**5.2.2 Return on investment**

Several US hospitals reported in detail on return on investment. The Vanderbilt group (Greelish, 2009) focused on the growth of a cardiac surgery program through a hybrid room. In the year 2004 the annual case volume of adult cardiac cases was 464. 2004 was also the year when the institution built their first hybrid OR. In the next 3 years the case load almost tripled based upon the hybrid OR set-up.

A similar case load development as in Vanderbilt Heart is to be seen in Beijing's Fu Wai Hospital. The annual report 2008 shows an increase of over 60% of the hybrid procedures a year after their hybrid OR was installed (Fu Wai, 2008).

In an initial pro forma from St. Vincent Heart Center of Indiana (Cronin & Schroyer, 2010) the calculations showed that incremental discharges of 150 patients led to a gross patient revenue of \$ 6.2m and net patient revenue of \$ 2.4m. Deducting total expenses of \$ 0.8, the excess of revenues over expenses was \$ 1.6m. The net present value was calculated to be \$ 0.8m in 2010 and \$ 5.4m in 2015, leading to an internal rate of return of 185% in 2010 and 285% in 2015, respectively.

Data from Cleveland Clinic Foundation showed the return on investment of their cardiac hybrid OR to take only 2 years and 3 months (Cronin & Schroyer, 2010).

The Advisory Board Company reported a detailed investment calculation for a room focusing solely on TAVI procedures in the USA (Katz, 2010). In reality the wide majority of rooms will be used for a multitude of procedures, often from different surgical disciplines in order to make best use of the room capacity. In the Advisory Board Company's pro forma, focussing only on TAVI cases, the cumulated investment came up to \$ 3.4m, consisting of \$

Building a hybrid operating room is a considerable economic investment for every hospital. Sound business models and optimal usage of the room are prerequisites to make this

The costs for hybrid rooms vary considerably depending on whether or not re- or new

Furthermore, it may be necessary to hire additional staff such as radiology technicians that are familiar with interventional imaging systems. Both new and existing staff may require outside training to be able to use the equipment properly. These decisions depend on the

A recent study (Neumann, 2009) compared the investment necessary for hybrid suites, cath labs and standard ORs. Room size, construction requirements, angiography system, other equipment, depreciation, maintenance and debt service were taken into account. Overall, investment costs for the standard OR were lowest, followed by the cath lab with a 25% higher price tag. The costs for a hybrid OR were additional 120% of the costs of the standard OR. When comparing the operating costs (maintenance, depreciation, debt service and rent) the same relations applied. The costs for the cath lab were 25% higher than for the OR. Comparing the OR with the hybrid OR, an additional 90% were required per annum. These figures may differ, depending on system choice, building costs and local requirements but the above mentioned figures give a good indication on the comparative costs. Taking these reasonably high costs into account, the obvious question arises how a hybrid OR can

Several US hospitals reported in detail on return on investment. The Vanderbilt group (Greelish, 2009) focused on the growth of a cardiac surgery program through a hybrid room. In the year 2004 the annual case volume of adult cardiac cases was 464. 2004 was also the year when the institution built their first hybrid OR. In the next 3 years the case load almost

A similar case load development as in Vanderbilt Heart is to be seen in Beijing's Fu Wai Hospital. The annual report 2008 shows an increase of over 60% of the hybrid procedures a

In an initial pro forma from St. Vincent Heart Center of Indiana (Cronin & Schroyer, 2010) the calculations showed that incremental discharges of 150 patients led to a gross patient revenue of \$ 6.2m and net patient revenue of \$ 2.4m. Deducting total expenses of \$ 0.8, the excess of revenues over expenses was \$ 1.6m. The net present value was calculated to be \$ 0.8m in 2010 and \$ 5.4m in 2015, leading to an internal rate of return of 185% in 2010 and

Data from Cleveland Clinic Foundation showed the return on investment of their cardiac

The Advisory Board Company reported a detailed investment calculation for a room focusing solely on TAVI procedures in the USA (Katz, 2010). In reality the wide majority of rooms will be used for a multitude of procedures, often from different surgical disciplines in order to make best use of the room capacity. In the Advisory Board Company's pro forma, focussing only on TAVI cases, the cumulated investment came up to \$ 3.4m, consisting of \$

hybrid OR to take only 2 years and 3 months (Cronin & Schroyer, 2010).

existing knowledge in the hospital and on what procedures will be performed.

**5.2 Financial considerations** 

endeavour a financial success.

construction is necessary.

be a profitable investment.

**5.2.2 Return on investment** 

285% in 2015, respectively.

tripled based upon the hybrid OR set-up.

year after their hybrid OR was installed (Fu Wai, 2008).

**5.2.1 Costs** 

1.3m for construction work and \$ 2.1 for the equipment. In the first year, starting with a very low volume of TAVI patients of 24 and consequently lower revenue of \$ 1m, the total net revenue was \$ 0.9m after reducing bad debt allowance and billing & collection. Annual total fixed costs accumulated to \$ 0.1m, variable costs for devices, labour etc. to \$ 0.9m leading to total costs of \$ 1m during year one. Consequently the net income was negative by \$ 23k in the first year. With an increase in patient volume to 37, however, already in year two a net income of \$ 0.4m could be realized.

