an ASC setting.

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Excellent. Appreciate the background. And I'm I'm sitting

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in front of a microphone here in Chicago,

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so certainly have a bias for for for

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your your education that you what you what

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you did and what you learned,

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at Rush. So appreciate that that piece of

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the background as well.

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You have,

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a pension, I'd say, I guess, for for

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pioneer pioneering new technologies within the ASC space.

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With so many new technologies hitting the market,

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how do you decipher which ones you want

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to trial?

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That's a great question. You know, whenever something's

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presented to you, you have to take into

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account,

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what could be helpful and what might just

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be noise. During my journey of trying to

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transition cases to the outpatient setting, I was

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trying to look and see what we actually

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really needed.

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Our surgery center, which is Presidio Surgery Center

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in San Francisco, is a multi specialty center.

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So you have

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general surgeons, ENT, orthopedic surgeons, spine surgeons, all

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practicing at one facility.

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So when we started our total joint program

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about ten years ago, we were looking for

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different efficiencies that could help

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us not only start the program, you know,

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but also save us in terms of trying

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to navigate bringing a whole new service line

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to an already busy center. So when presented

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with new technologies,

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oftentimes we're looking to

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we were looking to solve a problem and

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fortunately somebody came up with one and and

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presented it to us. And as as we

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began our journey, as we got going, there

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were things that that came along the way

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that we realized, you know, operating on younger

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patients,

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with better bone quality

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just required

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the use of tools that we didn't have.

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And so,

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as we started to see, tools like Concise

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come along, we were introduced to efficiencies and

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technologies that were,

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greatly needed in our space. So, you know,

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anytime a new tech comes up, you know,

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I'm eager to at least look at it,

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evaluate it, and see if there can be

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something that we can apply for usage in

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our center.

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Yeah. And it sounds like based on your

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response there,

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the the technology has to be solving for

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something. Correct? There's gotta be a problem present.

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Exactly. Yeah. Yeah.

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I wanna get to sort of a quote

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that we hear from time to time when

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talking to to leaders in this space is,

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you know, if you can't measure it, then

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you can't manage it. How does this, I

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I guess, relate to you? Are there any

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particular technologies that that come to mind that

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you and your center are currently using to

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to measure and manage?

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Yes. So the we're doing total hip and

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total knee replacements.

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When we started our total joint program, you

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know, ten years ago, now we do shoulders

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and elbows. I have partners that do shoulders

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and elbows. But in the very beginning, one

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of our struggles was inventory. So we were

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having a conflict of

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booking six cases, trying

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to manage the inventory for those cases,

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and the reps were bringing in, you know,

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six trays, you know, actually more than six

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sets of trays for every case because we

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were at that time, this is before Actus

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came out. So we

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were ordering Karai, but then we'd have a

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Summit on backup. And so the inventory grew

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exponentially. And in San Francisco, we don't have

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a lot of real estate and we were

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trying to manage all this inventory. So,

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one of the original technologies that I was

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introduced was advanced case management.

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It's a partnership between DoxSpera and J and

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J Medtech.

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And one of the things that they were

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able to measure was on the preoperative templating

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side, you know, to get an idea of,

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you know, the patient's age

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and the, templated

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side so that we had a better idea

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of what to expect.

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That was the first time that we were

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able to really truly

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quantitate

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our needs in terms of what sizes are

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we going to need, what inventory do we

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need.

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That was roughly around 2018

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and soon thereafter we started using Actus. So

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the combination of both ACM and Actus

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cut back dramatically on the number of boxes

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of stems and cups that were sent, to

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the center, you know, for a surgical day.

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Fast forward to, you know, ten years later,

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you know, now we are, like most centers,

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obsessed with time and efficiency in trying to

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manage, you know, the different,

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throughputs of the center.

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And constantly, we're looking at different types of

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technologies

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to record our day and to see

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where we are efficient and where we could

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be more efficient. Another technology that was presented

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by my DePuy sales representative was the DEO

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solution.

