Are you seeking ways to enhance the efficiency of your IVF lab and improve patient outcomes? We invite you to listen to the latest episode of Inside Reproductive Health, where host Griffin Jones engaged with Dr. Liesl Nel-Themaat, IVF Lab Director and Associate Clinical Professor at Stanford University.
Here are some key takeaways:
Identifying and addressing common inefficiencies in the IVF lab.
The importance of standardization and its impact on success rates.
Strategies for optimizing workflow and reducing turnaround times.
The role of technology in enhancing lab efficiency and patient care.
Overcoming resistance to change and implementing effective process improvements.
Best practices and practical tips for managing patient flow and scheduling.
Stanford Fertility and Reproductive Health
Dr. Liesl Nel-Themaat’s LinkedIn
Transcript
Dr. Liesl Nel-Themaat 00:00
You don't have to spend 1000s of dollars to implement very expensive new technologies to become more efficient. You can start tomorrow in your own lab just by making some small adjustments in your own workflow or products that you pick staffing models, things like that.
Griffin Jones 00:24
Ask 23, IVF, lab directors and embryologist. What the biggest inefficiency in the IVF lab is and get 23 different answers that was part of the talk that my guest a vet PCRs Her name is Dr. Liesl nelta Ma. She's the lab director at Stanford's IVF lab. She has been an embryologist and lab director at different labs throughout the country over the last 20 years. And her model was about the inefficiency or talk was about the inefficiencies in the IVF lab. And I started the conversation off equating that with automation, we sort of got into a little bit of a semantic discussion, I hopefully still wasn't thinking that I perceived her as being anti automation. But I also didn't think it was entirely semantics, she was painting something for me where I could see that it's not just automating things in the IVF lab that is going to make it more efficient that you could automate quite a bit in the IVF. Lab. And you'd still have inefficiencies in different areas. So she made that clear to me. And it's I'm also on this cake that you hear me talk about with David sable a lot about when does it just make sense to replace a model entirely? You know, we could have made faster cars, but eventually you come up with something that replaces that entirely with aviation, for example, when does the existing IVF model just become marginal at best with the improvements, you can make an efficiency versus scrapping it and starting with something all together? And so I was having that like, philosophical question in my mind while she was thinking of the particular inefficiencies that she was isolating. So hopefully, that didn't mean she didn't feel like I thought she was anti automation. I certainly didn't. But I moved on past that part of the conversation for your sake inside reproductive health listener. And we got into specific examples talking about plastic where how that became worse. During the COVID pandemic, we talk about paperwork and what paperwork could be automated. We talk about those times sets or inefficiencies in the IVF lab that should be eliminated altogether, because you should never delegate something that should be automated. It also should never automated something that could be eliminated altogether. Then I made the sole say what she thinks is the biggest inefficiency in the IVF lab and extend that to globally as opposed to being in the IVF lab because in her view, it's something that affects the IVF lab is related to the IVF lab, but isn't coming from the IVF lab after this episode. I would love it if you email me or comment on any of the social media platforms that you came across the episode on what you think the biggest inefficiency is, if you think we missed anything. I would love your opinions of what you think are the biggest inefficiencies in the IVF lab. But right now enjoy it from the viewpoint of my guest, Dr. Liesl Melton on Dr. nelta mod, Liesl, welcome to Inside reproductive health.
Dr. Liesl Nel-Themaat 03:40
Thank you very much. I'm thrilled to be here.
Griffin Jones 03:43
I became aware of you at PCRs you are giving a talk about automation in the IVF lab or maybe about the lack of automation happening in the IVF Lab is a very comical talk, you involved a lot of people, you had a couple of different things in your giving examples of things that are all, you know, antiquated in the lab that could should be automated should be improved. At least I want to go into those examples today. But maybe let's start with just a synopsis of what was your talk about and what were you seeking to educate the audience about?
Dr. Liesl Nel-Themaat 04:19
Well, in essence, actually, it was not pushing towards automation. More what I was going for is the base back to the basic lab efficiency. So a lot of times these days people are getting excited about the automation, the new technologies, robotics, fluidics AI, things that make very cool presentations. But what I was trying to more convey to the audience is that the vast majority of labs are still working with basic things, basic skills, basic supplies. In the lab, and there is a huge opportunity to make things much more efficient. If you just look at the things that you already have and work with, you don't have to spend 1000s of dollars to implement very expensive new technologies to become more efficient. You can start tomorrow in your own lab just by making some small adjustments in your own workflow or products that you pick staffing models, things like that. Automation would be a completely the next step. You know, if you want, I think there's a lot you can do before the automation,
Griffin Jones 05:38
I want to make sure I understand this difference. So what would a couple of examples be of just those basic skills or supplies that could be made more efficient?
