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Leading Cost and Quality Strategies for the Healthcare Supply Chain

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Enhancing Patient Experience Through Adult and Pediatric VAT Implementation

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Contents Healthcare Value Analysis & Utilization Management Magazine

4 FROM THE PUBLISHER’S DESK By Robert T. Yokl

Simplify, Systemize, and Automate Value Analysis Workflow Processes for Maximum Results

Healthcare Value Analysis & Utilization Management Magazine is published Bi-monthly by SVAH Solutions®

6 FROM THE MANAGING

P.O. Box 939, Skippack, Pa 19474

EDITOR’S DESK

Phone: 800-220-4274

By Robert W. Yokl

FAX: 610-489-1073

Defining Healthcare Value Analysis in 2022 and Steps for Achieving Better Results

bobpres@ValueAnalysisMagazine.com

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Editorial Staff

9 FEATURED ARTICLE By Shonda Morrow, Kimberly Alsbrooks, Guadalupe Ordaz-Nielsen, Cathy Heinzinger, and Mary Zack

Enhancing Patient Experience Through Adult and Pediatric VAT Implementation

Publisher Robert T. Yokl bobpres@ValueAnalysisMagazine.com

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Managing Editor

18 SUPPLY CHAIN Interview with Vincent Matozzo and Shawn Kenavan

The Supply Chain Paradigm/Shift

Robert W. Yokl ryokl@ValueAnalysisMagazine.com

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25 VALUE ANALYSIS 101

Senior Editor

By Robert T. Yokl

Value Analysis Balanced Scorecard Can Up Your VA Performance

Patricia A. Yokl ————————————

28 VALUE ANALYSIS ADVISOR

Editor and Graphic Design

By Robert T. Yokl

What Can Your Customers Get Excited About?

31 UTILIZATION MANAGEMENT By Robert W. Yokl

How Utilization Reporting Helps You Pick Up Savings Opportunities Including Price

33 PERSPECTIVE By Robert T. Yokl

Why Group Purchasing Is Only One Side of the Savings Triangle Equation

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Danielle K. Miller

Copyright 2022 SVAH Solutions. All rights reserved. Reproduction, translation, or usage of any part of this work beyond that permitted by Section 107 or 108 of the 1976 United States Copyright Act without permission of the copyright owner is unlawful. For permission, call, fax, or e-mail Robert W. Yokl, Managing Editor. Phone: 800-220-4271 E-Mail: ryokl@valueanalysismagazine.com for approval to reprint, excerpt, or translate articles. 3


From the Publisher's Desk Simplify, Systemize, and Automate Value Analysis Workflow Processes for Maximum Results Robert T. Yokl

We just conducted a survey regarding the biggest challenges for value analysis professionals and found that their #1 challenge is needing more help to get their job done efficiently and effectively. While this answer wasn’t a surprise, it is concerning since we see value analysis practitioners taking on more responsibilities every day without adding FTEs. However, we do see a light at the end of the tunnel if value analysis practitioners embrace these three time and motion concepts: 1. Simplify Request Process: How many new purchase requisitions are you receiving every day, week, month, or year? Are they approved in your current year’s budget - per line item? If not, these new requests are not following a typical budget process and should be rejected out of hand. This tactic is the best way we know of to simplify and reduce your purchase requests down to a manageable number. For you see, only the most pressing product, service, and technology requests will be approved in your healthcare organization’s budgeted process, not just because it would be nice to have them. 2. Systemize Workflow Process: We see too many freeform value analysis workflow processes with too many handoffs, requiring too much information and too many approvals. A much better way is to have a standardized, repeatable, and auditable systemized workflow process that meets the needs of all customers, stakeholders, and experts without burdening them with minutia. 3. Automate Workflow Process: Eliminate paper processes by automating them, such as, automate notifications on actions taken on new product requests, savings and spend reports, customer surveys, and tracking and reporting key performance metrics. This automation will have the effect of streamlining your new product, service, and technology requests workflow and value analysis process. Automation can have the effect of deciding to go up an elevator vs. going up the stairs to get your job done. Value analysis has become a very mature function of supply chain management yet is still a stepchild when allocating resources to perform VA jobs efficiently and effectively. My suggestion is to take a hard look at this function to uncover where it can be simplified, systematized, and automated for maximum results. Remember, it is the entrance point of all new products, services, and technologies into your hospital, system, or IDN.

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From the Managing Editor’s Desk

Defining Healthcare Value Analysis in 2022 and Steps for Achieving Better Results By Robert W. Yokl, Sr. VP, Supply Chain & Value Analysis — SVAH Solutions There are many different iterations that value analysis has morphed, evolved, and emerged into leading up to 2022. Value analysis is predominantly applied to products, services, and technologies in the healthcare supply chain. The primary focus of value analysis practitioners is working with hospital and/or system-based value analysis teams that are assigned categories of products and services to review. The main goal is to validate the efficacy of these products and services but also to assist with the selection of the right product used in the clinical environment. Lastly, hospital-based value analysis should be a catch point for savings and quality improvements while performing various reviews, studies, and evaluations on an ongoing basis.

What Should Value Analysis Program Goals Look Like for 2022 and Beyond to Get Better Results? I thought I would just outline what health systems should be targeting with their value analysis teams and practitioners in 2022 and beyond to make the most of their value opportunities and not leave any dollars on the table or miss quality improvement opportunities. Your Value Analysis Program Should Have Goals. If you are a value analysis or supply chain leader then you should have goals for all your programs from contract to inventory, and yes, to value analysis as well. Without solid goals, your teams will just be running as they always have and historically this is when value analysis programs tend to sputter out altogether. Setting savings goals by team or establishing better objectives for improved review times for new products are two simple examples of value analysis goals that can go a long way.

