**2. Need assessment**

Prior to the acquisition of highly expensive robotic technology, 'Need Assessment' is an imperative step for hospitals, especially small community hospitals with limited cash reserve. Despite the rapid rise of robotic surgery, its usefulness, mainly attributed to cost concern in gynecological surgeries, has been questioned by many [16]. However, to compete with the current market and other hospitals, regional hospitals have to enter into a 'medical arms race" to acquire a robotic platform [17]. Since more and more trainees graduating from residency programs are trained on a robotic platform, small community hospitals view da Vinci as a survival tool to retain and/or recruit surgeons which will keep them in business. It is not an uncommon belief among administrators that a robotic platform can be used as a marketing tool to attract more patients. Medicare in the US helps to absorb the partial cost of robotic systems for critical access hospitals based on the number of the patients on Medicare using those facilities. However, that partial cost may still be too much for the small community hospital with scarce resources to spend. Therefore, they should have to have a thorough 'need assessment' to determine whether the purchase of a robotic system is worth a 'buy.' 'Need Assessment' is a standard industry procedure routinely being carried out in large businesses to analyze the 'need,' which is the gap between the current condition and the desired

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forward.

**Figure 1.**

*Important factors for need assessment.*

*Present Challenges of Robotics in Gynecology DOI: http://dx.doi.org/10.5772/intechopen.96780*

condition. Need assessment to acquire costly surgical instruments is a multistep process [18] including confirmation of necessity or define the need to acquire technology from surgeons based on evidence-based science, research the market, budget, projected rise in revenue, and room for a potential marketing strategy to increase payer mix. It is essential that hospitals should investigate the readiness of their surgeons to get trained, or hospitals should be recruiting new surgeons who are already trained. Many hospitals hire independent agencies to perform market research and viability analysis to find a sweet spot. Regardless, market research involving a rise in case volume by getting new patients who may otherwise travel far to undergo robotic procedure and internal research to determine the proportion of current surgeries which can be performed using a robotic platform are two extremely important data points in decision making. Balancing resource spending and budgeting is an integral part of the financial health of any institution, and, especially, small community hospitals walking on the thin and sharp edge of the sword. In addition to cost-effectiveness, hospitals should focus on hammering down the training program not only limited to surgeons but the entire operating room team. Finally, quite often, a hospital system which acquires the da Vinci should understand that marketing is the key to success for the program [19]. The absence of a marketing plan in place often becomes the reason for the failure of the program [20]. Therefore, research performed well in advance to investigate potential avenues of marketing strategies addressing demography or geographical needs must be well thought out prior to acquiring the system in the need assessment phase. Need Assessment phase is not only limited to investigating and analyzing the need for the da Vinci system (**Figure 1**) but also the initial planning and strategy development phase, so that when the system is acquired, administration and the entire team have a clear vision and direction of how they will be developing the program moving

**3. Team building - the cornerstone of a robotic program often neglected**

Teams in the operating room have conventionally been trained in traditional open or laparoscopic surgery where the flow of the surgery is largely directed by surgeons. The mere presence of the da Vinci platform in the operating room changes many aspects of surgery as we know it, including the dynamics of the operating

*Present Challenges of Robotics in Gynecology DOI: http://dx.doi.org/10.5772/intechopen.96780*

#### **Figure 1.**

*Latest Developments in Medical Robotics Systems*

costs (ranging from \$700–\$3,500 per procedure).

compared to laparoscopic hysterectomies [5, 6]. The robotic approach, indeed, has longer operative times [7] for certain operations and is more expensive, not exclusively limited to only operative cost (6–25% more than laparoscopy) [8] but also initial acquisition cost and maintenance cost compared to the standard laparoscopic approach [9]. The da Vinci system requires an initial investment of \$1.5 to \$2.5 million, depending on the model and configuration. Ongoing costs include annual service contracts (ranging in price from \$150 to \$170 K), instrument and accessory

