The Dana-Farber Successfully Sutures the Surgical Efficiency Gap

The Dana-Farber Cancer Institute (DFCI) has turned a newly developed sedation suite into value-enhancements for its patients.

Unlike many capital expenditures in medicine that implicate more layers of costly care, the sedation suite at the Dana-Farber Cancer Institute (DFCI) allows for the reallocation of capital and labor resources to promote patient value and process efficiency.[1] Traditionally, patients at medical centers such as the DFCI receive all surgical care at an affiliate hospital. For DFCI’s pediatric patients, this was Boston Children’s Hospital (BCH). However, the resource-intensity at a major hospital such as BCH is often unnecessary for routine procedures.[2] By shifting the site of care from BCH to its own sedation suite, the DFCI has executed a series of strategies that successfully promote its mission of providing high-value care to patients.[3]

I. Patient Stratification. The DFCI recognizes that different patients require different types of care. For “high-risk” patients, as classified by the American Society of Anesthesiologists, care continues to be provided at BCH. However, for patients without anesthesia risks, a value-based alternative is used, optimizing clinical outcomes and patient satisfaction as a function of cost. Stratification was successful in assigning patients of lower risk classifications to receive care at the DFCI, as there were no differences between the outcomes of patients randomized to the traditional system versus the sedation suite.[3]

II. Predictable Procedure Schedule. The sedation clinic offers a small selection of procedures, all of which are routine and predictable. While the sedation suite houses much of the same equipment as a traditional operating room, the setup and the range of resources required in the room is more limited. Most importantly, the procedures that are undertaken in the suite are extremely predicable in length, thus minimizing the cycle time of an episode of surgical care. Since emergency procedures are not scheduled at the sedation suite, the operating schedule does not have to allocate provisionary time-slots for potential emergencies.[3] By knowing with more certainty the procedure length and the occupancy of each space during the various phases of the procedure, labor and capital use can be optimized.

III. Fewer Patient Handoffs. In traditional surgical settings, each clinical staff member has a specific set of roles at a very specific point during the care process. While the process works in managing large numbers of highly complex procedures, it can be unnecessarily time consuming for shorter and simpler procedures.[2] In contrast, the DFCI model has a single duo of nurses in addition to the core physician team see a patient through all phases of care, thus minimizing handoff time.

IV. Patient Satisfaction. Patients and their parents express advantages to receiving surgical care at the DFCI, including feeling less apprehensive about the surgery and more confident in the team’s execution of care. These sentiments appear to drive perceived quality of care and cause parents to feel more comfortable leaving the recovery area after their child has been stabilized instead of unnecessarily lingering.[3] This behavior thus potentially shortens the average throughput time of the recovery phase, leading to time and cost savings.

V. Precise Value Measurement. While the precision of clinical outcomes has long been a focus of the medical community, less attention has been paid to satisfaction and true costs of care. The DFCI and BCH jointly evaluated all three of these elements in order to measure how the implementation of the sedation suite and its processes were optimizing value. Importantly, costs are not measured using the hospital-based algorithmic allocation based on charges. Rather, true costs derived from Time-Driven Activity Based Costing studies are used to derive more accurate value measurement.[4],[5]

*          *          *

Delivering on patient value is becoming increasingly more important as insurance companies negotiate contracts that reward value, patient outcomes/unit cost, and penalize low-value care. Through the sedation suite initiative, the DFCI has been able to impact both components of the value equation. With respect to outcomes, the model has improved patient satisfaction while maintaining clinical outcomes. With respect to costs, there has been a dramatic reduction in costs (upward of 20%).[3] These cost savings can be used to cross-subsidize other procedures that are inherently more complicated, and thus may not be amenable to alternative care structures. Additionally, the time savings can facilitate more expedient surgical care at BCH, as the current surgical schedule is limited in its capacity to serve patient demands.[3]

Value-based performance is a reality that will universally hit almost all healthcare institutions.[6] Thus, continuous process innovation initiatives like the sedation suite will help to position the DFCI to excel in this new healthcare compensation climate.


[1] Moses, Hamilton, et al. “The anatomy of health care in the United States.” JAMA 310.18 (2013): 1947-1964.

[2] Dhupar, R. et al. Delayed operating room availability significantly impacts the total hospital costs of an urgent surgical procedure. Surgery 150, 299–305 (2011).

[3] Devji, T. et al. Safety and Cost-Effectiveness of Port Removal Outside of the Operating Room among Pediatric Patients. Journal of Surgical Research. Submitted for Publication.

[4] Kaplan, R. S. & Porter, M. E. How to solve the cost crisis in health care. Harv. Bus. Rev. (2011).

[5] Chan, Y. C. Improving hospital cost accounting with activity-based costing. Health Care Manage. Rev. 18, 71–77 (1993).

[6] Gordon, J. E., Leiman, J. M., Deland, E. L. & Pardes, H. Delivering value: provider efforts to improve the quality and reduce the cost of health care. Annu. Rev. Med. 65, 447–458 (2014).