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From the Managing Editor’s Desk

Robert W. Yokl

You and Your Teams Should Have Training At Least Two to Three Times a Year. Yes, you may be an outstanding practitioner/leader of value analysis, but you should never underestimate the fact that your teams are ever evolving and require training too. If you want to have the same results, then just keep doing the same things repeatedly, but if you want your program to grow and evolve then train your team members in newer and more advanced value analysis skills. Let Technology Make Your Job Easier. Let’s face it, value analysis is a sub-section of supply chain. Supply chain procures millions of dollars in contract purchases but normally does not incur many budget expenditures. CFOs like this aspect of supply chain which many times limits supply chain to spreadsheets. Spreadsheets are very versatile tools but are also very limiting with roll-ups of large purchase/inventory data, and new product request information is far too vast for the common spreadsheet in 2022 and beyond. The solution is to look to the value analysis software on the marketplace today to take the burden off your VA and Supply Chain Analysts that support VA. Yes, they are going to worry that the new software will somehow replace what they do, but the reality is that instead of your VA Practitioner and Analyst spending 80%-90% of their time crunching data, they can now free up their valuable time to spend on true value analysis with the end customers instead. Get Back to Core Value Analysis Reviews. Back when I started in the healthcare supply chain 30+ years ago, value analysis was commonly used to review existing contracted product categories to reduce costs further. With the evolution of the group purchasing program and new product evaluations and recalls, value analysis teams and practitioners have gotten away from these cost and quality reviews. It is time that value analysis take a step back and open up 20% to 40% of their agendas to these major category reviews again to further reduce costs beyond contract price. There are big dollars sitting there, but without any formal review these dollars will be lost forever year after year. Remember, you could have the best price on a Rolls Royce but your costs to maintain it are always going to be extremely high. There are lower cost alternatives that will not only reduce costs dramatically but also improve quality. You just have to initiate looking for these now in order to gain the results today and in the future.

Value Analysis Is the Game Changer in 2022 and Beyond Value analysis in healthcare is just scratching the surface of the great value that can be brought to the healthcare supply chain and the organizational bottom line. Many don’t realize this because it has been pigeon toed into only handling new product requests and recalls at many organizations. The organizations that start to think differently and take the next step with their value analysis program are going to reap huge benefits beyond the contract savings they are getting. Don’t overlook the added value that value analysis can achieve today!

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Featured Article Enhancing Patient Experience Through Adult and Pediatric VAT Implementation Shonda Morrow, JD, MS, RN, CENP; Rush University Medical Center, Chicago, Illinois Kimberly Alsbrooks, BSN, RN, RT (R), VA-BC; BD, Franklin Lakes, NJ, USA Guadalupe Ordaz-Nielsen, BSN, RN, VA-BC; Rush University Medical Center, Chicago, Illinois Cathy Heinzinger, RN, RNC-NIC, VA-BC; Rush University Medical Center, Chicago, Illinois Mary Zack, BSN, RN, VA-BC; Rush University Medical Center, Chicago, Illinois

The Importance of Vascular Access Vascular access (VA) is a critical component of patient care that allows clinicians to safely administer medications and fluids, obtain blood samples, and provide other necessary treatment1. VA is achieved by providers through the insertion of a peripheral or central vascular access device (VAD) into a blood vessel2. Over 90% of inpatients will require a VAD at some point during their hospital stay, and worldwide the annual number of VAD insertions is estimated to be in the billions3. Given the increasing role of VADs in patient care, there is a demonstrated need for dedicated VA teams (VATs) to place and maintain VADs3. VATs are composed of specialized clinicians with responsibilities including VAD selection, placement, and management3. The implementation of VATs in clinical settings has been shown to improve multiple clinical metrics, including rates of thrombosis, infection, and device failure3,4. Furthermore, a recent publication detailing in-depth interviews with VAT members/leaders from nine countries revealed that, when combined with advanced technologies (i.e., point-of-care ultrasound) and evidence-based practices, VATs can significantly improve clinical, economic, and patient satisfaction outcomes5.

Recognizing the Obstacles The Rush University System for Health is an extensive network of hospitals and outpatient care facilities located in Illinois with a mission to improve the health of the greater Chicago community6.

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Featured Article The flagship hospital of the health system, Rush University Medical Center, previously had an intravenous (IV) service team that specifically managed VAD placements, but it was dissolved in 2012 due to lack of utilization. Following the termination of the IV team, Rush’s interventional radiology (IR) department resumed responsibility for most VAD placements between 2012 and 2019. Losing the dedicated IV team was not without consequences; the access to specialists who support and educate on VAD Losing the dedicated IV selection, placement, and management was significantly team was not without reduced. Furthermore, the elimination of the IV service team consequences. and resumption of services by the IR department increased the use of hospital resources. VAD insertions in IR require the use of IR suites, IR specialists, sedation medication, and an accompanying nurse, which utilized substantial resources for simple line placements. Additionally, in the absence of a dedicated VAT, nurses at Rush’s neonatal intensive care unit (NICU) placed peripheral IVs (PIVs) for their own patients, as well as patients in other departments. As a result, nurses experienced additional travel times when responding to VA requests in various units.

Planning a VAT Initiative To address the VA-related challenges identified by administrators and clinicians, Rush’s Chief Nursing Officer (CNO) approached hospital leadership in 2018 regarding forming a dedicated, nurse-led VAT. To explore this opportunity, a task force consisting of clinicians with significant VArelated experience (including Leoford D. De Guzman and Guadalupe Ordaz-Nielsen) was created, who then made a comprehensive plan for the team formation, training program, responsibilities, and hours of coverage. The IR department was included in the early stages of VAT formation to inform the planning process and determine the percentage of VA procedures that could be completed at the bedside. Initially, the IR physicians were concerned about the nursing department overseeing the VAT since IR specialists were considered experts in line placements. The VAT also needed to maintain a strong working partnership with IR since some insertions could not be at the bedside and would require coordination between departments. To address this challenge, the task force recruited an IR physician champion to assist in future VAT efforts and establish lines of communication between VAT specialists and the IR department. As a result, the team was able to utilize their expertise while collaborating with IR on complex VA cases. Multiple Rush stakeholders, including nursing leadership and finance managers, were consulted to provide valuable input and guide the VAT’s integration into the hospital system.

