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— Design Process

— Problem summary

“When you deal with humans and money is the biggest factor, reliability, safety, control and efficiency can never be good enough!”

A surgical power tool needs to meet many requirements in case of usability, cleanability, and safety. In addition, the tool comes in touch with different users during the hospital tool cycle and each of them has specific needs which must be considered. At the end of the funnel, the tool gets reduced to its minimum to fulfill in the best case all requirements. The outcome is that many tools in different price ranges are almost the same from usability and functions. Not much has changed over the years and the reason is a fear to interrupt the habit of the users.

Orthopedic surgery is the most physically demanding sector. Surgeons are suffering under wrist pain, joint damage, tendonitis, etc.
In the future, physically demanding working steps should be reduced by increasing the usage of power tools. But there is a need for less weighty tools and batteries to approach these issues. As a result, the focus must be on increasing the ergonomics and safety for the surgeon.

The healthcare sector is constantly under cost pressure and investments are not used equally over various fields. In case of a surgical power tool, there is the decision of investing in quantity or quality. Today, unavailable instrument sets or tool failures are among the ten most frequent causes of operation delays. With more available tools, hospital management can plan more flexible. But to improve the work-life for the surgeon more quality tools are needed which increases the investment costs and fewer tools need to do the same amount of work.

To approach the current situation a quality tool needs to be worth the money. First, it must improve the work-life for the surgeon. The tool needs to be flexible to use for various applications by allowing to change adapters. Now, the motor unit can be used for any procedure and in case of a tool failure the motor unit can be easily replaced without blocking a full instrument set. Second, the tool needs to be maintained over time which doesn´t happen regularly today. By creating data during the usage, the maintenance can be customized and planned instead of assumption.

01 | Problem

The healthcare sector is facing many challenges and opportunities in the future!

• • •

“Historically, many med-techs have been technology-centric rather than user-centric.

…patient-centric and clinician-centric design offers a key to stand out from competitors…”

Sebastian Liedtke | www.mckinsey.com

Customers expect more from their products today… Companies like Google and Netflix constantly deploy the latest technologies to improve the customer experience.”

Henrik Norström | www.mckinsey.com

“Problems with instruments are amongst the ten most frequent causes of operation  delays

due to incorrectly assembled or unavailable instrument sets…”

GS1 UK Healthcare User Group

“The future of surgery offers an amazing
cooperation between humans and technology, which could elevate…the efficiency of surgeries…”

www.medicalfuturist.com

»Aesculap / B.Braun wanted me to review the surgical power tool market to oversee future challenges and focus on an enhanced product and service experience«

— It was important to get a holistic overview of the current situation!

25  interviews

Part of 2 hospital tool cycles

4 accompanied surgeries

The healthcare system is a complex industry and the hospital is the core where a multitude of professional disciplines come together to efficiently perform an immense amount of work. There are many regulations and requirements to standardize medical procedures and instruments. To find solutions and to overcome some of these issues it is important to get a holistic overview.

 On the basis of a new generation of a surgical power tool, I reviewed the tool cycle which included all key users and departments. Enhanced communication and usability can be one key to increase efficiency and to reduce failures in the future. A small improvement can already have a valuable impact and be adapted to a bigger scale later on.

Pain points beyond the product

A surgical power tool passes through many departments over a lifetime. The infographic above describes simplified the involved personnel starting from purchasing a new tool, the tool cycle inside the hospital and the related steps which are necessary for repair and maintenance. It is obvious that traceability and communication are key to share information successfully between the users.

