(1)
Texas Institute for Robotic Surgery, Hospital Corporation of America, Austin, TX, USA
(2)
Intuitive Surgical International, Austin, TX, USA
Abstract
Although there are many challenges in setting up a successful daVinci surgery program, a clear reproducible path to success is within every program’s reach. By using a proven leadership and communication pathway and following a path of reducing variability, parallel tasks, and a continuous improvement cycle, you can join the hundreds of daVinci surgery programs across the country that have used this model to create growth and success. The results achieved can be dramatic and sustainable, revenue and growth simultaneously.
Background
There are currently thousands of da Vinci surgical systems at hospitals around the world. They are being used by surgeons on every continent except Africa and Antarctica, and when it comes to setting up, maintaining, and growing a successful daVinci surgery program, I can say with complete confidence that most of these hospitals consider themselves unique in the challenges they face. Most feel quite strongly that the culture and size of their hospital, the resources they have access to, the politics of medicine where they live, the size of their city, the number and personality of the surgeons they work with, and the presence of unions or residents or both all pose unique challenges that are unlike any other program. I’ve heard it so often that there must be some statistic like “every 8 s a healthcare team member involved in daVinci surgery says…Well that may work for THEM, but you don’t understand, things are different here.”
However, when you examine successful da Vinci surgery programs across the globe, you find that regardless of the size of the hospital or city, no matter what the politics and competitive forces are at play in their medical community, regardless of whether their surgeons are demanding or supportive, whether their staff has unions or they work with residents, there is a clear and common pathway to success in setting up, maintaining, and growing a da Vinci surgery program. This common pathway contains six elements:
1.
A clear noble purpose
2.
The right leadership structure
3.
Consistent communication pathways
4.
Standardization
5.
Parallel tasks
6.
A continuous improvement cycle
Before we explore these six elements, we must start by acknowledging a few truths:
1.
Just because your hospital owns a da Vinci surgical system, and there are surgeons who come to that hospital to use, it does not mean you have a da Vinci surgery program. It is possible that all you have is a surgical tool that surgeons come to use.
2.
If your hospital has successfully increased the number and type of da Vinci surgeries it performs, it still does not mean that you have a da Vinci surgery program. It is possible that all you have is a surgical tool that more surgeons are choosing to use as more surgeons and patients see the value in da Vinci surgery.
A daVinci surgery program exists only when elements 1, 2, and 3 exist
1.
A clear noble purpose
2.
The right leadership structure
3.
Consistent communication pathways and its success is dependent on its ability to apply elements 4, 5, and 6
4.
Standardization
5.
Parallel tasks
6.
A continuous improvement cycle
In the following pages I will detail for you a straightforward and reproducible plan for creating a da Vinci surgery program at your hospital and driving its success using the above six elements and the resources you already have in place.
A Clear Noble Purpose
We are in the business of helping people, treating diseases, and changing lives for the better. We all would like to see our volumes and revenue increase and often, our success is judged by our ability to achieve those goals. However, increases in revenue and surgical volume can be the result of work towards your goal, but they cannot be the goal itself. To create a da Vinci surgery program every team member must come to work with a common, clear, and noble purpose beyond the fulfillment of their job’s responsibilities and beyond the achievement of increasing volume and revenue.
To find your program’s noble purpose, start by having your surgeons and administrative leadership answer the following questions:
“What do we want our da Vinci surgery program to achieve?”
“How are we going to measure that success?”
Do you want to achieve the best clinical outcomes in your city? Then you need to define what a “best clinical outcome” is for each surgery and specialty, decide how you will measure for these “best clinical outcomes,” and determine the path towards achieving that goal. Maybe you want to be at the leading edge of new surgical innovations. Then you need to define what will count as an innovation, decide who your surgeon champions are that will be developing these innovations, determine how you will prioritize which innovations your program will support, and agree on how you will measure the success of using these innovations and how you will share your innovations with others. Is your program centered around a small number of key surgeons or is it structured to accommodate a diverse population of surgeons from practices across your city? You need to define who you are as a program, find your noble purpose, before you can achieve true and lasting success.
This noble purpose must be what is referred to as a S.M.A.R.T. goal. It must be Specific, Measurable, Attainable, Relevant, and Time-bound.