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Featured Article Various departments, including IT, infection control, and pharmacy, served as key contributors by offering support and advice during the planning stages. Physician champions from other units (e.g., infectious disease, nephrology) were enlisted to bolster the team’s expertise and validity. Hospital leadership also played a crucial role in VAT development by providing ample financial and institutional support. For instance, the Associate Vice President for IR offered valuable input by sharing the VAT-related experience they previously gained at another institution. Moreover, the funds made available enabled the purchase of additional equipment, including two new ultrasound machines to assist in VAD placements and reduce radiation exposure. Rush leadership provided significant investment into training for the VAT and utilized the partnership with their primary VAD vendor (BD, Franklin Lakes, NJ, USA), which provided equipment, educational resources, and training protocols. The involvement of the VAD vendor in Rush’s orientation program further streamlined the VAT implementation process and contributed significantly to the team’s formation. Specifically, the vendor provided a comprehensive and proven approach to VA care that included clinical practice assessments and education programs, which was utilized by Rush to develop the VAT orientation process. The vendor also provided VA equipment, training supplies, and instructors for the orientation process, and referred an experienced VA nurse to the team who became the VAT’s only external hire at the time. The support from the vendor ultimately saved valuable time by eliminating the need for Rush clinicians to create their own educational modules and dedicate staff to manage VAT training.

Formation of Multiple VATs The hospital initiated the recruitment for the VAT for adult patients in early 2019. The search was expedited by an abundance of nurses at the health system with ultrasound or IV insertion experience who were qualified to join the team. Four internal candidates with relevant skills and interests were chosen to reduce orientation time, and their six-week training began in May 2019. During the training, the cohort was divided into two groups which alternated practicing sterile techniques and gaining floor experience under the guidance of two experienced nurses. Post-orientation, all four nurses were hired for the team and fulfilled additional training and qualification steps (e.g., acquiring board certification within a year). The VAT went live on July 1 st, 2019, and immediately saw a significant number of consults due to the existing high demand for VA services at the hospital. The team then expanded into Saturday coverage that same month to meet increasing VA needs and improve patient discharge rates. The team's success motivated the hospital leadership to form a VAT dedicated to pediatric patients (pediatric VAT). Three nurses were recruited in January 2020 and were trained using similar processes as the adult team. Prospective pediatric VAT members also received additional training from an external instructor to educate the team on pediatric-specific ultrasound-guided peripherally inserted central catheter (PICC) insertions. The pediatric VAT went live in April 2020 and was initially responsible for two pediatric floors. Due to their success, the team expanded coverage to include the pediatric emergency department, outpatient clinic, and infusion center.

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Featured Article Overcoming Hurdles Following the implementation of the adult and pediatric VATs, Rush identified and addressed issues facing their newly established clinical teams. First, the IR department, the central line-associated bloodstream infection (CLABSI) team, and several physicians expressed concerns about the VAT’s expertise in VAD selection and insertion. To address these concerns, physician champions engaged in peer-to-peer discussions to assure Rush stakeholders of the VAT’s proficiency in VA-related clinical practices. Through these efforts, providers began heavily consulting the VATs within a few months, which proved the strength and longevity of the initiative. Second, as Rush is an academic hospital, the yearly turnover of interns and residents created an ongoing challenge to re-educate providers on the VAT’s role in VA-related decisions. To address this challenge, the team began circulating a one-page document multiple times a year to all clinicians, which increased awareness of VAT policies and improved the sustainability of the VAT-clinician partnership. Finally, the global COVID-19 pandemic initially caused a dip in consults for both the adult and pediatric teams due to a low-capacity ICU that prioritized more acute CVC insertions and limited patient exposure. The adult team could fill the void in consults by assisting in PIV placements for the ICU and other departments. However, the pediatric VAT saw a more sizeable drop in consults as they did not have the flexibility to extend their coverage to other locations. Eventually, consults for both teams increased significantly and have been steady since the beginning of 2021.

Achieving Results Enhanced Safety for Patients and Providers Implementation of the adult and pediatric VATs resulted in significant advancements to patient and provider safety at Rush. Clinicians noticed reductions in treatment delays and an increase in line placements as the VAT had a greater capacity to fulfill VAD placement requests compared to the IR 7. VAT members traveled to patients’ bedsides and completed same-day catheter placements, allowing timely administration of medications and a reduction in length-of-stay7. The enhancement in line placement efficiency allowed the adult VAT to perform about 1,000 insertions annually in the first two fiscal years7. Additionally, the pediatric team has completed 517 successful insertions in the last six months7. Both adult and pediatric VATs observed significant reductions in catheter-related complications (i.e., infection and thrombus rates) across their patient populations. Since the teams’ inception, a significantly lower number of CLABSI and DVT cases have been reported within both adult and pediatric patient populations7.

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Featured Article Furthermore, the reduction in the use of IR services led to a decrease in radiation exposure to both patients and providers since fewer patients were sent to IR for line placements 7. Radiation exposure to patients and providers should not be overlooked considering the increasing role of IR-based procedures in healthcare8. The individual risk may be minimal for a single, low dose exposure from a chest x-ray. However, repeated procedures combined with the significant volume of imaging exams performed each year in the United States make radiation exposure a public health issue 9. Therefore, it may be beneficial for patients and providers to avoid radiation exposure, especially when alternatives are available. Improved Clinical Practice and Efficiency As a result of their enhanced education and expertise, the VATs effectively addressed multiple VAD-related concerns that providers had observed prior to the teams’ implementation. The adult VAT reduced VAD-related readmissions by providing patients with instructional videos that allowed them to address common device problems at home. Consequently, the team reduced the total number of VAD-related readmissions by 74% within one year7. Moreover, the pediatric team switched to new, longer catheters that increased dwell time and resulted in fewer complications, including extravasations, treatment interruptions, and line migrations7. Thanks to the additional available device choices and related training, Rush achieved an average pediatric dwell time of 4.6 days7, which surpassed the National cVAD Registry average of 2 days7. The adult and pediatric VATs also engaged in patient rounding, which allowed the teams to address VA-related challenges earlier and implement proper line maintenance techniques such as dressing changes and catheter monitoring.

Boosting Patient Experience and Provider Satisfaction Patient and clinician satisfaction significantly increased at Rush due to improved first insertion rates, faster discharges, fewer treatment delays, and a decrease in VA-related complications. There were also improvements in venous preservation due to increased first-time success rates, patient education efforts, and longer catheter dwell times. The teams achieved 97.6% and 97% first-time insertion success rates for adult and pediatric patients, respectively 7. The reduction in multiple insertion attempts promotes patient comfort and may have downstream impacts such as decreasing needle phobia, which was shown to be caused by repeated/painful needle sticks10-12.

