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Behind The Scenes At A Physician-Owned Specialty Hospital

Behind the Scenes at a Physician-Owned Specialty Hospital

By David Hogberg
Sidebar article toObamaCare: Rx for Crisis

March 7, 2012 -- The incision Dr. Thomas Tkach makes into his patient’s knee is almost like clockwork. It is Friday morning, and within minutes Dr. Tkach will be doing a knee replacement on a patient who just happens to also be a physician. It is his fifth surgery of the day.

Dr. Tkach is an orthopedic surgeon who practices at the McBride Orthopedic Hospital in Oklahoma City, Oklahoma. He has been in private practice for about sixteen years. He is a bit unusual in that he is the type of surgeon who can do ten or eleven surgeries in a day.
 
McBride is the sort of hospital that enables Dr. Tkach to do that.
 Dr. Thomas Tkach
“When I go into the operating room, I don’t have to tell my technician which instrument to hand me at what point in the surgery,” he said. “He or she has done it so many times they already know. The nurses know exactly what to do.”
 
“He can do about 600 to 800 joint replacements a year,” said Todd Wilson, a distributor for implant devices who works closely with McBride Orthopedic Hospital. “Because he’s done it so many times, he’s knows exactly what he’s doing and able to get it done quicker. At other hospitals, a surgeon may perform only a few dozen a year, so it can take them longer to perform a surgery.”

McBride is a physician-owned specialty hospital, owned by the nineteen physicians who founded it in 2005. The physicians are also part of the “McBride Clinic” which is located in downtown Oklahoma City and has been in existence since 1923. The physicians have their offices at the clinic, where they do most of their consulting with the patients. McBride has 20 physician-owners, 400 employees, and treats some 5,000 patients annually, according to The Oklahoman.

“When you invest in yourself, it incentivizes you to work hard.”

- Dr. Thomas Tkach
The lobby of the McBride Orthopedic Hospital is expansive, filled with cushioned chairs and sofas. The walls are cream colored, the doors painted mahogany, and the lighting is soft. On the other side of the inner wall of the lobby is an atrium with green plants and a small, artificial waterfall. Behind the waterfall is a “reflection area” where patients and their family can go to pray and meditate. The hospital will make accommodations if the patients or family wish to have clergy with them in the reflection area.
 
The chair and sofas in the lobby are already about half full by 7:15am. Mark Galliart’s office is just off to the right of the lobby. Galliart is the chief executive officer of McBride.
 
The building is only one-story, shaped like a “Y”. Galliart says that was a deliberate decision on the part of the physicians.
 
“Our physicians didn’t want the elderly patients to have to worry about going to this floor or that floor,” he says. “It’s pretty easy. You go to one end or the other, and in the middle are the operating rooms.”  
 
McBride, he says, has a patient to nurse ratio of 4 to 1. Patients have their own rooms, and accommodations can be made to let family members spend the night.
 
Most patients that come to McBride Orthopedic Hospital for surgery have already visited one of the three locations of the McBride Clinic for an appointment with a surgeon. If the surgeon determines that surgery is needed, then surgery will be scheduled at the McBride Hospital.
 
However, McBride has a small Emergency Room with four beds.
 
“On average, patients are seen within fifteen minutes of coming in to our emergency room,” Stephanie, a nurse, says. “At most it takes about an hour and a half to get a patient from the emergency room to a hospital bed.” How long it takes to get the patient into surgery varies. The shortest amount of time from the emergency room to the operating room, according to Stephanie, is about two hours. In the case of a patient who came in the previous day with an injured elbow, the surgery could be delayed so he was put on the list for surgery the following day.

The physicians who started McBride wanted far greater control over the quality of care that the patient received.
The desire to open McBride Orthopedic Hospital was driven, in part, by the experience the physicians at the McBride Clinic had with the Surgery Center of Oklahoma, an outpatient facility in which they are also part owners.
 
“We were very pleased with the product that we got there,” said Dr. Tom Janssen, who does a lot of hip and knee replacements. “We found that center was by far and away our preferred place to work. We could get twice as much done. We were far more efficient and the level of care was good. We wanted to have the same experience with our inpatient facility.”
 
The orthopedic surgeons at the McBride Clinic were doing their inpatient work at the Bone and Joint Hospital, which is part of St. Anthony’s Hospital.  In 2000, a number of new surgeons joined the McBride Clinic.
 
“Suddenly, Bone and Joint hospital became insufficient,” says Dr. David Holden who does a lot of shoulder surgery. He has a large sports medicine practice and is one of the team physicians for the University of Oklahoma. “To expand it was going to be difficult, given the layout of the building. But we really needed more space.”
 
But St. Anthony’s management wasn’t too keen on the idea, recalls Dr. Mark Pascale, who also has a sports medicine practice and does inpatient surgery on Medicare patients.
 