– Cost pressure makes it hard to invest in a whole new system set up (interval purchases)
> Therefore, each tool needs to get maintained differently over time.
– Old and cheaper systems are often more attractive due to quantity vs. quality. More cheap tools ease the planning phase and more surgeries can be done. Cheap systems are often used till they are dysfunctioning and it comes to a new purchase.
> A high-quality tool needs to be worth the cost. Only maintenance and the right treatment offers
the value over a long time if the service/maintenance procedure is guaranteed and done right over a long time.
– Not every hospital has a maintenance contract which is a reason why just a few tools get sent every year (they forget about the date, they don´t care, maintenance is too expensive and they don´t have (want to spend) the money.
– Is the need not big enough (level of suffering)? > The tools have a high quality and work without maintenance but troubles occur than more often.
Does a surgery delay/fall out, a bad outcome or a handicapped surgeon costs not way more over time and gives the patient a bad impression?
-Hospitals run down their instruments because of several reasons (cost pressure, save money for new investments)
– Investment costs come from a different pot than repair and maintenance.
– The overall tool cycle is “working” but the communication between surgery management and CSSD management lacks behind. (Surgery integration). It complicates surgery planning if the management is not always up to date.
– If it comes to dysfunctioning tools more departments get integrated and a lack of communication and information exchange hinders a smooth flow.
> Is it not already too late if a tool fails during surgery? Can this be prevented ahead?
– A lack of knowledge and control is a reason why tools are not processed correctly after usage and wear down earlier.

The surgical power tool passes through many hands and departments every day for usage and processing. A working communication and information exchange is therefore key to plan efficiently surgeries without interruptions. This spectrum gets even bigger if the tool is not processed properly or maintained regularly and a dysfunctioning tool needs to get repaired more often. In this case, a contractor or Aesculap takes over to eliminate the problems which include more people and communication into the cycle. It is necessary to understand the users’ needs and wishes to find the main pain points around the tool and the system.

Personas & touchpoints

I interviewed everybody who is involved inside the hospital tool cycle. The goal was to collect insights about their problems, responsibilities, and thoughts.

On the base of the information, I created key personas who have specific needs that should be addressed in a future surgical power tool. The abstract personas helped me to get a better understanding of the user and to pinpoint specific ideas & solutions later on in the process.

On the left side, you can see three examples of that method.

Surgeon

Surgeons are surely the key user of a surgical power tool. Their goal is to perform many surgeries in a reasonable timeframe. They need to work efficiently and economically. Therefore, reliable and durable systems are preferred so the hospital can plan and invest more accurate in the future. Each delayed or canceled surgery means lost money which is urgently needed to expand or update their instruments. For them, personal safety is really important to protect their own health. Ergonomy and usability are always an objective that should be improved because wrist and neck pain is still widespread under orthopedics due to heavy, vibrating tools and bad working postures. In addition, a lack of guidance or control through slippery tools or unsuitable handles lead to dangerous hand positions around the action area. Increased visibility, easier handling and feedback (tissue change) could be valuable to support the precision. Instruments and accessories which can enhance their workflow are more likely to be accepted. Surgeons are proud of their job and want to work with the latest tools and technologies. This does not always include new technologies which will take over their tasks or make standard procedures more complicated. 

CSSD Employee

They need to process the incoming instruments as quickly as possible to ensure a smooth workflow for the next surgeries. Their goal is to work efficiently but the immense amount of instruments and the different requirements makes it hard to keep an overview. Sometimes they are annoyed about the condition tools or instrument sets are coming back or are placed inside the containers. Many manual steps are required to wash and prepare the washing machines and the modular instrument sets are not intuitive enough to work fast and always correct. They are not every time guilty of missing or misplaced tools. Often tools are already misplaced or forgotten in the surgery room. A better control about the tools is always good but they have a specific timeframe to do the job and there is not much space left to check the devices properly or review the maintenance date on the device.

Scrub Nurse / Circulation Nurse

Their goal is to serve surgeons in the best way so they can fulfill their tasks easily without interruptions. They need to know every step of each surgery to hand over the right tools to the right time. Broad knowledge about surgical procedures and instrument requirements is necessary. Therefore, complex or unintuitive instruments or gadgets disturb their workflow. It is hard to handle all the tools with two hands in a short time during procedures. When tools get slippery or are unergonomic it hinders their tasks. Due to time pressure and bad visibility of the lock mechanism, adapters of the surgical power tools are changed by pressing it against their body to prevent it from falling and to increase the grip without using the lock mechanism which could lead to injuries. If the tool is used for a long time the housing can get hot which makes it difficult to handle. If a device is not functioning properly they have to check quickly if another system is available in the storage. This can lead to an extense interruption for current and upcoming surgeries.