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Featured Article Patients often expressed gratitude towards the VAT and specifically requested the VAT’s services. The practice of VAT rounding also improved patient experience as patients appreciated having an advocate on their side to monitor lines and answer VA-related questions and concerns. Moreover, provider satisfaction was enhanced as the VATs managed complex cases and inserted lines when other clinicians faced challenges. Providers thus expressed gratitude for the advice, education, and support they received from the specialized teams. Contributing to Financial Health

The team reduced the total number of VAD-related readmissions by 74% within one year.

There was a noticeable economic impact as a result of decreased resource utilization. Fewer catheters and less equipment were used thanks to the increase in firsttime insertion, overall success rates, and increased catheter dwell times. Adult VAT members worked in pairs to ensure the proper sterile techniques minimizing equipment waste. There were also savings in nursing resources since the staff was no longer required to transport patients to IR for line placements. As a result, nurses allocated more time to patient-related clinical tasks. There was also a significant increase in hospital revenue due to VAT improvements, including a reduction in patient days and an improvement in discharge rates. The IR department could also focus on more revenue-generating procedures as they were no longer responsible for simple line placements. Moreover, the VATs could complete more VAD placement procedures, representing a significant return on investment for Rush.

Unique Aspects of Implementing a Pediatric VAT Rush’s experience forming adult and pediatric VATs emphasizes the VA-related differences among these populations, including management of complications and VAD selection. Therefore, Rush used a tailored approach to pediatric VAT formation to address the unique needs of the pediatric patient population. To avoid VAD-related complications such as sedation-related challenges, CLABSI, and needlephobia, pediatric patients may require additional care from providers. Sedation during IR procedures may lead to more severe complications in younger children compared to adults, including cardiovascular or respiratory instability, pulmonary aspiration, and airway obstruction 13-15. In previous studies, young age and low body weight have been identified as risk factors for increased CLABSI rates16. Invasive, needle-related events may also cause lasting fear and anxiety in pediatric patients, which may lead to an increase in perceived pain during subsequent procedures17.

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Featured Article Furthermore, younger patients have smaller vein sizes and require appropriately sized VADs for catheter insertions. Placement, management, and removal of VADs in pediatric populations require close monitoring since they may not effectively communicate their medical needs. Pediatric patients with VADs require more immediate attention and the use of appropriate line maintenance and removal techniques, which may prove more complex. Since placing and managing catheters in younger patients is more complicated, providers who are more experienced in this area tend to do the majority of line placements. Therefore, it is vital to create opportunities for other practitioners to build and develop these VADrelated skills. To overcome these obstacles, Rush ensured that the formation/training of the pediatric VAT included additional elements that addressed the unique nature of pediatric care and that VAT candidates had prior pediatric experience. Pediatric VAT members also received special instruction regarding line placements and education on the use of ultrasound to guide VAD insertions. Additionally, the pediatric team was provided with specialized equipment (e.g., different types of ultrasound machines, catheter lengths/sizes) to safely place VADs in younger children. The pediatric VAT assisted Rush clinicians by providing VA-related instructional materials, engaging in evidence-based discussions, and serving as a resource to address pediatric-specific VA issues. The team provided nurses with a reference binder containing VA-related information, including instructions on catheter selection and management of complications in pediatric patients. As a result, the VAT increased awareness regarding the unique challenges of VA-related pediatric care and contributed to the long-term sustainability of the initiative. The pediatric VAT also created a difficult intravenous access (DIVA) system that scored patients based on specific criteria. Floor nurses were thus able to practice line insertions, and the team was only called if patients reached a certain score. Overall, the pediatric VAT initiative successfully addressed the multiple VA-related obstacles that Rush previously faced. Implementation of the pediatric team resulted in improved clinical and patient safety outcomes, increased patient/provider satisfaction, and significant benefits to Rush’s financial health. This experience serves as an example for other institutions and highlights the importance of pediatric-specific considerations (i.e., formation, implementation, unique challenges) when forming VATs.

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Featured Article Final Remarks and Future Directions VA is a critical component of patient care, and clinicians face multiple challenges when placing VADs in children and adults. This case study demonstrates that significant improvements in clinical, economic, and patient and provider satisfaction outcomes can be achieved through VAT implementation. Although there are unique challenges in their formation and implementation, establishing a pediatric-specific VAT is feasible and provides similar benefits to their adult counterparts. Currently, Rush is looking to expand the VAT initiative to its two sister hospitals and establish a local network of VAT professionals to share their knowledge and experience with hospitals in the Chicago/Illinois area.