“They didn’t want to expand,” he said. “I suspect it had something to do with the fact that they wanted their beds to always be full than to have more capacity but sometimes have beds empty.”
 
Dr. Pascale remembers the problems that would create.
 
“We got to a point where we were doing more surgeries than the hospital had beds for patients to be in. Sometimes we’d have to cancel an elective surgery the week the surgery was supposed to occur because there wouldn’t be a bed for the patient to go into after the surgery.”
 
The physicians at the McBride Clinic had to decide if they wanted to continue to pressure St. Anthony’s, or take their services to another hospital, or start their own hospital.
 
Dr. Thomas Janssen“We had a meeting two years before we opened McBride Hospital,” says Dr. Janssen. “We all sat down and asked, ‘How serious are we? Do we want to build our own hospital and take the risk?’ We looked around the room and everyone raised his hand.”
 
Another factor that drove the physicians to open McBride Hospital can be summed up in the word “control.” They wanted control over how the hospital was run and they wanted control over the decision-making process. Ultimately, they believed that would give them far greater control over the quality of care that the patient received.
 
“We built it because we were afraid that elsewhere we’d be limited in how we could take care of our patients,” says Dr. Pascale. “We were afraid that if we got told what to do and where to go we’d be compromising our patients’ care. We wanted control over our patients’ care.”
 
Dr. Pascale notes that by having a hospital that specializes in orthopedic care, he doesn’t have to worry about doing a surgery in an operating room where an infected bowel resection occurred the day before as might be the case in a large general hospital.

McBride has a patient-to-nurse ratio of four to one.
 “Yes, they clean the rooms, but bacteria are where they are,” he says. “The more complicated joint procedures where you’ve got a lot of metal out in the open and the patient’s joints are opened—it takes just one contamination and you’ve got a big problem on your hands. We don’t have those bugs in our hospital because we don’t do [bowel resections] there.”
 
The physicians enjoy being able to make decisions about how the hospital is run without having to get approval from various vice presidents and committees as they would at a major hospital.
 
“If we want to get something done, we don’t have to ask for permission,” says Dr. Jannsen. “We have to agree amongst ourselves, but for the most part we can do that. We are the executive committee.”
 
Dr. Holden thinks one of the biggest differences is in the nursing staff.
 
“The complaint everybody has at every hospital is nursing care. It’s always the main issue,” he says. “That’s what everybody cares about because that’s what the patient sees. Physicians don’t have control over that at a large hospital. We do at our hospital.”
 
Dr. Holden was chief-of-staff at McBride Hospital when it first opened, a position that he says was not an enviable one.
 
“I saw a lot of complaints and it was all about the nursing care. Getting the personnel to the level we wanted was not easy. But because we had control over it we were able to work at it and keep working at it. Now that we’ve been open these many years, everybody has glowing reports about our nursing care. We can control that, and that’s the number one thing that makes a difference in a patient’s care.”
 
While McBride Hospital runs smoothly now, getting it open was an enormous undertaking.
 
“Honestly, I’m sure none of us really fully knew what we were getting into as far as the amount of work that it took to get it going,” said Dr. Janssen.
 
Each of the nineteen physicians had to sign a line of credit worth $2 million with a bank.
 
“It was a big risk,” says Dr. Pascale. “I think there were a lot of guys who lost a lot of sleep worrying about it.”
 
Dr. Tkach was not one of them.
 
“Was I concerned about it? Not really. That was an investment we made in ourselves. When you invest in yourself, it incentivizes you to work hard. I had no concern that this would not go well.”
 
Dr. Tkach is heading to his next knee replacement surgery. He stops at a large sink just outside the operating room and thoroughly scrubs his hands and arms.

“The less time in the operating room, the less risk of infection.”

-Dr. Tkach
He enters operating room number 2 at about 9:20am. The staff is already there. They have prepped the patient, who lies on the operating table. A dressing called “coban” that looks like an ace bandage runs from the middle of the patient’s right leg to his ankle. That keeps in place a “stockingnette” that goes from the foot to the middle of the calf.
 
“That walls off the foot,” says Dr. Tkach. “We consider the foot to be dirty. We put the stockingnette on there to keep germs from travelling up the leg and into the surgical wound.”
 
Dr. Tkach and a nurse then wrap a blue, elastic material around the patient’s leg. It is called an “eschmarch.” It exsanguinates the leg—that is, it pushes all of the blood out of it. Once that is done, a tourniquet, located near the patient’s groin, is inflated.
 
The scrub technician—the operating room employee whose job it is to make sure the surgeon has the tools he needs—moves three tables filled with orthopedic surgical tools forward so that they form a “C” at the end of the operating table. He stands in the opening of the “C”.
 
