SPARKING INNOVATION

Harvard Business School inquiry leads to innovation in the surgery suite

Bradford Shingleton MD already had a thriving cataract and glaucoma surgical practice when he was approached in the late 1990s by Prof H Kent Bowen of the Harvard Business School. 'Prof Bowen wanted to see if issues related to improving quality and production efficiency at Toyota could be extrapolated to the healthcare industry,' Dr Shingleton recalled.

To that end, Prof Bowen sent students to observe and comment on how the practice operates. As a result, Dr Shingleton's practice, Ophthalmic Consultants of Boston, has become one of the most studied and best known in all of ophthalmology.

The analysis was published as a Case Study in the Harvard Business Review in 1997 and revised in 2008. It has been the basis for discussion at the ESCRS EuroTimes Practice Development Masterclasses presented in 2009 and 2010, and will be once again in Vienna in September. 'The Case Study sheds light on many issues for professionals in developing a practice that meets business, professional and personal needs,' says Keith Willey BSc, MBA, of London Business School, who conducts the annual ESCRS Masterclass.

Dr Shingleton says the exercise improved the efficiency and clinical outcomes of his practice. 'Without question, the input provided was highly productive for me. We had bright, inquisitive minds who were not biased by medical training asking a lot of questions. My answer often was 'we've always done it this way.' It forced me to take an unbiased look at what I was doing.'

Doing more with less

The business problem Dr Shingleton faced was declining reimbursement. He either had to accept lower pay or expand volume. With his surgical team already operating near its capacity, expanding meant increasing efficiency. Doing so without sacrificing clinical quality was the real challenge.

The insights from the Harvard business students were invaluable, Dr Shingleton says. Work in the operating room was staged to minimise surgical time and turnaround between cases. For example, the students suggested that left eye and right eye cases be segregated, which made it easier and quicker to turnaround operating rooms.

The students also asked why Dr Shingleton spent time at the beginning of each surgery adjusting equipment foot pedals and the operating microscope. Borrowing from industrial best practices, grids were developed so these items were in place when he entered the operating theatre. Templates were also developed to precisely position the bed and patients' heads. All of this is now done by highly trained team members. 'These changes alone save 30 to 60 seconds per case. That doesn't sound like much, but when you are doing 30, 40 or 50 cases in a day this has a significant impact.'

This extensive preparation also helps Dr Shingleton focus by eliminating distractions, he says. 'It allows the surgeon to concentrate on what the surgeon needs to do, and to do the best job.'

In the interest of increasing efficiency – and quality – Dr Shingleton also delegates many other pre-op, post-op, and follow-up tasks to his team of ophthalmologists, optometrists, nurses and technicians. Incoming patients are 'triaged', with routine follow-up and checkups performed by his personally trained team, reserving the bulk of Dr Shingleton's time for more complex problems requiring his higher level of expertise.

Collaboration counts

Clinical fellows in ophthalmology, optometrists and technicians routinely collect and analyse outcomes data on new surgical techniques, pharmacologic treatment, and other product and process changes, which helps ensure continuous quality improvement. It also means that Dr Shingleton is readily able to document the quality of his work.

The clinic's staff meets regularly to review performance and process changes. Dr Shingleton's management style is to identify and correct errors as soon as they are made, which helps reduce future errors. But the work atmosphere is highly collaborative, and staff members are also semi-autonomous, authorised to make and analyse process changes on their own. For example, nurses began giving post-op patient instructions before surgery rather than after, in part to make better use of waiting time before surgery. Outcomes analysis showed that patients retained information delivered before surgery better than after, possibly because the patient is more alert and less distracted by the after-effects of surgery. The change stuck.

About three-quarters of staff-initiated process changes end up being adopted, Dr Shingleton says. This, too, is consistent with basic industrial process improvement theory, which holds that the people doing the job are in the best position to tell you how to improve quality – if you allow them.

Not every surgeon is as comfortable with this level of delegation, nor as flexible in constantly changing care processes. Indeed, the 2008 Harvard Case Study identified the lack of adoption of Dr Shingleton's methods by the 18 other surgeons at Ophthalmic Consultants of Boston as a significant dilemma. Accommodating Dr Shingleton's unique scheduling needs and administrative practices to the overall practice has been problematic at times.

In the ESCRS Masterclasses, Dr Shingleton's approaches have also been the subject of lively debate.

'All ophthalmologists should have some knowledge of healthcare management to improve their situations. To see what other doctors are doing helps me refine my own ideas,' Miguel Sousa Neves MD, of Povoa de Varzim, Portugal told EuroTimes at the Paris Masterclass.

'It does not matter where you come from in the world, we are all doctors and we have the same problems. It's good to come together with physicians of different ages and see the path they took to build their own clinic. They had the same challenges we are having,' said Herminio Luis Negri MD, of Buenos Aires, Argentina.

While many physicians would be leery of airing the intimate details of their practice so publicly, Dr Shingleton is glad to do it. 'If I can make things better for my patients, we have achieved our goal. If our experience benefits other surgeons and their patients, that is even better.'