Citations 1. Kelly LJ. The family of vascular access devices. Journal of Infection Prevention. 2009;10(1_suppl):S7-S12. doi:10.1177/1757177409342156 2. Moureau NL, Alexandrou E. Device Selection. In: Moureau NL, ed. Vessel Health and Preservation: The Right Approach for Vascular Access. Springer International Publishing; 2019:23-41. 3. Corcuera Martínez MI, Aldonza Torres M, Díez Revilla AM, et al. Impact assessment following implementation of a vascular access team. J Vasc Access. Dec 26 2020:1129729820984284. doi:10.1177/1129729820984284 4. Bell JA, Spencer TR. Implementing an emergency department vascular access team: A quality review of training, competency, and outcomes. J Vasc Access. Jan 2021;22(1):81-89. doi:10.1177/1129729820924554 5. Morrow S, DeBoer E, Potter C, Gala S, Alsbrooks K. Vascular Access Teams: A Global Outlook on Challenges, Benefits, Opportunities, and Future Perspectives. Journal of the Association for Vascular Access. 2021;doi:10.2309/java-d-2100020 6. About Our System. Accessed November 17, 2021. https://www.rush.edu/about-us/about-our-system 7. Heizinger C, Morrow S, Zack M, Ordaz-Nielsen G. Interview with Rush Vascular Access Teams. In: Johnson P, editor. 2021. 8. Lee T, Shin SW, Choi D, et al. Risk factors of radiation dose in patients undergoing peripherally-inserted central catheter procedure using conventional angiography equipment and flat panel detector-based mobile C-arm fluoroscopy. Acta Radiol. Dec 2014;55(10):1234-8. doi:10.1177/0284185113514221 9. Administration USFaD. Initiative to reduce unnecessary radiation exposure from medical imaging [White paper]. https://www.fda.gov/radiation-emitting-products/initiative-reduce-unnecessary-radiation-exposure-medicalimaging/white-paper-initiative-reduce-unnecessary-radiation-exposure-medical-imaging 10. McMurtry CM, Pillai Riddell R, Taddio A, et al. Far From "Just a Poke": Common Painful Needle Procedures and the Development of Needle Fear. Clin J Pain. Oct 2015;31(10 Suppl):S3-11. doi:10.1097/ajp.0000000000000272 11. Cook LS. Needle Phobia. J Infus Nurs. Sep-Oct 2016;39(5):273-9. doi:10.1097/nan.0000000000000184 12. Kour G, Masih U, Singh C, Srivastava M, Yadav P, Kushwah J. Insulin Syringe: A Gimmick in Pediatric Dentistry. Int J Clin Pediatr Dent. Oct-Dec 2017;10(4):319-323. doi:10.5005/jp-journals-10005-1458 13. Cote CJ, Karl HW, Notterman DA, Weinberg JA, McCloskey C. Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics. Oct 2000;106(4):633-44. doi:10.1542/peds.106.4.633 14. Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg. Mar 2009;108(3):795-804. doi:10.1213/ane.0b013e31818fc334 15. Cote CJ, Wilson S. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics. Jun 2019;143(6)doi:10.1542/peds.2019-1000 16. Duesing LA, Fawley JA, Wagner AJ. Central Venous Access in the Pediatric Population With Emphasis on Complications and Prevention Strategies. Nutr Clin Pract. Aug 2016;31(4):490-501. doi:10.1177/0884533616640454 17. Czech O, Wrzeciono A, Rutkowska A, Guzik A, Kiper P, Rutkowski S. Virtual Reality Interventions for Needle-Related Procedural Pain, Fear and Anxiety-A Systematic Review and Meta-Analysis. J Clin Med. Jul 23 2021;10(15)doi:10.3390/ jcm10153248

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Supply Chain Interview The Supply Chain Paradigm/Shift Vincent Matozzo, CEO & Managing Partner, Paradigm Venture Group LLC

Shawn Kenavan, Managing Director, SPK Consulting LLC

This is a very different and exciting Value Analysis Leadership Interview that we conducted with Vince Matozzo and Shaun Kenavan who are the principles of the Paradigm Venture Group. Vin and Shaun have been knee deep in working with healthcare organizations to help solve many of their challenges and disruptions but also aiding them in their strategic visions for the future. They are helping organizations to shape a whole new future based on technology with smart tech like artificial intelligence, machine learning, and so much more. Let’s learn more from Vin and Shaun. HVAUM: Tell us a little bit about your history in the supply chain and value analysis worlds. VM: My background was first as a buyer in procurement, in positions in and out of healthcare. I was trained in Lean/Six Sigma through GE and attained a master black belt status. All along I was always really curious about applying that to my role in procurement and in

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supply chain. Supply chain turned into an accidental career from my original path of forensic science. Those skills have come in handy in my roles as a Chief Contracting Officer, as a Director of Strategic Sourcing, and as an Executive Director in supply chain. I not only worked in the sourcing and contracting side but also in transforming multiple supply chain value analysis groups. I focused on creating interoperability from the receiving dock to the C-suite table, whether it be developing metrics, giving those tap times, and then evolving with the technology to further the supply chain to C-Suite collaborations. I am a huge proponent of applying technology tools to the supply chain like Microsoft Excel and Minitab all the way through Crystal Reports with the goal of taking workflow, project management, and collaboration software and programming these to new levels of interoperability in areas within healthcare that have taken a very long time to evolve. For me, it was being passionate about the way we automated work getting done, whether it was an expiring contract report or a back-order report, connecting that across those

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Supply Chain Interview verticals, and creating a layer of business intelligence that has served a few of the organizations that we've been fortunate enough to work with. SK: I started out working with one of the top medical distributors for about 16 years, wearing many hats. This ranged from operations to director of warehouses on the East Coast and the Northeast, managing primarily the New York Boston areas, from a distribution warehouse operational standpoint. My work continued into the corporate world in the distribution business where we started a consultant team. This team was assigned to the top 25 accounts with the focus on implementing processing improvements. The goal was to work with larger accounts and make things more efficient. We wanted to understand what was driving the lack of response, the lack of results, that really impacted the overall operational health and the relationship between a customer and a distributor. I worked in this consulting role for about eight years. It was a great learning experience for me sitting on the fence, listening to the customer, but also really understanding the dynamic and the challenges that a distributor faces. One of the biggest takeaways was the fact that sales are made, but when you go to implement them and apply the logistics, the technology, and the processes, the overall performance is not there. How do you manufacture those results in an operating environment that does not exist? So, the big disconnect is the fact that the distributor’s job traditionally stops at the dock doors but there is much more that can be done. Recognizing this, I formed my own consulting firm and worked with large healthcare organizations on distribution implementations and establishing/

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improving operational processes. The big win is bringing together supply chain, value analysis, frontline staff, and clinicians to expose them to the challenges that are being tackled as well as help them understand the distribution dynamics. Then we create transparency and visibility upstream and downstream in distribution of supplies at organizations like Stanford Health. My engagements have ranged from distribution implementations to fitting up a new hospital to far location, storeroom, and other inventory and logistics solutions. HVAUM: You are a champion of utilizing cutting edge technology to close the gaps that are disrupting the healthcare supply chain that are causing major cost, quality, and performance issues. Can you explain how technology can solve all these issues? SK: From my perspective, this cutting-edge technology helps us think of supply chain and processes as an assembly line. There's a project or task that starts with Step A and ends with Step Z, right? If you can envision, Step A hands off to Step B, Step B hands off to Step C, Step C hands off to Step D, and so on down the line. It's truly like an assembly line at a manufacturer. Think of Toyota. You start with the bolts, steel, rubber, and everyone hands it down. Everyone has their responsibility within that process or work stream. The technology that we've created helps us establish line of sight to when and where there's a defect in those handoffs. In real life, that process goes from purchasing materials to value analysis, to analytics, to support staff to clinicians. That's one task in a series of probably a hundred deliverables.