At the end of the operating table near the patient’s head is a machine with what looks like a vacuum with a hose coming out of it. It is hooked up to a special gown that is wrapped around the patient.
 
“It’s called a ‘Bear Hugger’,” explains one of the nurses. “It blows warm air on to the patient. If the patient gets cold, it makes the wound healing take longer and increases the chance of infection. It also increases the patient’s oxygen demand.”
 
Is this standard is most hospitals?
 
“It is here,” she says.
 
At a few minutes past 9:30 am, Dr. Tkach draws a thick black line down the middle of the patient’s right knee. He then makes a long incision down that line. The scrub technician gives Dr. Tkach a “baby retractor” which Tkach uses to pull away the soft tissue from the knee so that the bone is exposed.
 
The scrub technician then hands Dr. Tkach a drill that he uses to drill pins into the femur and tibia. The pins will stabilize the bones and act as a “guide” to help Dr. Tkach as he saws off portions of the knee bone.
 
Dr. Tkach hands the drill back to the scrub technician who gives him another drill with a small saw blade on the end of it. Dr. Tkach removes the knee cap—patella—and then begins to saw away at the knee bone, cutting away at the lower part of the femur and the upper part of the tibia.  He also saws away the back part of the patella.
 
Dr. Tkach washes the knee area out with a saline solution. He then inserts the “trial” components of the knee prosthesis. These are components that he will use to test the knee. He bends and extends it several times to make certain that the components fit. If they do not, he will either have to saw off some more bone or get different sized components.
 
The femoral component is a thin, curved object that is made out of a combination of chrome and cobalt. It will be attached to the bottom of the femur with a special cement.
 
The tibial component looks like small tray with a wedge underneath. It is also made out of chrome and cobalt. It will be fixed to the top part of the tibia with the cement. However, Dr. Tkach will not need to drill into the bone to make a hole for the wedge. The bone is soft enough that the wedge will go in simply by using hammer to tap on the top part of the tibial component. On top of the tibial component sits a plastic called polyethylene that will act as the cartilage in the new knee.
 
Then the patellar component, a small, plastic disc, is attached to the back of the patella with cement. It will be held in place by special grooves that are in the femoral and tibial components.
 
“The company says these will last 30 years,” says Dr. Tkach. “That means probably 15 to 20. Engineers testing these things in a lab is a lot different than the wear and tear from a human leg.”
 
The patient was admitted to McBride at 5:46 am and was in the operating room at 8:44 am. Dr. Tkach finishes up the surgery at about 10:10 am. His physician assistant will suture up the incision.
 
Upon leaving the operating room, a nurse approaches Dr. Tkach and informs him that he will be in operating room number 3 next, and then return to number 2.
 
He then heads to the physician lounge to get some coffee and chat briefly with another physician.
 
Then it is time to call the family of the patient that he just operated on. He lets them know that the surgery went well. After speaking with them, he calls another number and gives dictation—he makes a brief recording of what just happened in the surgery that will go in the patient’s chart.
 
On his way to the next operation, Dr. Tkach reveals his love of hunting.
 
“I once had a patient who didn’t have the money to pay me, but he had a whole bunch of hunting rifles. He asked me if we could settle up that way. I said ‘sure!’”
 
Outside of operating room number 3 he heads to the sink to scrub down. When he walks in a little before 10:30 am, another crew has the patient all prepared for him.
 
At 10:33am he makes an incision on the patient’s left leg.
 
This patient was admitted to McBride at 7:15am. He was brought to the operating room at 9:55am. Dr. Tkach and his surgical team work with the same sort of efficiency as with the last patient. He finishes at about 11:05, leaving the physician assistant to suture up the incision.
 
“One of the benefits of being able to work this efficiently is the patient has the tourniquet on for a shorter period of time,” says Dr. Tkach. “The less time the tourniquet is on, the less pain the patient will have after surgery. Also, the less time in the operating room, the less risk of infection.” 
 
Then it’s off to the physician lounge, dictation, and a call to the patient’s family.
 
He scrubs up and is in operating room 2 a little before 11:30 am. At 11:32 am, he makes the incision in the knee. The patient was admitted to the hospital at about 8:41 am and was in the operating room a little after 11 am. Dr. Tkach will finish a little after noon.


> read related sidebar:  Institutionalized Inefficiency: Behind the Scenes at a General Hospital

> return to ObamaCare: Rx for Crisis

 


DAVID HOGBERG is a Washington-based correspondent for Investor's Business Daily and the author of an upcoming book on Medicare. He was formerly a senior fellow at the National Center for Public Policy Research, and a fellow at the Rio Grande Institute. You can follow David on Twitter at: @DavidHogberg

 

 

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