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And I'm not sure if you're familiar with

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that one, but that's one where

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a cell phone is anchored in the corner

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of the room.

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And

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through their proprietary technology, they're able to record

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the work flow during a surgery and in

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between turnover.

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And what they can do is they can,

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this is video recording and then they translate

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to, you know, a table that actually graphs

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time. So you can track what different team

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members are doing

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and what the surgeon is or is not

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doing during a case and in between cases.

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So we were able to see what our

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turnover time was, what our time efficiency was

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from wheels in to cut, to close, to

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wheels out.

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And so I think that technology gave us

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great insight into where we could be more

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efficient. And they were able to identify

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things as granular as this one assistant tends

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to take a lot longer

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in closing the wound.

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So we were able to then help you

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know, our teammates,

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you know, point out where we could be

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more efficient. And by doing that, you know,

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now you see your case numbers improve because

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you're able to do more cases in in,

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you know, the same amount of time.

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That that that's really fascinating. Appreciate the background

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on the technology. Can you share a little

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bit I mean, because that's just gotta I

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I would imagine for for for someone who's

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been doing this a while, that's just gotta

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be such a new unlocking some new potentials

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there. Can you just share, I guess, personally,

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what that experience has been like for you

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in terms of the time savings? And also,

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any tips in terms of how you communicate,

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you you know, like, using this data, putting

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it into play? Because I imagine there there

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could be some hesitancy.

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Did that come up at all? Anything you

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can share there?

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Yeah. Absolutely. I think the open collaboration with

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everybody in your facility, whether it's a hospital

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or an ASC,

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is crucial. So, we one of the first

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things that we did was we created a

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total joints team, and that consisted of our

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administrator,

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our Medical Director who is an anesthesiologist,

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myself

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and then a data collections person as well

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as our

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lead nurse on the Total Joint team. And

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we meet monthly. We have met monthly for

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ten years, you know, and at each meeting

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try to be open and honest with our

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feedback on what's going right and what's going

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wrong with the program. We review

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outcomes data, we review complications,

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we review new technologies,

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and see or try to see where we

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could become more efficient,

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and what we can do to optimize the

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program.

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I think the the biggest thing there is

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to have

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a team that feels that they can speak

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honestly,

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that can,

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present constructive criticism

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to the anesthesiologist.

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You're taking too long on doing spinals or

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blocks. To the surgeon, you're taking too long

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to, you know, do this. Is there something

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that you could do quicker because doctor

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a does it faster than you do? So

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I think open communication is is the key

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to

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having the honest dialogues that will improve your

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efficiencies

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along the way. But you're right, I mean,

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having these technologies that come up and

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being able to see

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what your day looks like on a step

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by step printout is very impressive.

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I imagine so. And struck by your comments

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there too around like sort of,

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you know, really maximizing the use of the

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technology requires this culture of transparency that you've

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built over time.

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Thinking about that, that culture of transparency, it

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seems like your team is

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very well positioned to adapt new technologies.

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Are there anything else that that that you're

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working on in this space in terms of

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bringing in technologies to,

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to to support different things in the ASC?

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Are are you what what else are you

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finding value in?

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I I mean, several things. So,

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I don't want to get into the weeds

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of some of the other stuff that we

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do in orthopedics because we have partners that

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are great in total shoulders and spine and

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whatnot. So focusing mostly on hip and knee,

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anytime a new tech comes in, especially being

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in San Francisco where technology is very common

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and patients have a patients are well read,

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they are well informed, they understand

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what's in the marketplace and what the marketplace

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has to offer. So I think us being

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willing to

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at least evaluate something to see if it's

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going to be a potential

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benefit to our practice, our center, our patients

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is very important.

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And I think

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our most recent

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focus has been our expansion.

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I mentioned that we were, you know, a

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multi specialty center. We had five we have

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five operating rooms, but we found that as

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our total joint program grew, we were running

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out of space. So we opened up two

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brand new ORs

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on another floor in our surgery center.

