Since 2000 the annual growth in robotic assisted surgery has increased tremendously. Between 2009 – 2014 the number of procedures performed on the da Vinci platform from Intuitive Surgical has tripled from approximately 40,000 to 120,000[1]. It is not just the number of procedures that is growing, but also the volume of literature. In 2014 there were approximately 1400 articles published in peer reviewed journals on this topic. This growth in procedures along with the advancements in the robotic technology and knowledge has created an interesting challenge for healthcare systems. How do we manage this?
In the past when a hospital purchased a piece of equipment for the operating room, there was an understanding that once the surgeons and nursing staff were trained on the equipment, that was all that was needed. Robotics changed that. In addition to the procedural growth and knowledge came an explosion in data. We began to learn not just about the strengths and weaknesses of the technology but also, more importantly, about the context in which the technology was being deployed. As it turns out, people, process and culture are just as important as the technology for determining outcomes and therefore the success of robotics programs. There is a tendency to blame the technology, when more often than not, the issue is one of people, process and culture. More specifically, the issue is how the people, process and technology are organized and work together as a program.
During the process of organizing our system Robotics Committee, we collected outcomes data for each of the facilities. There were obvious differences between facilities, and the first hypothesis was that these were facilities with greater experience and volume. This wasn’t always the case. High-volume surgeons were distributed across all the facilities. Something else was driving outcomes at each facility. About this time, we were collecting data on the organizational structure of Robotics Committees based at each hospital. Our goal was for the System Oversight Committee to get a better understanding of how each facility approached robotics. What we found was that some facilities were very organized and highly functional. Other facilities were either poorly organized or did not have a Robotics Committee. We then documented all of the organizational elements these committees had. We were able to grade each of the facilities based on the number of organizational elements each had. We defined highly structured programs as facilities that consistently used more than 75% of these elements. Less structured facilities used less than 75%. We then compared the outcomes (complications and cost) of highly structured to less structured programs. The results were very interesting.
Less structured Robotics Programs had a complication rate that was 46% greater than Robotics Programs that were highly structured. This data was risk adjusted and bench marked nationally. When the same analysis was performed for cost there was also a difference. Less structured Robotics Programs were found to have costs that were 37% higher compared to highly structured programs. Needless to say, our organization decided to support the development of highly structured Robotics Programs across the system.
As I speak to physicians and healthcare organizations across the country, I tend to find two camps. Those who support robotics and those who don’t. With just a few questions, I can usually tell very quickly who has a highly structured robotics program and who doesn’t. Invariably those without a structured program tend not to be very supportive of robotics, because they believe it has higher cost and complications. Those with a highly structured program tend to be very supportive, and believe it has lower cost and complications due to how their program is organized. Since the organizational structure of a robotics program appears to be a determining factor in outcomes, it may be time to include this as a variable in any robotics study. It also may be time for physician leaders and hospitals to consider developing highly structured robotics programs for their organizations.
*This is an excerpt from the recently published book by Dr. Loftus, titled The Robotics Program: A How-to-Guide for Physician Leaders on Starting Up a Successful Program. To learn more click on this link or the Books tab above.
Disclosure: Dr. Loftus has been a speaker for Intuitive Surgical, Inc. in the past year.
[1] Intuitive Surgical, Inc. 2014 Annual Report