Table 3 gives an overview and comparison of the cost and return situation (by St. Vincent Heart Center and the Advisory Board Company).


*Rounded figures in k USD* 

Table 3. Financial comparison of pro forma from St. Vincent Heart Center and The Advisory Board Company (Cronin & Schroyer, 2010)

As a general fact, the set-up of hybrid rooms allows for the treatment of previously untreatable patients. Good examples are TAVIs. Now, patients previously deemed too old or weak for surgery, can be treated by transcatheter valve implantation. With an aging population and developments in medicine, the number of octogenarians and nonagenarians to be treated with new hybrid and minimally invasive procedures that are best performed in a hybrid OR will continue to grow. This will lead to increasing usage of the room capacity and consequently a quicker return on investment. Also, with less invasive treatment the necessity to stay in the ICU and the hospital for a long time in general decreases, along with the risk of infections. This allows discharging patients quicker, which again leads to an improved cost situation in the hospital. Furthermore hybrid rooms help to increase efficiency and decrease turnover time which can lead to additional cases being performed in the hybrid room as compared to a standard OR (Benjamin, 2008). A conventional surgical valve replacement often takes more than three hours, whereas a transcatheter valve implantation can be done in one. Calculations indicate that the mean incremental operating room profit per procedure is about \$ 1,500 per hour. If the hospital manages to add only one single hour-long case each day, the hybrid OR could help increase profitability by about \$ 300k p.a.

In cardiac surgery, the operating room profit is usually even about 25-30% above the mean incremental OR profit (Resnick et al., 2005).

## **5.2.3 Positive marketing effects**

Another soft factor that can have a positive financial impact is to use the hybrid OR to position the hospital among the technologically most advanced institutions in the area. This

The Hybrid Operating Room 103

also needs to assure that cross trained physicians are available to work in the new room

A multi-disciplinary approach is necessary to make best use of the hybrid OR and achieve the best patient and hospital outcomes. A key factor herein is a good working relationship between sometimes competing clinical disciplines. For example, cardiac surgeons and interventional cardiologists have to cooperate in numerous cardiac procedures such as TAVI. Multi-disciplinary case conferences in order to discuss the best treatment options are mandatory. Also, consensus and support from other functions in the hospital, such as anesthesia, intensive care, and hospital administration, are essential (Galantowicz &

However, not only operational integration is necessary, but also financial integration. Accounting practice needs to change with the usage of a hybrid OR. To start with, some institutions split the charges for hybrid procedures into a percutaneous component performed by the interventionist and billed by the cathlab, as well as a surgical component

Moving forward, full financial integration is of utmost importance in order to avoid competition between different clinical disciplines. Consequently, all involved cardiovascular departments should be under one profit and loss statement of an integrated cardiovascular

To support the process of implementing a hybrid program it makes sense to set up best practice teams (cardiac and vascular surgery, cardiology, nurses etc.) who jointly develop the approach in the hospital. Visiting other institutions with a successful hybrid OR in operation is of major help in the planning process. Learning from their experience and understanding their mistakes can help shorten the process for all involved staff

Ahmed, A.S.; Deuerling-Zheng, Y.; Strother, C.M.; Pulfer, K.A.; Zellerhoff, M.; Redel, T.; Royalty,

Bacha, E.A.; Marshall, A.C.; McElhinney, D.B. & del Nido, P.J. (2007). Expanding the hybrid

Biasi, L.; Ali, T.; Ratnam, L.A.; Morgan, R.; Loftus, I. & Thompson, M. (2009). Intra-operative

*American Journal of Neuroradiology*, Vol.30, No.7, (August 2009), pp. 1337-1341 Bacha E.A.; Daves, S.; Hardin, J.; Abdulla, R.I.; Anderson, J.; Kahana, M.; Koenig, P.; Mora,

No.1, (January 2006), pp. 163-171, PII S0022-5223(05)01370-X

K.; Consigny, D.; Lindstrom, M.J. & Niemann, D.B. (2009). Impact of intra-arterial injection parameters on arterial, capillary, and venous time-concentration curves in a canine model.

B.N.; Gulecyuz, M.; Starr, J.P.; Alboliras, E.; Sandhu, S. & Hijazi, Z.M. (2006). Single-ventricle palliation for high-risk neonates: the emergence of an alternative hybrid stage I strategy. *The Journal of Thoracic and Cardiovascular Surgery*, Vol.131,

concept in congenital heart surgery. *Seminars in Thoracic and Cardiovascular Surgery Pediatric Cardiac Surgery* Vol.10, No.1, pp. 146-150, PII S1092-9126(07)00020-8 Balter, S.; Hopewell, J.W.; Miller, D.L.; Wagner, L.K. & Zelefsky, M.J. (2010).

