An Effective Business Plan from Neurosurgery

Mike Tymianski

The Neurosurgery Division at UHN performed 2300 operating room cases in 2010 in Oncology, Functional, Vascular, and Spinal Neurosurgery and published 150 peer-reviewed papers in 2010. There are four active labs in the division and they are currently running 3 multi-centered trials with $8.4 million per year in funding for research.

Acting Division Chief Mike Tymianski inherited a unique challenge: “In a certain sense this level of success presented a problem: ‘lots of chiefs and no indians’. Shaf Keshavjee had charged me to keep the division the best in the world, but we had no room for new junior faculty”. The paradox was crystallized last year when the division was unable to recruit an excellent candidate for lack of resources. The OR budget for neurosurgery regularly ran a deficit of $750,000 per year. Option one would be to cut operating room time, reduce beds and ruin practice and retention - a poor business solution. A second option would be to increase practice and turn a profit. “We decided to make up 50% of the shortfall this year without reducing activity.”

There are certain cases that bring increased income to the hospital, based on volume targets negotiated with the government. Deep Brain Stimulation, Spine Stimulation, Aneurysm coils, Workmen’s Compensation, Neurooncology and cases referred through CritiCall (see also: http://www.surgicalspotlight.ca/Article.aspx?
ver=Summer_2010&f=AcuteCareService). In contrast the 80 -year old with a subdural on Coumadin who is admitted from the hospital’s surrounding community is not a volume-funded case, and has been a traditional source of accumulating deficit. The solution is to route the patients through CritiCall. The CritiCall cases are approximately 60% intracranial bleeding, 30% spine and 10% oncology. Since intracranial hemorrhage and subdural hematomas stall out the operating room, Mike and his colleagues developed a procedure room for draining subdural hematomas, hydrocephalus and similar problems. This unit is run by the neurosurgery residents. A second initiative is the development of a neurovascular unit - a multidisciplinary stroke unit with much better outcomes and lower cost than the intensive care unit. Lastly, everyone in the Division of neurosurgery was asked to manage their own budget, which was assigned and spent according to the decisions of the individual surgeons. Everyone became engaged in the fiscal management of the division. This empowered the surgeons to solve the financial problems through awareness. They were highly motivated by enthusiasm to recruit to the division. The key to the success of the program was that every expendable item used in the operating room was labeled with its cost. An expensive $500 item that might have been opened routinely was left untouched unless the surgeon specifically asked for it. There are now prices on everything in the operating room from a $14,000 laser catheter to a ¢65 pair of gloves. The bill is printed for the surgeon at the end of each case, just like it is at the Home Depot cash register. Surgeons quickly learned not to open the gelfoam or floseal (a costly hemostatic agent), unless they were clearly needed. The bills were sent every week and summarized every month. Currently, they are now available monthly, but really are no longer necessary. The savings from this program have been dramatic and the division is now in the position to recruit five more neurosurgeons. The money saved is also used to buy equipment needed for the operating room.

Volume funding from the Ministry of Health started with heart surgery. The government negotiated for a certain number of cases to be done, based on pressure from the public. They now volume fund joint surgery, bariatric surgery, CritiCall, neuromodulation and endovascular surgery for brain aneurysms. “The increased awareness and selectivity of costly items is the result of knowledge that empowered the surgeons.” By routing appropriate referrals though CritiCall, the budget makes room for cases that are otherwise unfunded. The take home message from this experience is that a mandate from administration to save in the old days simply meant “do fewer cases”. The current surgical response is “become more aware and cost effective in order to do more cases”.

Michael’s business experience did not come from a course in management, but from running a biotech company with excellent corporate mentors on its board of directors, including the legendary physician executive John Evans. They are savvy investors with extensive business experience.

“The Stroke Unit, which includes stroke neurologists, interventionists, neurosurgeons, nurses and an allied health team - all focused on one theme, opened in September of 2011. Beds were shifted into the unit from medicine, neurosurgery and elsewhere. It has acute monitoring like a step-down unit and integrated care. This has increased the number of patients who walk home after a stroke.”

Michael trained at the University of Toronto and extended his training in skull base and vascular neurosurgery at the Barrow Neurological Institute in Phoenix. He completed a PhD in stroke research under Charles Tator’s mentorship and holds a Canada Research Chair in Translational Stroke Research.

His company NoNO Inc. has developed a drug that has the potential to dramatically reduce the damaging effects of stroke, preventing the death of brain cells in stroke patients and thereby reducing the life altering consequences of strokes. This program has been supported by UHN’s Technology Development and Commercialization Office. “I am very pragmatic about research; basic science has very little accountability. Five years of research with no productivity is ok under a grant system, but it is not ok in biotechnology where we are accountable to the board, the investors and to the law. We should deliver research on the same scale. I do it as Division Head of neurosurgery, in the lab, and in the company.” Just as “excellence” is Jim Rutka’s guiding value, “accountability” seems to be Michael’s. At Michael’s Grand Rounds presentation, Tom Waddell asked about the motivation to achieve a profit in a surgical unit, when any savings disappear back into the total budget of UHN. The answer is that “a critical motivating factor for success is keeping the savings within the unit.”

He is married to Dawn who heads the advanced practice program in the School of Nursing. Together they have four children. Mike and Dawn Tymianski are avid cyclists and hikers. With the exception of extensive travel related to Michael’s jobs as a neurosurgeon, scientist, and company CEO, Mike and Dawn hide away whenever they can in a small house on the south shore of Nova Scotia. They are avid collectors of Canadian Inuit art, contemporary and fine Canadian art, and fine wine. With the latter, Mike Tymianski states: “We don’t have enough time to drink it. But I really like anything that’s done really well. It’s remarkable what some people can create out of grape juice.”

M.M.