Advancing quadruple aim performance: Impact of alignment, standardization and sole source arrangement

The quadruple aim is a hallmark of how many ASCs do business. For years, administrators have paid close attention to care quality, cost and patient satisfaction. Many surgery centers also prioritize surgeon experience, creating an efficient and effective surgical environment.

As the broader healthcare industry continues to face scrutiny on case quality and costs, placing more pressure on surgeons to do more for less, administrators will need to increasingly focus on fostering a positive experience for providers. Physicians can easily experience burnout when reimbursement declines, and they must see a higher volume of patients to keep their practice afloat. Physician burnout has a negative ripple effect on the entire clinical team, potentially creating a toxic environment that repels patients and could lead to clinical errors.

Each tenet of the quadruple aim is interconnected. With the right partners, ASCs can satisfy each element for optimal performance.

Independent practice survival
Umesh Bhagia, MD, saw the ramifications of physician burnout firsthand when he joined an orthopedic group as the total joint replacement surgeon fresh out of fellowship.

"I looked around and saw my colleagues, some older and some younger, trying to survive with lower reimbursements and increasing regulations," he said. "They tried to do more work to keep up their income. We didn't consider changing our process or practice, but instead focused on seeing more patients. I could see the burnout coming."

When the physicians became more stressed, they complained more to staff and became frustrated. Dr. Bhagia decided to take a different route and strike out on his own, opening Arc Orthopedic Group Joint Replacement Specialists in West Hills, Calif. He wanted to own a surgery center and obtain the ability to gather and own his data; this led to a rewarding practice and business.

"If you aren't satisfied as a physician, you can't deal with your patients properly and take their feedback to make improvements to your practice," Dr. Bhagia said. "Someone who isn't satisfied is more closed-minded and can stagnate the practice. Someone who is happy continues to make improvements and patients become more satisfied."

Waltham,Mass.-based ASC administrator Gregory DeConciliis agrees with that sentiment. He has led Boston Out-Patient Surgical Suites (BOSS) for several years and witnessed how an ASC can transform a surgeon's ability to provide better care to more patients.

"ASCs in general have done an excellent job at improving surgeons' livelihoods by facilitating more procedures in a shorter amount of time, sometimes around 1.5 to 2 times the hospital block," Mr. DeConciliis said. "Surgeons then eliminate their backlog and have minimal downtime during the day so they can have an overall more efficient surgical day. They are usually out on their scheduled time or earlier and can fit in their lives outside of medicine better."

Standardization with total joints
Total joint replacements have emerged as a successful high-acuity procedure in the ASC setting. Outpatient surgery can potentially lead to lower costs for properly selected outpatient total joint patients and aligning the ASC team makes those procedures even more efficient.

Mr. DeConciliis aligned his team around total joint replacements so high-volume surgeons have the same teams working together on every patient. BOSS also standardized the preoperative patient education protocol, so patients visit the center, meet their nursing team and tour the facility beforehand. Patients also learn physical therapy exercises and internalize postoperative expectations before the day of surgery.

"Hands down, this process has helped us tremendously," Mr. DeConciliis said. "The patients that don't go through the process stay longer in the recovery room and they don't progress as well."

Another point of standardization for total joint replacements is with the implants. Dr. Bhagia's center has a sole-source arrangment with DePuy Synthes. Dr. Bhagia's center launched 15 months ago and he set out to align with a device company right away.

"Alignment can lower costs and the stress level," he said. "When the stress level decreases, you can actually do your work without worrying about paying down your debt for years and years. When you align, you can build protocols and narrow variation in implants to improve efficiency and reduce stress among employees, which is a positive outcome."

Since his center is so new, Dr. Bhagia was able to standardize quickly and found value in connecting with surgeons and administrators within DePuy Synthes’ network, both in the U.S. and abroad, to improve his center and the patient experience. On the other hand, as an existing center with multiple physicians, Mr. DeConciliis spent about a year on the standardization process.

"We wanted to standardize from the onset, but when we selected a company there were always some physicians that didn't want to do it," he said. "As time went on, we realized how beneficial standardization was for a small facility like ours. There is maximal coordination that needs to take place with these procedures not being routine. Equipment, implant, supply coordination and reliability are paramount."

Mr. DeConciliis is currently researching several different opportunities including DePuy Synthes due to the strength of their services, expansive product portfolio and willingness to work with them on pricing due to the ASC's unique reimbursement structure. The center's surgeons were also comfortable with the product performance and DePuy Synthes company representatives.

"When looking at a sole source arrangement, you must consider companies such as
DePuy Synthes which crosses so many lines of orthopedic products and has alliances with other companies that are beneficial to us," Mr. DeConciliis said. "Also, from the ordering and inventory management perspective, the standardization makes these processes a lot easier. The time is now to consider this type of arrangement."

The value of good partners
Over time, Dr. Bhagia sees the value of outpatient total joints and his arrangement with DePuy Synthes growing for patients, especially as payers have become excited about the procedure.

"Local payers with a presence in Southern California serve a large population and have come around to see what our center is doing," he said. "They acknowledge the value we bring because we can save them money and we have really good patient feedback. They are trying to drive business out of other places and now into our center."

Resources available at or contact your DePuy Synthes representative to attend an educational program or schedule a local dinner meeting.

DePuy Synthes 2019. All rights reserved.124326-190925 DSUS

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