Despite all shortcomings, surgeons still appreciate excellent visualization providing [6] more precision in surgery and better ergonomics, allowing them to do certain complex tasks, which would be very difficult with standard laparoscopic procedure. Many studies have shown the utility of the robotic platform with better outcomes and safety profiles for various benign conditions, including robotic myomectomies [10] for fibroids, robotic-assisted laparoscopic sacrocolpopexy for pelvic organ prolapse, endometriosis, benign ovarian tumors, etc. [7, 10]. The role of minimally invasive surgery for endometrial cancer has been well established by LAP 2 study [11, 12]. In addition, the role of robotic platform for other gynecological cancer including early cervical and ovarian cancer have been investigated as well [13]. In 2012, the Clinical Practice Robotics Task Force of the Society of Gynecologic Oncology stated that robotic-assisted surgery in the field of gynecology-oncology provides an advantage over traditional methods, including conventional laparoscopic approaches and laparotomies [14]. The use of robotic platform has been well established in many gynecological procedures and in other specialties like general surgery, urology, cardiothoracic surgery, etc. However, with higher acquisition and maintenance costs and with no difference in reimbursement compared to the standard laparoscopic procedure, many small community hospitals that initially acquired a robotic platform by using all cash reserves are struggling to keep it going, and many are rolling back on their decision in 1–3 years [8, 15]. In addition to a higher financial burden, many other factors are roadblocks for widespread implementation or failures of robotic programs. In this article, we would like to expand further on these roadblocks and provide reasonable, evidence-based solutions.

Prior to the acquisition of highly expensive robotic technology, 'Need Assessment' is an imperative step for hospitals, especially small community hospitals with limited cash reserve. Despite the rapid rise of robotic surgery, its usefulness, mainly attributed to cost concern in gynecological surgeries, has been questioned by many [16]. However, to compete with the current market and other hospitals, regional hospitals have to enter into a 'medical arms race" to acquire a robotic platform [17]. Since more and more trainees graduating from residency programs are trained on a robotic platform, small community hospitals view da Vinci as a survival tool to retain and/or recruit surgeons which will keep them in business. It is not an uncommon belief among administrators that a robotic platform can be used as a marketing tool to attract more patients. Medicare in the US helps to absorb the partial cost of robotic systems for critical access hospitals based on the number of the patients on Medicare using those facilities. However, that partial cost may still be too much for the small community hospital with scarce resources to spend. Therefore, they should have to have a thorough 'need assessment' to determine whether the purchase of a robotic system is worth a 'buy.' 'Need Assessment' is a standard industry procedure routinely being carried out in large businesses to analyze the 'need,' which is the gap between the current condition and the desired

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**2. Need assessment**

*Important factors for need assessment.*

condition. Need assessment to acquire costly surgical instruments is a multistep process [18] including confirmation of necessity or define the need to acquire technology from surgeons based on evidence-based science, research the market, budget, projected rise in revenue, and room for a potential marketing strategy to increase payer mix. It is essential that hospitals should investigate the readiness of their surgeons to get trained, or hospitals should be recruiting new surgeons who are already trained. Many hospitals hire independent agencies to perform market research and viability analysis to find a sweet spot. Regardless, market research involving a rise in case volume by getting new patients who may otherwise travel far to undergo robotic procedure and internal research to determine the proportion of current surgeries which can be performed using a robotic platform are two extremely important data points in decision making. Balancing resource spending and budgeting is an integral part of the financial health of any institution, and, especially, small community hospitals walking on the thin and sharp edge of the sword. In addition to cost-effectiveness, hospitals should focus on hammering down the training program not only limited to surgeons but the entire operating room team. Finally, quite often, a hospital system which acquires the da Vinci should understand that marketing is the key to success for the program [19]. The absence of a marketing plan in place often becomes the reason for the failure of the program [20]. Therefore, research performed well in advance to investigate potential avenues of marketing strategies addressing demography or geographical needs must be well thought out prior to acquiring the system in the need assessment phase. Need Assessment phase is not only limited to investigating and analyzing the need for the da Vinci system (**Figure 1**) but also the initial planning and strategy development phase, so that when the system is acquired, administration and the entire team have a clear vision and direction of how they will be developing the program moving forward.