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So our current, you know, project is trying

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to manage

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manage this and trying to truly become a

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high efficiency,

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center for total joint replacement.

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So one of the most recent projects that

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we're taking on is is tracking, you know,

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tracking where people are in the workflow

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of a day of surgery. So where the

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patient is, how much time they're spending in

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pre op, how much time they're in the

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Operating Room, how much time they're in PACU

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before discharge.

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Same thing goes for anesthesia and the surgeon

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and the surgical team,

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and then

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our turnover teams.

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That's our current focus.

329
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Excellent. I appreciate that background. You've shared so

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many sort of really,

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you know, tangible details about how you're how

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you're operating with this technology in your practice,

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but zooming out here. And I don't know

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if this is news to you. You you're

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probably aware, but, you do have a reputation

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as a as a thought thought leader in

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this industry.

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So curious to close out here. I would

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I would love to you just, I guess,

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hear your reactions to that. How do you

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take that? Or or what ways, I guess,

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do you try to lean into that, give

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back to the community,

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or or share your your expertise with other

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colleagues?

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I mean, I'm very flattered by that statement.

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You know, you come into practice and you

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think

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you're trying to basically stand on the shoulders

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of giants so that trained you, right, and

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trying to apply what they have taught you

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and then bring it into practice. And outpatient

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surgery is not new.

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We've learned from doctor Berger, you know, how

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to how to successfully do a total joint

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replacement and send a patient home the same

357
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day. But it was coming into practice into

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an area that was not doing that, that

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was eye opening because,

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again, I have fantastic partners that are that

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are excellent surgeons. But, patients were staying in

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the hospital for two to three days and

363
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then being sent to skilled nursing sixty percent

364
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of the time. And so trying to change

365
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that needle,

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that's where it was a bit of a

367
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struggle in the beginning. And I think being

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one of the first ones at our center

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to do outpatient joints with the support of

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the administrator and our hospital partner

371
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was critical because that really enabled and empowered

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me to try to look for the things

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that can help us move our needle. And

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to be honest, we started off small. And

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if you look at our ten year track

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record, you'll see that it's an exponential

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improvement in terms of numbers of cases done

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per year. And it's because at each

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point over the years, we were able to

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get become better. We

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00:12:53,345 --> 00:12:54,404
were able to,

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A, prove that it worked, B, show that

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it was safe

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and then

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work on

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with industry and our industry partners on the

387
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different technologies. I mean, I can tell you

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2018 was a major inflection point in the

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00:13:06,839 --> 00:13:08,519
number of cases that we were able to

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00:13:08,519 --> 00:13:09,019
do

391
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because we had three technologies that came in

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all at once. We had ACM that was

393
00:13:13,879 --> 00:13:16,940
helping us plan and stock our inventory. We

394
00:13:17,480 --> 00:13:18,539
adapted Concise

395
00:13:18,919 --> 00:13:20,220
during that time and envelosibnab.

396
00:13:21,324 --> 00:13:23,324
And so in the ASC patients, as you

397
00:13:23,324 --> 00:13:24,684
are probably well aware, these are going to

398
00:13:24,684 --> 00:13:26,784
be your younger patients for the most part

399
00:13:27,084 --> 00:13:29,404
that are going to have increased expectations, higher

400
00:13:29,404 --> 00:13:30,865
demands, better bone quality.

401
00:13:31,245 --> 00:13:33,404
And so being able to template and to

402
00:13:33,404 --> 00:13:35,584
accurately execute your plan

403
00:13:36,204 --> 00:13:36,704
without

404
00:13:37,210 --> 00:13:38,669
destroying your body trying

405
00:13:39,129 --> 00:13:41,309
to broach the femur and pack the socket,

406
00:13:41,529 --> 00:13:44,250
you know, became very important for us. You

407
00:13:44,250 --> 00:13:46,409
know, now as the programs have matured, you

408
00:13:46,409 --> 00:13:48,409
know, we lean on technology once again. We're

409
00:13:48,409 --> 00:13:51,335
using the Velas robot for total knee replacements.