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Supply Chain Interview A great analogy to explain the technology we create is, “We know the plumbing, and now we see where the clogs are.” Now we know what is occurring to prevent a task from being completed. Then we can dive into the root cause analysis with real-time analytics in place that flag the cause of a bottleneck. For example, this will help encourage our clients to bring in a substitute product two weeks earlier to circumvent this bottleneck affecting clinical outcomes (procedures cancelled, clinicians not able to care for patients, etc.). Prior to this type of technology, it was a black hole. You didn't know where anything was sitting or why it was sitting there, let alone know how to address it. VM: It really starts with solid processes and those core tenants of reviewing the workflow, the cadences, the roles and responsibilities, and who's accountable, consulted, informed. What are those priorities? And then how do you automate that information strategically? How can you find the best way so you can efficiently kick off workflows to minimize the minutia and put the humans back where they belong, creating those value-added decisions and not necessarily addressing the white noise? I think that's critical, but you must be very intentional in creating that roadmap for interoperability. Then you really must have the outcomes and your key business metrics in mind. The challenge that has always been with technology, whether it's in or out of healthcare and supply chain or any industry, is truly visualizing that complex synergistic system, that neural network from end to end. HVAUM: Could you give us an example of how technology has helped make supply chain more efficient?

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“Be very intentional in creating the roadmap for interoperability.” Vincent Matozzo

VM: The interoperability of connecting what I call the neural network, or in simple terms, all the data points and silos in supply chain. It all comes down to understanding your technology and your current reporting and how to create the linchpins that focus on interoperability. Yes, these are dashboards, reports, and tools that are put in place to understand how your interoperability works and then attaching that to your care signature. This will clearly identify what you do for the allocations, how you handle the disruptions, the supplier consolidations, the recalls, etc. All the things that affect your best laid plans and your appropriately priced contracts that ultimately are now going to affect clinical education, material handling, potential case start times, as well as impact patient care workflow. For example, look at clinical integration. You know the quality, cost improvement, outcomes, all those end tails. It's about having that technology Swiss Army Knife and applying the best tools to the challenge, whether it's your data governance strategy or formulary control. It’s enabling your workflows and business intelligence, understanding how you make all those decisions and how that will affect your value, your cost, your additional incentives, your outcomes, or even your labor productivity, because all of those things are ripe for disruption.

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Supply Chain Interview “Healthcare systems want control back which is critical to have. Creating that network of interoperability offers so much efficiency and really helps you map those bottlenecks, and the solutions will naturally evolve.” Vin Matozzo

synchronize and create a cadence around those deliverables together. SK: Technology comes down to operational workflows and what it can do for you and your frontline staff such as physicians, nurses, supply chain techs, etc. We deploy a piece of technology that everyone uses every single day. Without a synchronized technology, can you imagine piecing together all the different actions or decisions from purchasing? Try sourcing widget ABC which is coming in direct after value analysis has approved it as a substitution. You could use these substitution analytics from the

HVAUM: How can a technology-optimized VA approved requirements set to create an image supply chain help supply chain & value on the technology portal, which has been done pretty much by phone previously. Basically, your analysis professionals? nurses or clinicians can say, I need a product, or VM: We like to call it reinforcing a lot of the an update on a product, and you can go in and cycles or the series of success. It helps you do type the centralized informatics number. That what you're doing more consistently by informatics technology becomes the common understanding the up and downstream effects. denominator that shows the history of the Plus, we're big proponents of accountability and product and what is currently happening with it. creating that centralized, connected structure. What does that mean? It means holding a Purchasing is getting this direct estimated time of monthly business review internally with supply arrival which is, Monday, January 31st. The chain to review the key performance indicators previous product had a red cone, but the that matter. Then you can fine tune your goals on substitute has a blue cone, and there will be a an ongoing basis into how you want to be change to the blue cone now. The technology performing versus those that may just look at shows all of this, instead of someone having to go KPIs once or twice a year, and then get into those back, contact customer service, wait on the fill rates, contract pricing, accuracy reports, the phone, email purchasing, wait for purchasing to true additional incentives, inventory flow. What- respond, and reply on all these emails. The point ever it is, you have those outcomes and those of view is right there on their phone, at the touch hack scores that are there. Then create that of a computer, in a portal, in a queue, with connected enterprise with accountability and specific information. That's how I see how it's efficiency so that people can cut through the going to drive value to the frontline users, white noise, clear the smoke, and break the creating a holistic transparency to what's going mirrors, but ultimately be reporting out on the on with specific items that they need to know same page. Constantly see where you could about.

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Supply Chain Interview HVAUM: What should supply chain leaders be doing in order to move their organizations to the next level of technology optimized supply chain? VM: Supply chain traditionally hasn’t had that central control power concept for a long time. It was a series of disparate assets in network that didn't necessarily communicate your stockouts and material reports from centralized or decentralized purchasing. We didn’t know it didn’t make it to the dock, what was happening to the deliveries, let alone beyond the dock. Healthcare systems want control back which is critical to have. Creating that network of interoperability offers so much efficiency and really helps you map those bottlenecks, and the solutions will naturally evolve. Those clogs will be reported out from what happens as it works through the system. By using technology to map that, to make that more efficient, to schedule, to document recurring solutions, and to apply those guardrails and opportunities, puts the human back in control in a value-added environment. Supply chain can then focus on utilization, looking at the outcomes instead of resolving the 97 back orders that they are getting hit with on a day-to-day basis.

“Technology comes down to operational workflows and what it can do for you and your frontline staff such as physicians, nurses, and supply chain techs.” Shawn Kenavan

have been right. This blueprint will act as a living, breathing operational clock. Now, walk through how everything flows and let someone visualize and see that most times there are line staff repairing the broken bridges and everything else from the bottom up. But imagine a health network’s CFO whose forward thinking could visualize what the next iteration of processes looks like. Then take those components, the technology, the education, and apply them to their world. There's really no roadmap like that today in this field that anyone could point to and say, “I could kind of Frankenstein this,” or, “There are some good processes to model.” You have the large university teaching organizations HVAUM: Are there any limits to what of the world and a few forward-thinking large supply chain can accomplish with health systems, but there are not many organizations you could point out to say they're advanced technologies? doing it great. SK: The only limits are what organizations put on themselves. That's from a budgetary, financial, or any possible kind of concept. I would love to see organizations take a blueprint of a health network and lay out the processes, lay out the technologies, lay out the different annexes that

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How do you create that possible blueprint and share it with the world? What’s it going to look like? In an agile and constantly evolving environment, it's never “set it and forget it.” It needs to constantly be evolving and moving forward.