Sales Person

The customer “never” comes to them willing to buy a system. They come with a problem they try to solve together with them. Aesculap shows how to optimize procedures through changing or updating their product portfolio. But hospitals often can´t invest in a whole system change or update so they provide the customer a plan on how to purchase the products in steps year for year. Old and cheaper systems are often more attractive due to quantity vs. quality. Aesculap machines are more expensive and so fewer tools need to do more work. Where is the added value to invest in a high-quality product if more cheap tools ease the planning phase and more surgeries can be done? But ergonomy, usability and outcome are important as well and a sick surgeon or a bad surgery outcome is worse for the hospital. Therefore, a high-quality product needs to ensure a long life-time without losing precision and power. To achieve this goal good maintenance is the key and hospitals need to be more aware of their tools´ condition. The sale persons stay in close communication with the hospital so if problems occur they often call them to get quick support and help. The more information Aescuap gains over a hospital and the application frequency of their tools a better-suited plan including repair and maintenance costs can be provided.

6 Key Insights

Field research summary which was the foundation of the process

Orthopedic surgery lacks behind in comparison to other fields like laparoscopy and neurosurgery. The healthcare sector is constantly under cost pressure and investments are not used equally over various fields. In the future, the tools also need to be gender-neutral because of more and more women entering this field.   

  • Physically demanding work steps should be reduced
  • The usage of power tools should be increased
  • There is a need for less weighty tools and batteries
  • Choose the most ergonomic tools on the market

While the surgical power tool is mainly designed for one-hand usage, in reality, the surgeons need to apply a second grip. Due to the minimalistic design, there is no space for a safe and controlled grip. The result is users bring their hands in dangerous positions to guarantee the best patient outcome.

Due to weighty tools and positions it must be held, even with a second hand, it is exhausting. There is a need for more safe grip possibilities and lighter tools. The surgical power tool plays an important role in the surgery outcome and the user should be supported to work more efficiently.

“At least at each 10th surgery, I need to change gloves during the procedure!”

Dr. Guschelbauer 2019

»This could happen up to 2-3 times a week.

Pain points product and accessories

The product system exists of the surgical power tool including accessories and adapters. The battery charger and the sterile container with the grid system. During the four accompanied surgeries, I reviewed the current usage scenarios to get an understanding if there are major issues or problems. On the top you can review similar usage applications I found online during the desktop research on Youtube and articles. It was not possible to do images during my visits inside a surgery room but the visualizations describe the same impressions I gained over the field research.

The surgical power tool is used in many different grip positions to reach relevant areas,
– Bad working postures lead to wrist, neck and body pain over time
– Even in an optimal position, the oscillating saw is hard to hold and control but the surgeon needs to change the firm grip to rotate the tool and reach relevant areas that reduce a safe performance.
– The tool actually allows flexible use but could it be further optimized to improve the ergonomics,
usability in more than one position?
> The reasons for different grip position is often visibility and accessibility
> Can the visibility and accessibility be improved without changing the grip position?
> Can the tool be more modular or modified for an extra grip?
The tools are designed to be held in one hand.
> This is good and bad – it offers flexibility and the decision is left by the user where to place the second hand. But the hand is often placed near the danger zone to achieve a safer operation for the patient.
– Due to a lack of guidance and control, the second hand is urgently needed
– During a hip surgery, the reamer can get stuck mostly at the end of the procedure.
> This can lead to major injuries for the surgeon (the tool breaks out and can injure the wrist)
Therefore, a second person is sometimes used to support the surgeon with a third hand on the tool.
– The wide handle diameter of the Acculan system and the tools´ weight makes is especially difficult to operate with dirty gloves. The shiny metal surface just gets to slippery.
– This is also a major problem when the scrub nurse needs to change adapters and press the tool against the body to increase friction.
– The lock mechanism should ensure a safe tool handle but if it is not used correctly due to reachability and visibility it is useless.

 

– The battery charger measures the battery condition and informs the user as soon as the battery should be changed. But the user often does not notice it or ignores the light indication. Is there a better way to ensure that an insufficient battery gets out of the usage cycle?

The surgery management needs to plan the operations efficiently to be economical at the end. Surgeons need to perform many surgeries a day in the prescribed time frame to be economical at the end. Any delay or canceled surgery leads to more work pressure and lost money. Therefore, any investment must be worth the money.  

