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The room was full of OR managers, eager to hear about how their peers had adopted a newer concept. “I want to make one thing very clear – we are not anti-vendor in any way,” stated Ilsa Nation, RN, MA. She’s the director of Loma Linda University Medical Center’s East Campus Perioperative Services and Loma Linda Health Perioperative Services Scheduling and Billing. With her was Dr. Gary Botimer, chair of Orthopedics at Loma Linda University School of Medicine and Chief Operating Officer of Loma Linda Health Faculty Medical Practices. They were getting ready to share their experience implementing a rep-less model.

The premise of a rep-less model is facilities can reduce the cost of a procedure by reducing the cost of the materials by bypassing the OEMs, GPOs, sales representatives and distributors and purchasing from the materials manufacturer. In this case, it was purchasing orthopedic implants. Botimer stressed the total hip and total knee primary and replacement sets they used are American-made, FDA cleared products, and worked just as well because “not much has changed” in implant design in the last 10 years.

Instead of a supplier’s representative selling product and being present in the OR, a facility connects with an individual manufacturer to obtain inventory and trains one of its surgical technicians as a rep. For Loma Linda, this hybrid position was a new, but Nation and Botimer both agreed it was paramount to the program.

The motivation for this change started when Loma Linda was founded in 1905. The organization wanted to provide high level care to its economy challenge community and pushed toward innovation by trying new methods in its university with the vision: innovating excellence in Christ-centered healthcare. Just like the in rest of the world, the university health system felt the new pressures in healthcare. The surrounding area experienced economic challenges, there was an increase stress on value based purchasing and costs to the facility, which is one of the few Christian medical schools, kept increasing. “With the changes in government funding, it's making it a challenge to keep the institute open. The other side of that coin is we have a moral obligation to try to provide care, and care that isn’t affordable, isn’t care,” Botimer explained.

When the idea of a rep-less system was first brought up, Nation recalls thinking it was a great idea, but that it would never happen. Reps had strong relationships with surgeons at Loma Linda, both financial and personal; brand loyalty was established and reps had influence on decisions when they were present in the OR- all of which are common issues, Nation explained. After a couple years of talking, the decision was made - the university was going to transition to a rep-less ystem.

Transition Time

They said the transition started with strong executive leadership support, finding surgical team champions, connecting with supply chain experts and identifying a change agent support company. In its case, the facility chose OrthoDirect.

To start, all of its surgeons were brought together for an evidenced-based review of the different implants available straight from the manufacturers. The surgeons narrowed it down to their top choices, and they trialed the implants to pick which one would be used regularly. During this time, the new position was created and the person with surgical technician experience was being trained as a rep by the manufacturer. This person was a hospital employee, and was also in charge of sharing their knowledge with the other surgical technicians.

After the training had been complete, the transition was theoretically complete. Of course, it was not.

For about the first year, Nation said she had to be diligent in stopping rumors and reiterating why this decision had been made. Surgical team members, sales representatives and others against this decision were adamant in resisting change, but, overtime, she said the OR teams realized the benefit to the system. Now, she says they are its biggest supporters and have taken ownership of the system. “What this has done is given us the confidence to take on the difficult tasks,” she said. “We can make a difference and we can make an impact on really difficult things.”

Currently, more than 90 percent of procedures are done with implants purchased directly from the manufacturer through the rep-less ystem. There has been nearly a 60 percent reduction in cost for total case cost in primary total knee procedures, and there has been a 54 percent reduction in total case cost in primary total hip procedures. 

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