Dr. Liesl Nel-Themaat 05:46
One big example, go to your staffing model. For example, in my talk, I talked about all these different types of personality get in the standard IVF lab, and that is heavily influenced by the size of your program. So the more IVF cycles you perform, the more people you need in the lab and a basic small program, maybe would have five embryologist and maybe two juniors maybe to seniors and a lab director. But then at the as this practice grow, are you going to one of these larger networks where you have a hub and spoke model, you might end up with, like 20 Different people in your lap. And it's the range from on site lab director, there's managers, supervisors, team leads, seniors, juniors assistants, shipping coordinator per DNS. And all of these different roles have different costs associated to it when it comes to your staffing model, right. And I shown in my presentation, just by adjusting how you put your team together, you can have enormous savings, and bring down your lab expense significantly, just by being wise with how you build your staffing model. So that's one example. You don't need any technology for that. Right.
Griffin Jones 07:03
So what maybe we'll get into a conversation about it, if that's necessary because of automation. But first, let's dig into those examples a little bit if we've got a hub and smoke model with a need for 20 people in the lab, how do you restructure that team so that you don't need as many people are so that you're getting more out of each of them?
Dr. Liesl Nel-Themaat 07:27
So a classical example is, a lot of times, senior embryologist, you know, as a practice grows, they small practice have limited number of staff and they can do up to a certain number of, you know, cycles, same average is about 150 per embryologist starting with minimum of two. But then what happens sometimes is as this practice grows, we need another embryologist, we need another embryologist. But the reality is a lot of this stuff that embryologist have been useful these days is data entry, administrative tasks, filing paperwork, retrieving paperwork, shipping coordination, all these things that you really don't need a very expensive, senior embryologist to do. So by replacing some of your high high cost center neurologists by more specialized people, like a lab assistant or shipping coordinator, or even using some per diems for when crunch time comes, you can actually significant, reduce your overall, you know, expense on your staff, just by redistributing the tasks and the responsibilities.
Griffin Jones 08:37
So wouldn't the proponent of automation just say well, yeah, but you shouldn't be giving those tasks to even a more junior person, if you don't have to the if you could totally automate the data entry. For example, if you could totally automate the renewal of ordering of supplies, then why give that to any human being? Why not just to have that as a part of the system? So why is efficiency important if automation seeks to make the efficiencies that we would gain by restructuring, pale in comparison?
Dr. Liesl Nel-Themaat 09:12
So just to you know, if there was any misunderstanding, I'm not against automation at all right. But let's say my program, we decided, you know, what we're going to automate that How long do you think that will take for the companies whoever is working on automation to complete developing, tasting, getting approval, then bringing it to market? Implementing it like, Yes, great. If five years from now, I can eliminate four of my staff members by bringing some fencing automated automation unit into my lab. Right, but I have five years that I don't have it right now. vast majorities of labs are not automated right now. So what can I do until I did get that technology. Again, I'm not against bringing in technology, I'm just trying to make efficient what we have and what you can easily achieve right now, before these next big things come into the picture, you know,
Griffin Jones 10:14
so I guess it depends on which next big thing is here and how now they are actually now actually present and ready there. Because I'm guessing that concern that you have is, which is we can automate. But there are things that we can do right now to be more efficient. If I'm a salesperson for any one of these companies, I'm thinking you trying to be more efficient is the waste of time, you should replace it entirely with our solution, whatever if whatever that solution might be for a particular thing. I'm thinking of one example, where I was recently speaking with the venture capitalists behind this new solution, that closets to be able to build a lab that can do 500 cycles a year with five techs, and nothing more. And so if that is the case, then I guess where I'm struggling is, is how do you know if the process of making it more efficient is worth the squeeze whether rather than trying to eliminate and automate the process? And,
Dr. Liesl Nel-Themaat 11:22
again, I don't know why there's that idea that I'm against automation. I'm not trying to eliminate it.
Griffin Jones 11:28
I'm not I'm not starting any I'm not starting any rumors on on this pocket? No, I know that you're not I'm asking because I'm thinking I'm trying to make the MCAT that calculus because I imagine that many of your peers are thinking, say, Well, should we do something or not? And I don't know what that what that calculus is for deciding, okay, we should try to just restructure and spend some time trying to restructure or we should seek a different solution. And how you approach that I
Dr. Liesl Nel-Themaat 11:58
think you should do both. I don't think it's one or the other, I think and even if you get your automation, there's still going to be places that the automation is not really touching, that you can still be more efficient paper usage. Let's talk about that. The amount of trees we are killing by doing paperwork and not going more electronic, you can have a machine that can automatically make your dishes it's not gonna resolve your your paperwork, wastage issue, right. Or you can restructure your staffing model, but it's not going to do anything for the plastic ware that you're using. So there's no one solution that's going to touch all the different areas that you can make more efficient. Like I played video, where I had asked multiple experts across the industry, what is the biggest lab inefficiency, not two people gave me the same answer. And that's the point I'm trying to make is yes, there are big ticket items that we could bring in new technologies. But there are so many places where you can be more efficient can save money for your organization can make your processes more streamlined and be friendlier to the environment. If you just conscientious and have this overall mission to be more efficient in everything you do, not just the one or two big ticket items that companies are trying to sell us right now,
Griffin Jones 13:27
as those examples that I want to make this conversation about, maybe we got bogged down in semantics for a second. But the you talked about paperwork as one of these examples. Why what's stopping the lab from being paperless right now, and what specifically should be paperless? And
Dr. Liesl Nel-Themaat 13:45
I think change is hard. I think everybody knows and use less paper and transition to all electronic and a lot of groups are moving towards that. But it is very difficult to make such a big change in a lab that you are used to I have my patient chart right here. This is where I document everything I do. It's first of all a big expense on the program. And then there's something about having a hard copy. And people just don't like change. It's difficult. I think we are definitely steadily moving towards it. But it's not something that you overnight going to be paperless than any practice right. So but you can make small steps towards it. And you can maybe double copy some of the things that you have at the moment still paperwork maybe the practice is not comfortable going completely paperless yet, but if you have the right mindset, you can move towards it or at least cut your paper usage in half like every time you print something Do I really need to print this is there a way I can have this electronically but doesn't interfere too much with my that workflow because there's always a balance, right?