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Value Analysis 101 Value Analysis Balanced Scorecard Can Up Your VA Performance Robert T. Yokl, President/CEO, SVAH Solutions

The Only Way to Get Better is Through Measurement A Value Analysis Balanced Scorecard is a tool used to measure financial, customer, processes, and learning and growth data by value analysis leaders to improve their value analysis teams’ results. It was developed by Robert S. Kaplin and Dave P. Norton to give a balanced view of what should be important to managers financially and operationally. “The Balanced Scorecard allows managers to look at (their operations) from four important perspectives (see the exhibit).” Just as important, the Balanced Scorecard links performance to measurement. Lastly, “The Balanced Scorecard forces managers to focus on the handful of measures that are most critical,” organized in a single concise report. Just as important, it provides answers to the most important value analysis questions that need to be answered.

Provides Answers To Most Important Questions If the Balanced Scorecard is designed properly, it will give you answers to the questions you require to succeed in your profession such as:

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Value Analysis 101

Robert T. Yokl

Categories

Objectives

Measures

Targets

Initiatives

Financial

Increase Savings

New Approved 7% Increase In Purchases/ Net Savings Annual Savings

Customer

Reduce The Time Of New Request Approvals

Number Of Days To Approve

45 Days

Processes

Increase Time For VA Study Completion

Number Of Days To Complete

90 Days

Automate VA Study Workflow

Learning & Growth

Increase Value Analysis Team Certification

Number of VA Certified Team Members

80% Certified

Hire Trainers For VA Certification

Reduce Number Of New Purchase Requests Or Increase Savings Automate New Product Request Process

How do our customers see us? Do they see value analysis professionals as partners in saving money; an impediment in getting their new products, services, or technologies approved; or, a resource to help them source the most appropriate products, services, and technologies for their intended use? What must we excel at? Quicker turnaround of new product, service, and technology requests; saving twice as much as new product, service, and technology approvals annually; or being a go-to resource for your supply chain and clinical staff? How do we look to finance? Are we implementing bottom-line improvements? Are our savings growing every year? Are we controlling the growth of new product, service, or technology requests? How can we continue to learn and grow more? Do our value analysis teams have the skills and training to be proficient in value analysis? Do they have project manager training? Are they ready to lead value analysis teams?

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Value Analysis 101

Robert T. Yokl Naturally, you can add your own questions and answers to this list as it relates to your own healthcare organization’s situation. The key is that you think through this development process so that you can continue to improve and create value for your hospital, system, or IDN.

Focusing On The Right Performance Measures Traditionally, performance measures were skewed towards a healthcare organization’s financial performance (e.g., revenues, ROI, liquidity, etc.), not its operations, thereby leaving a big performance measurement gap in other areas of your healthcare organization. As you can see, this challenge can be solved with a Balanced Scorecard that considers not only your financial performance, but also operational issues that you should be focusing on to succeed. This ensures that you are focusing on the right performance measures for your value analysis program. That’s how a Balanced Scorecard can up your value analysis performance.

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Value Analysis Advisor (For Sales Reps Only) What Can Your Customers Get Excited About? Robert T. Yokl, President/CEO, SVAH Solutions

From our vantage point, too many product, service, and technology offerings are similar propositions, which isn’t very exciting for your customers. Yet, there are a myriad of ways to differentiate your product, service, or technology to make it a new opportunity for your clients. For example, we recently gave a presentation on our CliniTrack™ Value Analysis software to a healthcare system’s value analysis team who were looking for a better way to manage their new product requests. Although our competition was also making a presentation and had some features that we don’t have, we emphasized that we customize our software to the client’s exact specifications which makes it their own. This got them excited about the opportunity that customization can be offered to their healthcare system.

Stop Selling Stuff and Start Selling Opportunities One way to stop selling stuff and start selling opportunities is to offer to conduct a value analysis study of your product category. Why? Nine out of ten times you will uncover an opportunity for your customer to save money and/or improve quality, safety, or their outcomes with your product.

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Value Analysis Advisor (For Sales Reps Only)

Robert T. Yokl

For instance, we conducted a value analysis study in the past after convincing our client that we estimated they were purchasing twice as many diabetes test strips as their peers. During our VA study, we identified the problem: This client’s nursing staff had to use two diabetes test strips from their current vendor to enable them to get the correct glucose reading. This one observation saved this client over $150,000 annually when a change was made to their test strip vendor. Wouldn’t you like to be the vendor who showed this customer a new savings opportunity?

Every Year Represents New Selling Opportunities Every year there is goal setting by healthcare organization department and division heads to Too many product, improve their operational areas. This goal setting service, and technology process opens the door for sales representatives to offerings are similar create selling opportunities for their corporation. However, this can’t be done unless you tap into these propositions, which isn’t individuals’ goals and objectives for the current year. very exciting for your One medical device manufacturer we worked with customers. accomplished this task by having a formal annual goal setting session with their customers. During these working sessions, the manufacturer’s representatives would ask their customers what their goals were for the coming year and then try to match them with corresponding goals that the manufacturer could meet. Examples of goals agreed to in these sessions might be to reduce catheter infections by five percent, decrease decubitus ulcers by eight percent, or guarantee 98% on time deliveries of their product line. Generally, the manufacturer would be permitted to have pilot studies of their products that would satisfy the goals that they agree to during these working sessions, hence, creating a win-win scenario or opportunities for both parties. That’s why every year represents new selling opportunities for you.