In the case of a surgical power tool, it comes down to one question. Should surgery management invest in quality or quantity? With more tools available the surgery management can plan and schedule more procedures easier in advance. Fewer quality tools are used more frequently and efficient planning is required.  

But in the case of usability, ergonomics, and safety, cheap or expensive tools on the market hardly distinguish from each other. Of course, the quality and long-life are better but if regular maintenance isn´t guaranteed the added value drops for the current expensive tools.

Each hospital has to manage over thousand of different surgical instruments. All these components are bought at different times and from various providers. The result is a lack of instrument control about the condition of the tools as well as regular maintenance.  

Summary key insight

“When you deal with humans and money is the biggest factor, reliability,
safety, control and efficiency can never be good enough.”

…and what is with assistant robotics?

The main objectives for the successful integration of assistant robotics are that it must be a common procedure, the result can only be achieved with this technology and it must fasten the workflow to be economical. But today’s procedures around orthopedic surgeries are standard interventions that take often less than one hour and can be done without robotics. The disadvantages are the preparation and after work time which can be as long as the procedure itself.

Therefore, I believe before adding more complexity and cost pressure to the orthopedic environment it is important to build a solid foundation before jumping into the future. Because a handheld surgical power tool will always be needed besides robotics. In many application scenarios like emergencies, simple standard operations robotics will only be a side technology for a long time.

“As soon as the investment costs, preparation and after work time drops, it will be a game-changer like it was in laparoscopy.”

02 | Process

My project goal

I wanted to address the current problems and to create a solid foundation to build on in the future. I aimed to be disruptive and push the borders which hinder today´s progress for a bigger change but still stay true to the problems and regulations.

The starting point was to get a holistic overview of the current situation around the usage and processing of a surgical power tool. As a result, I got to see the complexity each hospital needs to deal with. There are several areas that could be examined and improved but often it would require a bigger change in the existing system and infrastructure.

My conclusion, I narrowed down the scope mainly to the green and yellow areas shown on the infographic. It means the focus was 80% around the tool usage and 20% around an enhanced maintenance system. The outcome can be valuable for the hospital as well as the provider within the existing infrastructure.

— Ideal case 

From a customer point of view

Product

  • The product gives me always enough control and safety
  • It is clear, easy and comfortable to work with
  • I can plan and work most efficiently with the tools I have
  • I can invest in steps into the system
  • The product can be widely used in different scenarios

Safety | Guidance | Control | Flexibility

Service / Maintenance

  • As soon as I have the system I don´t want to think about maintenance
  • The company and I know exactly the tools condition
  • The running costs are predictable in the future
  • I can fully focus on my main tasks without interruptions

Supportive | Inconspicuous | Reliable | Manageable

Focus on the product interaction

In this short video, I showcase the need for a second hand to gain more control about the tool even the cut is done with a template. To mention is that this position is optimal and I don´t have wet and slippery hands. In real case scenarios, the front grip isn´t enough for a stable grip and the hand slips into the vibrating saw blade.  

Ergonomic study

I tried to understand the hand positions I saw during the field research and why no second-hand grip is optimal today. 

 

— Ideation

— Conception

For a better overview, I created three early concept directions to combine and structure the gained knowledge in reasonable concept packages. These directions served as a starting point for further depper ideation and examination.

In addition, many ideas were created to solve current issues that can be applied to each concept direction. The goal was to provide the surgeon with more control, guidance, and support during surgeries. 

— Concept evaluation

On the base of different concepts and mock-ups, I tested usability and ergonomics. The goal was to understand the integration of a second hand when it is needed and how a new architecture affects previous behaviors.

One main outcome is the different elbow heights by doing high cuts for example during artificial knee surgeries. While one concept is good in low cuts it worsens the situation in other scenarios. Therefore, to find a solution to improve hand positions in various combination was necessary.