Fluoroscopically Guided Interventional Procedures: A Review of Radiation Effects on Patients' Skin and Hair. *Radiology*, Vol.254, No.2, (February 2010), pp. 326-341 Benjamin, M.E. (2008). Building a Modern Endovascular Suite. *Endovascular Today,* Vol.3,

DynaCT improves technical success of endovascular repair of abdominal aortic

executed by the surgeon and billed by the OR department (Katz, 2010).

(Katz, 2010).

Cheatham, 2005).

center (Katz, 2010).

considerably.

**6. References** 

(March 2008), pp. 71-78

helps to both attract the top medical staff to work in the hospital as well as additional patients that are searching for the best possible treatment.

Also many hospitals make use of the increased publicity they can gain by marketing their hybrid ORs for the public e.g. in TV reports (see Fig. 22).

In summary, to justify the substantial investment in the hospital a detailed business plan needs to be created, taking into account the specific situation in the hospital. Hospital administration usually accepts a start-up phase with a negative margin but will expect positive numbers after. A detailed business plan will enable both users and hospital administration to base the decision for the hybrid OR on solid grounds and make sure it will be used to its full potential.

### **5.3 Building a hybrid program**

One key success factor for a hybrid operating room is the team approach of a committed interdisciplinary team that takes responsibility for the room. Imaging specialists, cross trained physicians, and nurses with the vision to establish new minimally invasive therapies are the cornerstones of a blooming hybrid therapy program.

Bonatti stresses the importance of a dedicated workflow coordinator (Bonatti et al., 2007) to direct the workflow. Since the workflow in a hybrid OR has major differences to the one in a conventional OR it is mandatory that the whole OR team approaches the new concept openmindedly and willing to change traditional processes fundamentally.

The workflow coordinator or hybrid OR manager takes care of traditional OR management topics such as staffing, ancillary support and inventory management. But he also manages some new tasks such as prioritizing the cases as in giving true hybrid cases priority over standard surgical or cardiologic procedures that can be done in a normal OR or cathlab. He

Fig. 22. Coverage on tv.berlin about the hybrid OR at German Heart Center Berlin, Germany

helps to both attract the top medical staff to work in the hospital as well as additional

Also many hospitals make use of the increased publicity they can gain by marketing their

In summary, to justify the substantial investment in the hospital a detailed business plan needs to be created, taking into account the specific situation in the hospital. Hospital administration usually accepts a start-up phase with a negative margin but will expect positive numbers after. A detailed business plan will enable both users and hospital administration to base the decision for the hybrid OR on solid grounds and make sure it will

One key success factor for a hybrid operating room is the team approach of a committed interdisciplinary team that takes responsibility for the room. Imaging specialists, cross trained physicians, and nurses with the vision to establish new minimally invasive therapies

Bonatti stresses the importance of a dedicated workflow coordinator (Bonatti et al., 2007) to direct the workflow. Since the workflow in a hybrid OR has major differences to the one in a conventional OR it is mandatory that the whole OR team approaches the new concept open-

The workflow coordinator or hybrid OR manager takes care of traditional OR management topics such as staffing, ancillary support and inventory management. But he also manages some new tasks such as prioritizing the cases as in giving true hybrid cases priority over standard surgical or cardiologic procedures that can be done in a normal OR or cathlab. He

Fig. 22. Coverage on tv.berlin about the hybrid OR at German Heart Center Berlin, Germany

patients that are searching for the best possible treatment.

hybrid ORs for the public e.g. in TV reports (see Fig. 22).

are the cornerstones of a blooming hybrid therapy program.

mindedly and willing to change traditional processes fundamentally.

be used to its full potential.

**5.3 Building a hybrid program** 

also needs to assure that cross trained physicians are available to work in the new room (Katz, 2010).

A multi-disciplinary approach is necessary to make best use of the hybrid OR and achieve the best patient and hospital outcomes. A key factor herein is a good working relationship between sometimes competing clinical disciplines. For example, cardiac surgeons and interventional cardiologists have to cooperate in numerous cardiac procedures such as TAVI. Multi-disciplinary case conferences in order to discuss the best treatment options are mandatory. Also, consensus and support from other functions in the hospital, such as anesthesia, intensive care, and hospital administration, are essential (Galantowicz & Cheatham, 2005).

However, not only operational integration is necessary, but also financial integration. Accounting practice needs to change with the usage of a hybrid OR. To start with, some institutions split the charges for hybrid procedures into a percutaneous component performed by the interventionist and billed by the cathlab, as well as a surgical component executed by the surgeon and billed by the OR department (Katz, 2010).

Moving forward, full financial integration is of utmost importance in order to avoid competition between different clinical disciplines. Consequently, all involved cardiovascular departments should be under one profit and loss statement of an integrated cardiovascular center (Katz, 2010).

To support the process of implementing a hybrid program it makes sense to set up best practice teams (cardiac and vascular surgery, cardiology, nurses etc.) who jointly develop the approach in the hospital. Visiting other institutions with a successful hybrid OR in operation is of major help in the planning process. Learning from their experience and understanding their mistakes can help shorten the process for all involved staff considerably.