Griffin Jones 15:02
Are there examples that you can think of, of things that shouldn't be printed almost categorically that, that that's just a waste
Dr. Liesl Nel-Themaat 15:10
consents, definitely. And I think COVID actually helped a lot with some of this where traditionally, patients would have signed paper copies of consents and get it notarized if they're not in the space, or gonna be able to come to the clinic. And I think COVID has forced the whole industry to become more electronic from telehealth visits to online consenting to, you know, explaining the treatment cycles, everything, instead of now giving paper handouts or welcome packets, and all that everything is done electronic. So we actually have COVID, to thank for some really good things that have come to our industry, I believe, the paper forms, I think sometimes there's a lot of duplicate things that might be recorded on forms where you could make it more concise, or just maybe have, if you if you're not comfortable going completely paperless, you can be wise about what has to be on a paper and what does not. So I think it depends on each practice, what kind of forms they do have, you know, when I was surveying a group of embryologist online and asking them, you know, how many pieces of papers was on average it 15 sheets? That would be things like, you know, your neurology worksheet and then you have your individual in row tracking sheets, you printing out your order, because you want it Do you really have to print out the order, you know, if that's electronic PGT worksheets that the company saying you print that out? Do you need to have a print out of that and your own PGT worksheet? You know, this, it really depends on every practice. But again, it's it's all about the mindset and the the, the vision and the mission to try to become more efficient. I'm sure every lab can go and look at the paperwork they use and identify at least one sheet of paper they can get rid of, you know,
Griffin Jones 17:02
can you give an example of where else it would go? Like, if you think back to the last five years or so where you were using paper? And some example it did it was? Was it something that changed to the EMR? Or was it something in a different type of workflow software? How did you eliminate paper?
Dr. Liesl Nel-Themaat 17:18
So we have not, we're still using a lot of paper, in fact, my my Kayla bow about six trees a year at the moment,
Griffin Jones 17:28
do they now listen to your talk? Yeah, you don't just you don't just sit them down and play the same talk for them.
Dr. Liesl Nel-Themaat 17:35
Now we started mentioning it, I haven't given this presentation to my whole clinic yet. But that gives you an example. So we have not but we started the conversation. Because when I had to find out how much does our whole clinic use, obviously our practice manager, I told her why wanted to know and say how, you know, we started the conversation, how much paper do you use? And now he's on the table. And then I say, Do you guys realize we kill six days a year? And now we're talking about it? So yes, I like I said paper consent to something, I think probably the majority of clinics I've gotten laid off, we still get copies in some instances. But we should not that that's the easiest for me to think of is that anything that can be electronic. And the good thing is this is not a form that we are generating on our end, when it gets difficult is when you have to do data entry. But you're not sitting at your computer while you're looking at, for example, embryo grading, right? I have I'm sitting at a microscope and looking at each embryo one at a time, and I have to write it down. And then I can take the computer and put it in my EMR. Now you could argue well, if you have the AI technologies with the live imaging, you don't have to do that, which is true, but most labs don't have that yet. Right. So can you get around that? Can you get comfortable enough that you might be can use the iPad instead of a piece of paper in real time while you're writing your embryos?
Griffin Jones 19:01
Oh, did COVID make plastic were more or less of a problem if it made paper less of a problem? What did it do with plastic where because you know where it didn't make plastic were any better? The whole effing rest of the world, you know, plastic everywhere. Now we have now everything's takeouts in styrofoam, it's in their individual wrap masks that all go everywhere. And so it seems like the plastic were got problem got worse in so many other areas of the economic sector. Was it better or worse after COVID
Dr. Liesl Nel-Themaat 19:40
classic where we've gotten much worse but for a different reason. It's because suddenly we have such big supply shortages because everyone was buying it at such a rate because they were worried we're going to run into supply shortages and then we created this superficial shortage or this this it wasn't real
Griffin Jones 20:00
Do you toilet paper and yourself? The IVF? The the IVF? Lab field toilet paper themselves said it.