Specific
Your goal must be clear and unambiguous. It must tell you who will be involved, what you wish to accomplish, and why you are doing it.
Measurable
You need well-defined criteria that you will use to measure your progress towards the goal.
Attainable
The goal you choose should not be easy to achieve but realistic enough that you can attain it.
Relevant
Your goal must be something that matters and will help drive your organization forward.
Time-Bound
You must set a deadline for completing milestones on the way to your goal. Without a deadline, achieving these critical milestones can be overtaken by day-to-day challenges.
The Right Leadership Structure
Once you have determined your noble purpose, you need to put into place a leadership structure that will facilitate your achieving the goals you have set. To develop the right leadership structure you need to first ensure that you are looking beyond the da Vinci surgical system as a tool that your surgeons use and are treating all da Vinci surgery in your hospital as its own service line. This means you cannot think of da Vinci surgery as part of your urology service line, part of your GYN service line, part of your general surgery service line, etc. da Vinci surgery must be its own service line with leaders and leadership that attend to its needs and are accountable to its noble purpose across surgical specialties, as we would traditionally describe them. This is a unique thought for a hospital that is used to creating silos of leadership around surgical specialties that are defined by the residency a surgeon completed (Urology, OB/GYN, General Surgery, etc.). Once we accept that da Vinci surgery is its own service line, and that it is a service line that crosses many surgical specialties, then we are ready to look at the leadership structure that will support it. Think about building the leadership structure for your da Vinci surgery service line like building a house. The house we are going to build has three levels (Fig. 32.1).
Fig. 32.1
Building a house
The ground floor of the house is literally the ground floor of your da Vinci surgery program. It is the boots on the ground support you depend on in your operating room for day-to-day operations. It includes your surgical techs, nurses, anesthesia providers, surgeons, housekeepers, and your da Vinci coordinator. Remember, since we agree that da Vinci surgery is its own service line, we need to ensure that we have a nurse coordinator that is specific to this service line—our da Vinci coordinator.
The second floor of the house is where your operational oversight team lives. This is typically a member of your operating room leadership team, your da Vinci coordinator, and one of your surgeon leaders. If the da Vinci service line were a company, the operational oversight team would be the Chief Operating Officer. Their role is focused on the establishment and optimization of day-to-day operations in the program. They advise the program management team (see next section) on key planning issues and make recommendations on planning and resource allocation. Based on the noble purpose of your program, they set operational and/or performance goals, establish processes for improvement, ensure quality control, and inform all the other “floors of the house” of their progress and achievements. In short, they look at what happens in every da Vinci surgery, ensure that all team members learn from what happens in every room and not just their room, and use that knowledge to create, implement, and measure improvements that bring the program closer to achieving its noble purpose.
The third floor of the house is the program management team. This team consists of an administrative leader (typically someone with a “C” in their title CEO, COO, CAO, CNO, CFO, CMO,…) and surgeon champions representing each of your surgical specialties performing da Vinci surgery. If we go back to our company analogy, the program management team serves as the Chief Executive Officer. Their role is focused on looking to the future, aligning and directing their team members, interfacing between the hospital leadership/board and the program team members, and managing the allocation of financial and physical resources. In short, they are the visionary leader who ensures that the program’s human and physical resources are allocated and aligned to work towards achieving their noble purpose.
Consistent Communication Pathways
In order for the leadership structure to function effectively in driving the program towards their noble purpose, consistent communication pathways must be created and enforced. Unfortunately, the typical communication pathways are ineffective at solving problems. Typically, people communicate with those who are either geographically closest to them, or who possess the highest “rank.” A surgeon and an anesthesiologist work out how they will position the patient in a way that satisfies both of them only to have a new combination of surgeon and anesthesiologist the next day forcing them each to go through the exercise all over again. Or maybe a surgeon is unhappy with the support he is getting in the operating room so he marches up to the CEO’s office to tell him how important he is to the hospital and why the CEO needs to fix “his” operating room. If we go back to our house analogy, this means people are trying to solve problems within a single level of the house, or they are skipping a level of the house. This simply does not work. Problems cannot be solved within a level of the house or by skipping a level of the house. To have an effective communication pathway we need to build stairs for our house (see Fig. 32.2).