1. Several workshops and role-plays helped to evaluate initial concept directions

2. In close collaboration with hospitals and users, I could iterate quickly and stay true to their issues 

— Concept validation

Together with the users, we came to the conclusion that the new generation of Acculan machines has to be an evolution of the current systems and at the same time be revolutionizing in terms of the overall architecture including the usage of a new battery constellation. Improvements in the main issues regarding usability and ergonomics are urgently needed. Minimal changes can already have a big impact on users but it shouldn´t break the behavior and habits of them.

Integrated second hand on the adapters

Additional safe grip possibilities increase the guidance and control of the tool even if the tool gets wet and slippery.  

High quality tool which is worth the money

Only a high-quality tool can improve the surgeon’s ergonomics but it needs to be flexible in usage at the same by allowing to change adapters. 

Increased maintenance possibility

By allowing to change adapters the motor unit can be used most flexible. Even if a tool fails, any other unit can be used without blocking a whole sterile set. 

Keeping the user habits

The pistol grip still offers in most cases the best control, accuracy, and grip if a second-hand position is ensured. Also, surgeons are familiar and trained with the product shape. 

— Design language

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— Branding & Design Details

Result in comparison with the current system

The new architecture allows the surgeon to place the second hand under the device for better orientation and balance. It doesn’t block visibility and leads to a better working posture and more control of the tool by slide the bottom hand over the chest. 

The oscillating saw adapter allows more freedom for various hand positions and still provides a safer grip. The closed top offers a better thumb position without being exposed to swing vibrations.

Focus on the customer service

— To design a customer service it is necessary to understand their personality and behavior

Do we deal with a passive, active customer or a lazy, unaware, overstrained, poor customer? The goal is to get all of the customers to be aware, active and has full control of their instruments with the help of the provider. Then the customer relationship is working and safe for the following years. But each “hospital” seen as a customer is on a different level of innovation and has its own challenges to handle. To cluster, the problems and behaviors can help to define different models of how the provider can optimize the service for specific cases to be most supportive and efficient.

 

Should the provider be an active, passive player or a caring, benevolent, precautionary player?

The healthcare system is a complex, interconnected industry and facing many challenges in the future. Medical providers try to optimate their instruments to constantly match the application requirements. But at the same time, they struggle to sell their latest innovations to the customers due to their investment shortage. Is it not time to review the problems on a bigger scale? Can medical providers not be supportive with more enhanced services to ease the complex infrastructure hospital personnel is exposed to daily?

Instrument management challenges

Each hospital has to manage over thousand of different surgical instruments from pincers to surgical needles, implants, power tools and much more. All these components are bought to different times and from various providers. A result is ”Our customers don´t have enough control about their own instruments!” But an overview is especially important to keep track of the condition of the tools for maintenance and repair. The result shows that only a few percentages of instruments in general arrive back to the companies for maintenance. The reason is an overtrained customer who is overwhelmed by the quantity and the existing investment shortage exacerbate the situation. Hospitals as well as providers are aware of this problem and are constantly trying to update and ease their instrument management software. But the integration lacks behind and each hospital is on a different level of innovation and owns various softwares. A qualitative surgical power tool is key for their daily work and requires regular maintenance for a well-functioning process. Today it is possible to review how often a sterile set was scheduled for surgery but doesn´t give information which tool was actually used on this set. Also, the information is often not combined or even visually structured and listed to use it time efficiently. The system also doesn´t highlight yet if a tool needs to get maintained over time. If a future tool system can provide more information than today (usage time, abrasion, problems etc.) and this information could be well integrated into the software, frequent problems could be prevented which is cost effective over time. But the full integration will take time and it is important to build a foundation step by step to reach the optimal solution. Therefore, it was important for this project to close the circle for a solid vision by proposing ideas how this created data of each power tool can get into the information cycle and to achieve a software integration over the different tool cycle interfaces.

Today lack of communication and knowledge about the tool´s condition is the reason for many problems. But without data, the hospital can´t improve their processes and the provider can´t customize their services to the actual needs. Therefore, the goal is to collect data without adding extra work and time. If the tool can safe data it just needs to be implemented on an interface where the tool gets processed. Then the maintenance can be planned with data, not by assumption and it can be done more cost-effectively for both the customer and provider. Therefore an enhanced cloud service is necessary for the hospital tool management software. 

— Data flow & user interaction

— Solution for better tool management and control

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