Dr. Liesl Nel-Themaat 20:06
Yeah, you were listening to my talk. It's my cousin's analogy. You know, yes, we, it's not like suddenly all the labs, were doubling using dishes, they were just not available because big, people were just ordering more than they actually needed because they were worried they were gonna run out. And then we created this to a certain extent, artificial shortage of plastic where so people were scrambling, trying, you know, just to find get their hands on what ever plastic they wish they could find not necessarily getting the true and tested and, you know, validated plastic containers and dishes and stuff, but just, you know, open it up more for whatever we can get. But I do think that it did make us or at least for myself, so thinking, you know, where can I eliminate some of this plastic usage in the lab. And so part of my presentation, also, I use an example of one of my previous labs, how many pieces of plastic we were using per cycle, and it was 27 pieces. And what can I do in my workflow? Where can I maybe reuse some of the plastics instead of throwing every you know, when you're doing retrieval? Do I really need a new tube for every follicle that gets asked to write it? For example? Do I really need to pour it into a new dish? Every time I search for an egg, you know, where can I reduce the number of plastic that I use. And by doing simple things like that, you can really make a big difference in that now, of course, again, people don't like change. And it's difficult to implement something like that, you might think it's such a simple thing. But if you have a shortage of whatever that thing is, you use you very quickly have to out of necessity, make that change. So I'm actually curious to know if labs started using less plastic due to COVID? Because of the shortages? And would they maintain that going forward?
Griffin Jones 22:04
As far as you can tell, are we still living with the consequences of that over ordering in the beginning?
Dr. Liesl Nel-Themaat 22:10
Now we've sitting with boxes full of expired product, because people over order, because they were worried they're gonna run out. And now, you know, we in during my talk, I surveyed the audience and several people raise their hands on ask how many of you have supplies that you ordered during COVID? Because you were worried you're gonna run out and now it's sits in your storage room, and it will expired? Which shows that it was really an artificially created partially at least crisis.
Griffin Jones 22:43
Is there any application for those expired product? Like, can they be used in different kinds of applications?
Dr. Liesl Nel-Themaat 22:50
Oh, absolutely. You can use it for research purposes. You know, we all know that plastic dish is not suddenly toxic. But because of regulations, you have to follow the manufacturer's expiration dates, but any research lab would welcome it, you could even try to sell it to, you know, the research labs, but what we would do is we just donate it to Stanford's, you know, whatever lab wants to take it, I have people that some of my fellows that do research in my lab, and I would just give it to them, and they would use it for whatever research they're doing.
Griffin Jones 23:27
How do you make some of that reuse some of that limitation of usage into a system into like protocols that and processes that staff follow? I think your example of freezing a retrieval tube for aspirating follicles are maybe one of the other examples you gave. Is that up to the individual embryologist to figure out is there a way of standardizing that. So that's a process to get the whole lab is using less plastic ware.
Dr. Liesl Nel-Themaat 24:00
And that's a very good point. Actually, it's not just up to the lab, right? It is really the whole clinic. It's the physicians, it's the nurses, it's, you know, everyone, it should be like a joint vision. But for example, when you do a retrieval, there is a physician amazing is the geologist, there's a medic or a nurse, you know, there's a team of people and, you know, putting your heads together and thinking, Okay, we typically use 25, round bottom tubes. How can we reduce that number? Is it possible to you know, we take the first five, we d canted and we give it back to you and you reuse those tubes. You know, this is just one thing I can think of we full disclosure, we haven't done it. But that is one example or
Griffin Jones 24:46
we're going to play this podcast episode for everyone that you work with the whole leadership team will pass on that will go to that will go beyond the division chief to the dean of the medical school or whatever they Is it Stanford circulate this, will LinkedIn, target everybody at Stanford and play this episode.
Dr. Liesl Nel-Themaat 25:07
I think when I show the financial part of it, then I would have some big fans on my side. And when I hit the green, the environmentalists, you know, so they are people that love me people that will hates me. But the truth that we can be much more efficient, especially with plastic use, I would even go as far as saying, Have you heard of glass? You know, do you know that in the good old days, we were washing glass tubes and autoclaving them. Now by no means am I saying we shouldn't be doing that. But just at least open your mind and think about, there was a time when we didn't have any of these things. Right. And it is my one year anniversary at Stanford today. Just FYI. So if I get fired,
Griffin Jones 25:48
often there's a two year anniversary after this episode comes, this is
Dr. Liesl Nel-Themaat 25:53
a big project. And it's something that you need to get buy in from many different parties. I'm not going to say that I have made or implemented all of the changes that I'm suggesting that it's possible, but I'm trying to throw ideas out there. Because every program is set up differently, something that might have worked in my lab, that's an easy improvement in efficiency might not work in the lab next door who has a different workflow, they use different products, or they'd like a different culture system. So that's why I say that every lab person has to walk in their own lab and look at every component and ask yourself the question, is there a way I can do this more efficiency? Is there a way I can do like, Can I not use so much paper towel? Can I get away with you know, switching off some of the electric components of my lab at night and but only only the person working in that lab, the lab director, supervisor, the biologist only they can really identify it. I can't identify in someone else's lab, what efficiencies they can implement. I can just give ideas and hopefully try to get people to think about these things more.
