Algorithm 2: Case Study

Unnecessary costs

Like most physicians in the United States, Trauma Medical Director Raminder Nirula, M.D., M.P.H., associate professor of surgery, had no idea how much his patients were charged or what the thousands of surgeries he’s performed have cost the system. The truth is, there was no way for him to know what the costs were. “Health care is the only industry in the United States where we don’t talk about costs,” says Nirula, who went to medical school in Canada and had cost-consciousness ingrained in his psyche. “No one would blatantly ignore financial details when buying a car or a house.”

Nirula admits that years of practice in the U.S. eroded his cost-containing fervor, but his frustrations about resources being wasted remained intact, regardless of who’s paying the bill. “It’s unfair to saddle anyone—the patients, the payers, or the government—with unnecessary costs.” His frugal mindset made him the perfect early adopter of the VDO tool. “We want to give the VDO tool to the physicians who are most excited about its potential, and who want to take the lead in redesigning clinical care,” explains Robert Pendleton, M.D., chief medical quality officer. A year ago, Nirula was in the first cohort of physicians trained in Lean principles through a partnership with the business school. Around that time he was also granted access to our brand-new VDO tool, which allowed him to dive into the details about his team’s costs for procedures, supplies, equipment and support staff.

Nirula has overlaid cost information from VDO on quality improvement opportunities identified through the American College of Surgeons National Trauma Registry to create projects that range from improving management of patients presenting with gallstone disease in the ED, to eliminating multiple head CT scans, to leaving the cervical collar that first responders place on patients instead of replacing it. He’s also one of a shrinking number of surgeons who still performs open appendectomies instead of laparoscopic, because it costs $5,000 less and the literature shows it has similar outcomes for select patients.

Conviction aside, he admits that it’s hard to break habits. When he found that using a reusable metal bile duct clip instead of a disposable one was less expensive, he confesses with a sheepish grin that it took him months to make the switch. “The first step is to accept that there’s a cheaper way to do it. But then you have to actually make the change,” he says. “And changing habits isn’t easy.”