Image courtesy of


Gilead Sciences: Innovation for growth


Xiabu Xiabu – Unique Hot Pot Chain

Student comments on The Dana-Farber Successfully Sutures the Surgical Efficiency Gap

  1. This is very interesting – thanks Tehsina. As you mentioned, Medical Centers like DFCI focus on research while associated patient care is handled by affiliate hospitals. Hence the shift to in-house patient care with the Sedation Suite seems like a major shift in business (and hence, operating) model. Among other realignment, patient care needs new elements like a different segment of clinical workforce, a focus on lean process, different KPIs and capital requirements.. Do you think it may have been more sustainable and scalable to find a delivery partner (other than BCH) to execute this value-based care idea, and themselves – stick to what they do best? Was there the option of a partner other than BCH for more routine procedures?

  2. Thanks for raising these points, Surabhi. For pediatric care, there aren’t too many options for this kind of procedure beyond BCH. The possibility of outsourcing these elective procedures to satellite hospitals outside of the city was considered. However, time-based costing studies revealed that the cost savings were minimal because the process was still very much in line with a traditional OR procedure setup. The nice thing about the DFCI is that it is just across the street from BCH. Therefore, the same anesthesia and surgical team from BCH deliver care, but the nurses and support staff are DFCI employees and the process is much more streamlined. The physical proximity allows the DFCI to leverage certain resources from BCH (such as any emergency intervention), and thus the sedation clinic strikes a nice balance between acting as an autonomous care provision site and being able to still rely on the extensive resource pool at BCH.

  3. Interesting article though I do agree with Surabhi’s point of view, it seems like a partnership with CHI would have been a better alignment with their business model. I wonder what the perspective/incentive was from BCH with this adjustment as the loss of these elective procedures could have dropped the efficiency of their perioperative unit. Since they are using the same surgical teams from BCH, do they have a revenue sharing agreement with BCH? (Since I believe they employ their anesthesia staff) Is the volume and/or surgical staff availability of the room high enough to run at capacity? It seems like it would have been more efficient to build the procedural rooms at BCH instead assuming this was done as a partnership of some sort. perspective.

  4. Spencer, you raise some really interesting questions. The billing at BCH is a little convoluted. For example, the surgical part of the service is paid to the Surgical Foundation rather than to the hospital. This does not change in the new model. However, shifting procedures to an alternate location allows the resource-intensive process at BCH to be applied to procedures that really require these inputs. The sedation suite is definitely not at full capacity at present, as many procedures are still in the pilot phases of testing. However, the vision is obviously for it to be used at almost-full capacity. As far as the site of care (FCI versus another site of care), housing the procedure at the DFCI enhances patient satisfaction due to familiarity and trust built with the institution over the course of patients’ cancer diagnoses and treatment phases of care. Furthermore, compared to an independent site, there is less required pre-procedure work due to the institution’s and clinical staff’s familiarity with patients’ extensive records. Even the pediatric surgeons that crossover between the two sites have most often already provided care to these patients in the past. Additionally, surgical visits can be effectively integrated with follow-up oncology visits, thus reducing redundant information transfer. Without even taking into account these last two advantages, the costs associated with the process at the DFCI were less than 80% that of BCH’s process, which represents quite a substantial cost saving. Of course, this does not preclude another site from being able to offer even further value, but DFCI’s approach has definitely made more than a dent in enhancing patient value and process efficiency.

  5. Tehsina, really interesting piece; I did my gen surg sub-i at BCH, absolutely inspiring place and awesome surgical care of patients, but also totally appreciate the importance of having separate facilities and teams for lower acuity procedures. Do you think this solution would work as well if some of the ORs in BCH were just designated as sedation suites, or is there an advantage to having these suites over at DFCI instead? With that sentiment as well, what do you think are the primary obstacles preventing the adoption of this model at other centers? Seems like a fairly common sense solution, but the implementation is definitely easier said than done.

    1. Greg, I think it would be great to have on-site sedation clinics at BCH so that this type of care can be delivered not only for oncology patients, but to all pediatric patients requiring lower acuity surgical care. Most of the value is realized from revamping the model of care rather than changing the physical site of care. Of course, the added benefits related to patient satisfaction and the potential care synergy that may be realized for oncology patients at the DFCI would not be realized if care were provided at BCH. However, the scale of offering this type of care would probably outweigh the benefits of implementing sedation suites at individual medical centers. To your question about adoption, I think there are several issues. One is that the institution needs to be comfortable to divert enough care from the OR to the sedation suite to justify its investment, and must also be able to efficiently fill the freed up main OR time with other procedures. Another issue has to do with justifying the cost/benefit to providing care using fewer resources and a more unfamiliar model. There are some additional costs in the DFCI model that seem “inefficient,” such as having more skilled nurses, for example, not always working at the “top of their licenses.” These are countered by time savings in terms of information gathering and transfer, but the true value of the trade-offs wasn’t realized until time-driven activity based costing studies were undertaken. Clearly, these trade-offs are very effective in producing value in the case of the DFCI. However, sometimes lower-resourced settings don’t translate into cost savings if there isn’t a well-executed process in place. This is true of the satellite clinics such as BCH-Waltham, where there actually weren’t significant cost savings in diverting the same lower acuity care. Unless there is a clear and quantifiable justification for changing care, I think there is an inertia among clinicians– to continue to practice in the way they always have.

Leave a comment