Griffin Jones 27:03
So plastic ware was a big area paper work was another big area of those. Yeah, I think you said 23 or something suggestions of what what the most, the biggest inefficiency in the IVF lab was and you have 23 different answers. What were some of the other ones that you can remember,
Dr. Liesl Nel-Themaat 27:20
time is like a half hour. But biggest resources as you know, and that's one of the things that we have the least amount of. And I think there are a lot of things that we do in the lab that takes a lot of time that we don't necessarily need to be doing. There are procedures, for example, trimming of your egg osios side cumulus complex after retrieval, just for background for you and an egg comes out. It's surrounded by these little cells called cumulus cells. Now a lot of labs routinely use syringe needles or some other device to trim it. And then later on, take all the cells off with the enzyme anyway, to make it clean or make it easier to strip is the term we use for cleaning of the egg. But a lot of labs don't do it. And one of my questions to the audience was, how many of you people are still trimming? And I think it was about half of them. And then the question is, why is it necessary, it takes so much time it takes resources, it takes more plastic, if you can eliminate that step, you can use your embryologist for something else, and eliminate how many ever minutes from that workflow. Another thing is how many times do you wash your sperm? Right? They are practices that wash everything twice after doing a gradient. They are devices microfluidic devices, that saves you a lot of time because it's you the way the procedure works, you basically put the sperm into this device, but even culture and you don't touch it again. Now that device is pretty expensive. So you have to decide for your own workflow. What is more valuable for me here to save my embryologist time, or to not make this big expense of using this expensive device? Right? So there's always a balance, but the main Time is money. We know that. But you have to think how much does it cost me to save this amount of time? Is it you know, Palin's a doubt?
Griffin Jones 29:20
So the the device itself it doesn't automate the process? Does it circumvent the process altogether to tell me more about that. It's just a different
Dr. Liesl Nel-Themaat 29:29
technology that instead of doing manual nation steps that someone have to come back repeatedly, you just can use this device and put it in the incubator and let the sperm swim through it. But there are cheaper ways to achieve the same thing. And I don't want to go into speaking about specific products or brands or anything like that and they are things that for example, changing out your biopsy. When you do low your biopsy fragments. They are programs have changed out that tip every single time between every single biopsy fragment. And there are groups that don't. And there hasn't been any apparent difference. If you just rinse it out, you're saving on plastic you're saving on time, because a lot of times, switch out these things. And then there are ways techniques that you can use when you're doing some of the procedures. For example, XE is a time consuming procedure. But if you look at how different people are doing xe, probably everyone does it slightly different the way you set up your dish, the way you move the eggs around the way, you know how many spam you catch at a time. And by adjusting some of those things, you can actually save a lot of time I actually showed a video during my talk of I actually wouldn't play unfortunately, the technical difficulties, but there's a way that this embryologist Lisa Ray, she she she manages to hold on to an egg and then just roll it with a very swift movement, like five, six eggs in a row, just injecting jig, it takes like two minutes where, you know, if you have a differently organized, it could take you 20 minutes to inject the same amount of eggs just by adjusting how you do that procedure.
Griffin Jones 31:14
So you're in that talk where you also asking for examples of things that still don't work was that was that a segment that I'm remembering correctly? Where you ask people? If for however many years you've been in the lab, what's one thing that still doesn't work properly or, or work the way you want it to was that was that a segment that you did
Dr. Liesl Nel-Themaat 31:35
to video was on pet peeves and frustrations that people keep doing that really can be quite irritating, for example, leaving bubbles in your culture drops, you know, or using the last of a pipette and not replenishing in the in the hood, or using too much paper napkins and put it in the Biohazard. Which when it's not biohazard, and just this again, small little things that can become really irritating or people that complain that they are always the only one that does this, or does that. And if you look at the distribution, no, really, it's not that these were just complaints or pet peeves of some of my peers that were quite funny. Not writing open data, little vials and, you know,
Griffin Jones 32:28
and so some of them might be sort of comical. But other of those might point to bigger process efficiencies, you know, the writing on the vial, for example, could be something that is, is changed or automated in some other way. And as you're going through a lot of these examples, I'm thinking of the acronym, eliminate automate delegate, I don't know if anyone's put that into an acronym that is more that sounds better than EAD. But, you know, you're you're focused a lot on the elimination or because while one could say well, don't delegate anything that should be automated, you could also make an argument that says don't automate anything that should just be eliminated altogether. Are there a couple other examples that you think of either from your talk or just from your day to day work that you think, are pretty easy to just simply eliminate in the IVF? Lab? And if so?