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Utilization Management

How Utilization Reporting Helps You Pick Up Savings Opportunities Including Price By Robert W. Yokl, Sr. VP, Supply Chain & Value Analysis — SVAH Solutions Price is a very simple element of the healthcare supply chain procurement process. You order the product at that price and get the total spend for that line-item product. This is the total spend that we see every day from the vendors and manufacturers that we purchase from. Now envision this same scenario happening to thousands or even tens of thousands of products on an ongoing basis at your health system. Standard operating procedure, right? That is a lot of prices to look after and, yes, a heck of a lot of spend to track after as well. There is a synergy to these that add up to the total spend cost at your organization. No surprises here, yet.

What You Can’t Read Between the Lines Is the Challenge None of this is surprising anyone in the healthcare supply chain world, but the true “total cost” really involves keeping the organization’s quantity used to the lowest possible level while maintaining the best price. There are many ways that price can get out of line, but we also need to track utilization cost, which goes beyond total cost and uses a patient volume centric metric to measure it. So, tracking Cost Per Adjusted Patient Day to the Supply Category Cost or Cost Per Cath Lab Case Per the Cath Lab Category is a quality measuring tool. So, why aren’t we employing this further?

Skin Staplers In a recent value analysis meeting where we were working on new savings opportunities for a healthcare system client, an unusual anomaly came up. Their skin staplers’ cost per surgical case was up by 62% over the previous year and over 68% higher than their cohort benchmark best practice. Two metrics pointing to a possible savings opportunity are worth looking into. It turns out, the organization had switched their GPO the prior year and the skin staplers were completely missed which resulted in the organization paying list price because their staplers were never converted. Volume 10/Issue 1

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Utilization Management

Robert W. Yokl

This has happened at many healthcare organizations, but at least this organization had utilization tracking in place to alert them to this, otherwise they would not have caught this increase because it was not on anyone’s radar screen to look into these further. They thought the skin staplers were already converted and that they were reporting out associated savings, but that did not happen. This organization got a prime example of how price increases the total cost and their utilization tracking helped them uncover this.

Orthopedic Spinal Pricing

The vendor owed the hospital substantial back credit to the sum of over $300K.

We saw a similar instance with a large health system that had negotiated new pricing with their primary orthopedic spinal vendor which would result in a 12% savings in this highpriced specialty category. In working with the organization on their utilization tracking, we started letting them know that all of a sudden, their spinal implant costs per case were increasing by over 8% over their own historical best practice levels. In conferring with the Director of Supply Chain, he stated that there was new pricing coming online and that they could not only expect the increase to go away, but savings in the range of 12%.

Utilization Tracking is Not a One-Time Event The good thing about utilization reporting is that it is not a one-time event. We continued to report to the supply chain director that they were still incurring increases and that they should look into this further. Eventually, six months later, the supply chain director called me and told me that we were right about the orthopedic spinal implant increases. The vendor never plugged in the new pricing for the organization, nor did his supply chain team pick this up in their ERP system. The net effect was that the vendor owed the hospital substantial back credit to the sum of over $300K and fixed the pricing on their system. Once again, this was picked up using the hospital’s own data but married to patient centric metrics and total cost of the product category.

What is Measured Happens - What is Not Measured Happens Too! Most organizations talk about utilization tracking and that it is important, yet they don’t really know anything about their true utilization and volume centric consumption because they are not tracking it. At some point, you may want to know what is happening with your utilization and consumption reporting, not just overall Supply Cost Per Adjusted Patient Day or to Net Revenue. Those are just the starting point, and let’s face it, they won’t tell you things like your orthopedics implants, skin staplers, or any other category are running too high in total cost per metric. There are over 700 major categories in your supply chain that you will find the next level of supply chain savings in, as well as issues with price and standardization that will power your next level of savings and quality performance for the next five years. A little tracking will go a long way!

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Perspective Why Group Purchasing Is Only One Side of the Savings Triangle Equation Robert T. Yokl, President/CEO, SVAH Solutions

It has been my experience that very few things in life and in business have one all-encompassing solution. However, group purchasing seems to be the only savings strategy that supply chain professionals have embraced since 1910 when the Hospital Bureau of New York was founded to provide group purchasing services nationwide. Don’t get me wrong! I’m a strong proponent of group purchasing, but it's only one side of the “Savings Triangle.” Only using this strategy limits you from obtaining maximum savings results at your healthcare organization. Here are the reasons why.

Standardization Vs. Customization: A Paradigm Shift While standardization goes hand in hand with group purchasing since you can’t maximize your GPO savings without standardizing on one product, service, or technology organization wide, it can also cost you money. That’s why customization might be a much better cost management tactic than standardization.

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Perspective

Robert T. Yokl

It comes down to this: Standardization necessitates you to embrace a one-size-fits-all philosophy (or one product, service, or technology to fit all situations), which is irrational at best and costly in almost all situations. For example, if you standardize on a 17” x 24” standard incontinence pad, you will find that 80% of your customers can use it effectively to “protect linens.” However, if you have done your research, you will discover that 20% of your customers (e.g., pharmacy, radiology, operating room, etc.) use these pads for different functions (table and shelf liners, catch drainage, drug preparation, etc.) and that, most often, you can find a lower cost alternative to meet their requirements. This way, your total overall cost will be lower than standardizing to one pad. As a general rule, customization will cost you less overall than standardizing on one product, service, or technology organization wide. More importantly, customization will provide the right product, service, or technology that is required for all of your customers as opposed to them ordering off contract or performing workarounds to employ the standardized products, services, or technologies you have provided for them.

Utilization: 1:4 Savings Ratio To Your Price Savings For every dollar you save in price, we have documented a minimum of $4.00 in utilization savings can be achieved on the hundreds of thousands of commodities you purchase annually. This is because once you hand over a product, service, or technology to a department, anything can happen (e.g., wasteful and inefficient consumption, misuse, misapplication, and value mismatches) to it and it usually does over its lifecycle. That’s why it’s just as important to master utilization management as it is to bid/negotiate to obtain the best price for your hospital, system, or IDN.

The Worst Number in Supply Chain Management is One It is an accepted axiom that “the worst number in supply chain management is one,” because it limits your options, holds you captive to one source, or restricts your alternatives. That’s why the Savings Triangle has three sides for savings: price, customization, and utilization. When one becomes depleted, you still have another two to dig deeper for savings, or you can utilize all three to maximize your supply chain expense savings!

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