410
00:13:51,335 --> 00:13:53,735
We're seeing our COO scores jump up five

411
00:13:53,735 --> 00:13:55,414
points compared to where they were prior to

412
00:13:55,414 --> 00:13:56,475
the use of the robot.

413
00:13:56,855 --> 00:13:58,855
It is driving patients to us. We don't

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00:13:58,855 --> 00:14:00,714
advertise that we have a robot. We don't

415
00:14:00,855 --> 00:14:03,009
try to to sell anything on that. Right?

416
00:14:03,009 --> 00:14:03,669
We just

417
00:14:04,049 --> 00:14:06,449
try to execute the appropriate surgical plan for

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00:14:06,449 --> 00:14:08,470
a patient and provide them the best outcome.

419
00:14:08,610 --> 00:14:10,049
If we can do that, then patients are

420
00:14:10,049 --> 00:14:12,289
going to be your microphone. They're going to

421
00:14:12,289 --> 00:14:14,769
drive patients to you because their outcomes are

422
00:14:14,769 --> 00:14:15,490
better. So,

423
00:14:16,504 --> 00:14:18,184
I think it's been an evolution to your

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00:14:18,184 --> 00:14:20,584
point. It's been ten years and that we've

425
00:14:20,584 --> 00:14:22,524
been doing it specifically there and

426
00:14:22,904 --> 00:14:24,024
I'd like to think we were kind of

427
00:14:24,024 --> 00:14:25,325
on the front end of the curve.

428
00:14:26,105 --> 00:14:28,504
And maybe that's why I get to have

429
00:14:28,504 --> 00:14:30,105
these conversations with people like you, right, where

430
00:14:30,105 --> 00:14:31,909
we're talking about you know, the different things

431
00:14:31,909 --> 00:14:33,110
of the AC. I've been on the journey.

432
00:14:33,110 --> 00:14:35,110
I've seen the complications. I've seen the struggles

433
00:14:35,110 --> 00:14:37,210
that that can happen and can occur.

434
00:14:38,230 --> 00:14:40,549
And, you know, I I do like to

435
00:14:40,549 --> 00:14:41,750
talk about it. I do like to share

436
00:14:41,750 --> 00:14:44,504
the experience with others because, you know, I'd

437
00:14:44,565 --> 00:14:47,524
rather see somebody be able to improve their

438
00:14:47,524 --> 00:14:49,845
learning curve, you know, in a much quicker

439
00:14:49,845 --> 00:14:51,924
fashion than have to go through all the

440
00:14:51,924 --> 00:14:53,705
trials and tribulations that we went through.

441
00:14:54,085 --> 00:14:56,565
You know, I think, sharing knowledge is how

442
00:14:56,565 --> 00:14:57,845
we all learn and how we all get

443
00:14:57,845 --> 00:14:58,345
better.

444
00:14:59,360 --> 00:15:01,440
Doctor Meili, I think that's that's a wonderful

445
00:15:01,440 --> 00:15:03,759
place to end. Appreciate the the generosity with

446
00:15:03,759 --> 00:15:05,860
your time and coming on the podcast to

447
00:15:06,159 --> 00:15:08,399
to share, your wisdom and insights with folks

448
00:15:08,399 --> 00:15:10,019
today. Truly appreciate it.

449
00:15:10,480 --> 00:15:12,100
Great. Thank you for having me.

450
00:15:12,565 --> 00:15:15,044
Also wanna thank our podcast sponsor, J and

451
00:15:15,044 --> 00:15:16,964
J MedTech. You can tune in to more

452
00:15:16,964 --> 00:15:19,684
podcasts from Becker's Healthcare by visiting our podcast

453
00:15:19,684 --> 00:15:22,584
page at beckerspodcast.com.