Device Fabrication: Then There Was One
November 2017 Issue
Anyone who has worked in O&P for any length of time knows that figuring out how to manage fabrication can be quite a challenge and is something that needs a regular review. There are many variables that impact what is best for a specific O&P company when it comes to how devices are fabricated, and they can change over time. Sometimes, those variables can happen within the organization, for example should a specific clinician or technician decide to leave the business. Other times, outside variables such as reductions in reimbursement can push practice managers to reconsider the best ways to fabricate a quality device but with a lower cost. Regardless of the cause, managing the changes to adapt to these factors can be like throwing darts at a dart board that's afraid of needles. For our practice, O&P Company, numerous variables have led us to make dramatic changes to how we managed our fabrication process over the past few years, and we have learned much about change management along the way.
I started working in O&P in 2008. I was the third full-time technician in the practice. At that time, there were five clinicians who saw a mix of patients covering the full spectrum of O&P care. We fabricated most of our lower-limb prosthetic, upper-limb prosthetic, and lower-limb orthotic devices at our fabrication lab in our main office, and only sent the more proprietary devices to an outside fabrication facility.
Over the next several years, we were like most other O&P practices, and we were simply humming along. The practice's billed dollars continued to grow, and we continued to expand the range of the devices that we fabricated in-house.
In 2012, things began to change for our team. The entire organization was feeling the pain from the new documentation requirements and the various forms of audits. For quite some time, those new hoops caused us to slow down our patient care process and to become overly conservative with our device recommendations. This didn't significantly impact me or the lab; the volume of work stayed the same. I just attached mechanical knees instead of microprocessors to the finished socket.
However, late in 2012, our most senior technician left abruptly. The company made the decision not to hire a replacement, and to begin to use central fabrication on a more regular basis. While we did not yet know it, the changes we made in 2012 would turn out to be minor compared to what was coming our way.
Around 2014, things got tough for our practice in several ways. Audits continued to grow and our billings flattened out, and the other technician decided to seek his fortune in the landscaping business. At that point, we were pushed into a spot that often leads to real change in an organization—we were desperate.
We had many discussions about different ways that we could approach the situation. We could go to a 100 percent central fabrication model. We could immediately seek to hire one or two technicians. But we decided on a third option: the lab would stay open, but with only one tech—me. Central fabrication would be used as needed, but the idea was to keep as much as possible in-house while still meeting business and patient needs. We thought that if we could pitch away some of our old habits and mindsets, we could make this approach work. The question was whether we could really move away from our past into an entirely new mindset surrounding device fabrication.
Our first challenge was related to our use of completion guidelines. For years, we had used a rigid timetable for device fabrication that had been established through years of discussions between the clinicians and the technicians. We had worked under a system that was nearly first in, first out, with some accommodations for the most complex jobs. This changed to giving priority to the jobs that took the least amount of time and were the least likely to slow down the workflow. The idea behind it was this: With one technician, we had the option of completing either two prosthetic sockets or one AFO. We chose the former. That logic may sound obvious to some, but for us, this simple step required a real paradigm shift in thinking throughout the organization.
Our plan took shape once the ideas were put in to practice. Virtually all the prosthetic work was done in-house, while orthotic jobs acted as a kind of filler. If things were a little slower in the lab, I'd do them; if I was busy, I'd send them out. In contrast to the old system where jobs were given equal priority, this new approach expressly gave me, the tech, the latitude to adjust what I was doing in real-time to maximize output and meet patient needs.
Our scheduling changed as well. Prosthetic diagnostic sockets are completed in three days from when the job gets to the lab, while laminated sockets are allocated five days for completion. These jobs are given a hard deadline, and the patient is pre-scheduled. In contrast, orthotic jobs are given two weeks and a soft due date. For example, if a clinician just casted for an AFO, he or she should tell the patient two weeks. If I can get the orthotic job done sooner, I let the clinician know. The default, though, is to not schedule the patient until the orthotic fabrication is complete. The power of this system shouldn't be underestimated. Yes, there is only one technician filling the orders of five clinicians. But that single technician really functions much more as a fabrication and logistics manager, controlling and directing the workflow for maximal effect.
Beyond the overall prioritization changes, we also made two more important fabrication changes. The first change was to switch to primarily using a cylindrical modular lock instead of a small lock and separate mounting plate. This significantly reduced fabrication time for most of our transtibial sockets. Our clinicians initially pushed back on this idea because of the alignment limitations involved with this style of lock, but once we made sure things like offset plates and rotatable adaptors were on hand in all our offices, this issue was minimized. Once the clinicians saw the lower turnaround times due to the ease of fabrication using the modular locks, they were fully on board with the change.
Our other significant change was to present copolymer sockets for permanent devices to our patients, and not default to laminations. While this socket design cannot work for all patients, copolymer does present several distinct advantages. Sockets that are easier to clean, that don't have a chemical smell, and that have more adjustability can be very attractive in certain cases. Transfer paper is also an interesting possible feature of copolymer sockets that can endear the material to patients because it allows for a great deal of customization. This change was a win/win situation as the patients benefited from properties of copolymer while we reduced our fabrication time.
What was the outcome of all this maneuvering? These changes took a while to feel right and there were bumps along the way as the company adjusted to a different dynamic. But, we have now adjusted to these major fabrication changes and the company has benefitted. We have not stopped changing and that's a good thing. Pain created by internal and external challenges has taught us all a great lesson. We all fall prey to the "currently" bias. We are inclined to believe that whatever practices we're currently using are the most efficient and necessary. Because of that human inclination, it can be very difficult to see another way until circumstances come along that force us to confront a moment of change or die. This O&P company chose to change, and we plan to keep on changing and continually look for a better way.
Lab Manager is the manager of fabrication for a busy O&P practice in the United States. Comments may be sent to firstname.lastname@example.org.