Dr. Liesl Nel-Themaat 33:26
Absolutely. You know, you talk about delegation and automation, and elimination. There are delegation, I think, is extremely important, not only for streamlining things, but also for team morale, I really believe you have to have a strong, solid, happy team. And if you give different people specific delegated duties that they can take ownership of, I think it's healthy for the team in general that everyone knows who's responsible for what, who is the go to person for any particular thing. But then I think a lot of the things that ultimately fell on the IVF lab to handle really should not be handled by IVF. For example, sort of data entry or sorry, the initial cycle initiation, when a patient's first come through, should really be falling on the clinical team and shipping coordination. There are many of these things that really should not be handled within the IVF lab and can be eliminated from the IVF lab. Now, if you don't have a person outside of the lab, to do it, then delegate it to someone that has protected time to do that role, because it becomes quite chaotic, and it becomes a sore point if, if no one has that specific role in the lab and whoever has time has to just do it and then people that well, I'm doing it more than this person and this stuff isn't didn't have a turn yet. If you delegate everything just becomes more organized. Of course, if you can eliminate it all together, if it's not something that appropriately should be in the lab. That's even better.
Griffin Jones 35:01
I can also see though, it's sometimes easier to know what to eliminate when you do a better job of delegating, because you're isolating that particular things. And one of the things that I've started doing with my own company in the last year is it just started jotting out and mapping it alongside our accountability chart, all of the outcomes that the company is responsible for doing, you can break those into more junior outcomes, and then section those off to more junior people. And then you could take bigger outcomes that are more complex and assign those to senior people. And those often require more resource. But by mapping it in that way, it's, it's clear what can be eliminated after some time. Because if if you just have it as part of someone's job, that isn't really part of their job, and it's also kind of somebody else's job, then you don't even really see what can be eliminated. Whereas if, if you start to parse these things out, you, it's easier to eliminate? Have you found any things like in the last year or two by ft after you delegated it that you were like, No, I think we could actually get rid of that altogether.
Dr. Liesl Nel-Themaat 36:17
You know, actually, but em our integrations with SAR has done that where, you know, in the old days, something like three, four years ago, you would have to manually enter data into sources, we talking about data entry, and you know, who should do that. But most of the EMRs now will talk directly to salt and will send the data directly to salt or to NAS. And that is actually a automation step. Yes, your data entry still has to happen somewhere, but at least it is. It's in one place. And these two systems talking to each other has made a huge difference, which is also why going to electronic medical medical record system is very valuable, because a lot of clinics honestly still don't or paper,
Griffin Jones 37:06
which is amazing to think about to begin with. But put please go off. Yes. But
Dr. Liesl Nel-Themaat 37:10
I'm telling you, it's a massive investment. It's not just oh, we're going to switch to EMR. And we're going to just do it. I mean, I lived through a transition recently where we had to start a brand new EMR and it is a very, very difficult process. And there's a reason why clinics are not just jumping on it, you think but it's such a no brainer. But yes, once you get on the other side, it's great, but it's a difficult process to go through. And if a clinic already doesn't have the bandwidth, people are hanging on edge. And you know, there's budget issues. And it's not that simple. And so again, back to my point is okay, well, if you don't if you're not ready for that big step, what can you do? That's easy, that still makes a difference.
Griffin Jones 37:55
But how do you model the costs? For example, like if you so you, we started the conversation talking about different staff models, and ways of making that more efficiency more efficient? How do you model the costs so that it's easier to see for someone that has to make that calculation of should we replace this system with that? Should we should we move from paper to an EMR? How do you model costs?
Dr. Liesl Nel-Themaat 38:23
Well, it really depends on the system you're talking about, right? And let's use cry storage as an exam. Because I know it's such a hot topic right now. And I'm sure some of these automations, you're referring to refer to that component. There are various different routes you can take if you want to restructure your price storage system. But there are so many different factors to consider everything from your staffing model, you know, does your staff have the capacity to keep managing it in house? Is your practice dependent on the revenue that you are hopefully getting from your patients, those that are in fact paying? You know, at what point does it make sense for me to outsource the entire thing, but then I'm giving up a big piece of revenue, but I'm also giving up a big legal liability. And we're actually in the process of that right now. And Stanford is building this future for our careers storage systems. And we haven't come up, you know, decided exactly where we're going to go yet. But it is a, it, there's so many different components. And at the end of the day, you know, you have to have your spreadsheet and say, Okay, this is this is what I'm gaining, this is what I'm sacrificing, but how do you put a monetary value on your legal liability, you know, and what your insurance costs you every year and like Stanford is extremely risk adverse, right? Every clinic has a different tolerance for that liability. So it's not a very simple question. Something that's more that's easier to do is like the use of plastic for example, Which dish do I want to use? And I showed a table where, you know, I have two different dishes. This is what these dishes cost. The one dish might cost more per He's but then the amount of volume of oil you use for this dish is this much versus that dish. But then the media that you use cost this much, and then how long it might it takes to make the dish that's a time component. And then then in the end, you make a table and you add it all up and say, Okay, what is the most what makes the most sense, economically? And is that what we want to make our decision on workflow wise? I mean, it's, it's complicated.
Griffin Jones 40:29
How do you factor people's time into that table? As an estimate? Is there any time tracking in the lab, like how a lot of client services firms, a lot of remote companies will use apps like Harvest? Or I think another one is tea sheets? And so harvest can go in your browser? Anytime you switch windows, it can say, are you working on a different task, you record at a time it integrates with a project management software, I suspect that it's it's pretty inaccurate, or at least that it's, it is it is far from purely accurate, because it still requires so much human use to say, this is what I was working on at this time. But you can get an idea, a lot of remote company, a lot of tech based companies, this is how long this task takes. And it's just once AI takes that over, then we could really get a good idea of what people are actually working on for how long is there any kind of time tracking like that happening in the lab right now?
Dr. Liesl Nel-Themaat 41:30
Are some of the witnessing systems or try starting to track that and look into that? Obviously, it can be met with some resistance. Because there is a balance, you know, I was talking the intro to my talk was really the difference between efficiency and effectiveness right. Now, when you start going down to that granularity, I think you do run the risk. If your staff knows they are being timed, every time they do a procedure, they may start going too fast, and then start making mistakes, or, you know, maybe you see more eggs per minute, but your fertilization rate goes down. So there's a sweet spot and my my hesitation to embrace this kind of tracking of staff is exactly that is I would rather have my staff workout is a comfortable pace. And not everyone is equally fast with everything right. But it doesn't mean one that is not as fast it's less effective in your overall outcome. So yes, it is that is coming into the market, I don't know how many clinics are actually using it. I know some of the bigger networks would have their staff much more a day much more structurally. With time, at 745, you can start doing this at 752. This should be done. Now you're going to do that I can see the necessity in very, very giant big programs and how that brings in that efficiency. I don't think any embryologist particularly likes working like that. And so that could touch your team at all.
Griffin Jones 43:11
The concern that you have is one that client services firm share with their own time tracking of that, if I'm am I being monitored on this because it's down to the billable hour, and you can err on either Sen, either end of the spectrum, you can err on work completely, we bill everything down to the hour, and everything has to be tracked. And that causes a lot of stress on the team. Because one they're worried about what it is that they're spending their time on. And it can affect quality, but too often just it can be inaccurate. And they spend so much time just doing the tracking itself and the logging of the tracking that it's it's it's futile. And then you could also err on the other end of the spectrum where you do no tracking and you just don't have any. So what we done in the past, is it say listen, you're not so we never aligned it with incentives, and we never aligned it with billable hours either. And I think that helped because it was just we're doing this just to get an idea just to be able to practice, but it wasn't against the billable hours. So they didn't have to feel like it was it was for that exclusive purpose. And I also didn't want them just every single time they were switching from one little task. Well now I'm checking email minute one, but I'm checking the project management software minute two, and I'm back to email minute three. And so if you did that in the lab, and you just kind of got an idea. What do you suspect is the biggest inefficiency in the IVF lab.
Dr. Liesl Nel-Themaat 44:46
Their biggest inefficiency is not based on a procedure. In my opinion, it's scheduling. The biggest inefficiency that I think is hurting our IVF lab the most is in with consistent scheduling on the clinical side, that the lab has to absorb, that you don't know how many procedures are going to come your way at any given day, which day they're going to fall on. We know there are ways that we can do this can be done more efficiently. But this is not up to the lab. You know, that is the problem. So I know you want me to say in the lab, the most inefficient thing is how we stripping our eggs, but I don't have an answer. But I think globally, what affects us the most probably, is inefficient scheduling of procedures. And that's a big pet peeve of many, many lab directors, where there is no template with X number of slots with only these types of patients can come through on this day. And once it's full, they have to wait for the next month. I think for me, that is a big one.
Griffin Jones 45:54
I could just say I will save that topic of how to fix it for somebody who speaks on scheduling. And that's their topic, but let's try to give them a little bit more to work with how, how do you suspect that can be improved? Yes. So
Dr. Liesl Nel-Themaat 46:08
what I have seen was very successful was when scheduling is outsourced, where it's centrally controlled by someone that is not emotionally pulled into the decision or have to make a decision on the spot. Because what we often hear is, Well, this patient is so nice, and she wants to go to Italy for her vacation, can we please add her. And now I'm standing there with the person making the request. And I have to make the decision right now. And the problem is for other very nice patients to scold three of the other doctors. And before I know it, I have five more patients than I can safely managing the lab. So by taking that off of the labs plate where this is centrally controlled, only the lab can make kind of proof an addition but I'm not dealing directly with the physician or the nurse or whoever has emotional relationship with the patient. You know, I think that has made what I've seen when, you know, during transition that I lived through that made a huge difference. When you
Griffin Jones 47:19
say centrally controlled, you mean like that scheduling function outsourced altogether, or simply concentrated somewhere within the clinic that it's not just the doctor doing here, the
Dr. Liesl Nel-Themaat 47:30
example I'm using is, you know, in a network and a big IVF practice network that was centralized by scheduling department that was not even on site where we were. But in a standalone clinic, you can have a person responsible for that. That's not part of the clinical team that doesn't have a relationship. And that person should have the authority to say yes or no and follow the rules. There's a reason we have a template, we know what would be an exception. For example, if I have a cancer patient coming through that starting chemotherapy next week, and we need to freeze her eggs 100% That is a legitimate reason for an exception, someone that wants to go to Italy and she doesn't want to wait till next month, that's not a reason, insurance expires, you know, but that needs to be written down in a policy. And if an answer to make a change, or to deviate from the rules is no then that should be no and everyone is on the same page. And it shouldn't come become emotional decision between the lab director or lab supervisor and the doctor
Griffin Jones 48:41
is that where the bulk of the problems are coming from with regard to scheduling and your view just from trying to fudge in different exceptions at different times?
Dr. Liesl Nel-Themaat 48:54
A lot of it is yes, also communication, you know, you hear of patients that suddenly appear on the schedule and that patient was never presented earlier or was not planned in advance. And somehow there was a communication gap that the lab somehow didn't know that this person was coming until the day before. Also just you know, the clinical practice. Now, I'm not a physician, I do not, you know, have no input in the stimulation protocols or the treatment plans at the patient's other than what happens in the lab. But we know there are ways to manage the volume of patients how many FTEs and which days they fall on by just doing program cycles, right? So and same with retrieval cycles, you know, do we do birth control or not we you know, some patient wants to be on natural cycles. But that is something that really the clinic should be everyone should be on the same page and the physicians, not everyone likes to change the way they've traditionally practiced medicine and there is still in the list. The chair, not there's not really an agreement on if if it affects outcomes or not. But I know that most of the large networks do have better workflow because they have these scheduling rules and templates. And the majority of the cycles can be predicted because they use program cycles instead of natural cycles. But a lot of divisions are are not comfortable with that yet.
Griffin Jones 50:32
Is this an argument for batching? Or is that something different?
Dr. Liesl Nel-Themaat 50:36
batching is something a little bit different. But for batching, you definitely need that's not natural cycle, right, because you have true batching, you do one week of basically, sometimes it's just two or three retrievals data retrieval days a month. And then the lab is very, very busy. But you know, what's coming your way you can plan accordingly. And then people can, you know, during the downtime, catch up on a lot of the administrative stuff, and, you know, ordering and setting up the lab and get ready for the next cycle. So true. batching is a little bit different. This is just basically managing if you're not a batching clinic, just managing the flow of your patients coming through.
Griffin Jones 51:22
Well, I want to let you conclude with what you how you would summarize remedying and efficiencies in the IVF lab where you would like to see things go we have a lot of lab directors and embryologist that listen to especially when we bring on someone to talk on a laptop, but we also have some CFOs listening that are responsible for p&l, and we have practice owners. And so some of that support on the clinic side. And we do have some DIVISION CHIEF So there are people thinking about how they can get through the red tape, but their health system? How would you like to conclude?
Dr. Liesl Nel-Themaat 51:57
Definitely saying that, you know, we talk now quite a bit about, you know, stimulation protocols. And you know, whether it's programmed on program cycles and how that affects scheduling, every clinic is different, right? What works, one clinic is not necessarily going to work for another clinic, which is why it's important that you have to within your own practice, put on the hat of what can I do to be more efficient in all these different aspects of my practice? What will work for me may not work for you, right? If if I say I can eliminate this process or delegate this process out of my lab, the way in a neighboring clinic is set up, it might not work at all. So the most important thing is to just be searching for ways that you can make your practice more efficient. The one is not right and the one is wrong. It is very individualized because everyone is doing things differently. Just wear the glasses off. I want to be more efficient. What small changes can I make sometimes mighty big changes, but what can I do right now to become more efficient? That could be my message.
Griffin Jones 53:09
Dr. Liesl Nel-Themaat, thank you so much for coming on inside reproductive health and sharing this for your lab colleagues and your colleagues and the rest of the field
Dr. Liesl Nel-Themaat 53:19
is a pleasure.
Sponsor 53:20
You've been listening to the inside reproductive health podcast with Griffin Jones. If you are ready to take action to make sure that your practice thrives beyond the revolutionary changes that are happening in our field and in society. Visit fertility bridge.com To begin the first piece of the fertility marketing system, the goal and competitive diagnostic. Thank you for listening to inside reproductive health