Fabrication Tips and Tricks for 2010
September 2010 Issue
Ask a simple question, and sometimes the answer is anything but simple. During our search to assemble a collection of practical tips and tricks used by some of the industry's most experienced fabrication experts, we discovered that "tricks" extend far beyond clever things to do with hosiery, and "tips" can include more complex advice than which type of rivet to use in a brace.
This article covers a wide range of fabrication issues, from the timely to the timeless and from the philosophical to the mechanical-all from professionals at the top of their games. We'll start with overviews on efficiency, education, and tooling, and then we'll give you more than 35 elegant ideas for addressing common fabrication problems.
Efficiency Means Money
Scott Wimberley, CTPO, Cornerstone P&O, Bellingham, Washington, and COO of Fabtech Systems, Mukilteo, Washington, believes that the virtual "mother tip" for fabricating wisely and economically boils down to applying simple common sense and careful waste control.
"We've been working with a Japanese consulting group out of Toyota for about 10 years for lean manufacturing, which has increased efficiency, productivity, and profitability through reduction of waste. Our business has grown anywhere from 14 to 20 percent annually for ten years-although I am operating with the same staff level I had ten years ago."
Sometimes "waste" isn't obvious and demands careful scrutiny of traditional time-honored methods/habits and willingness to change them. Here are some pointers Wimberley shares:
Use downtime wisely. During production downtime, people typically kick back because the workload has slowed down, and they should instead use the time to prepare for a future busy time by fixing broken equipment, addressing known problems, and organizing the shop.
Neatness pays. During downtime when you're organizing the shop, dispose of unnecessary items, surround workers with things they need to do their job effectively, and find a place for those things that are not immediately needed.
Don't save everything. In the name of thrift and saving, typically workspaces in O&P become cluttered with excess and remnants from previous jobs. And while it does seem thrifty to save each little nut, bolt, and screw, this actually creates clutter that causes confusion and problems that cost you much more than you ever saved with that particular part or product.
While you might have $3 worth of used hardware in a bin, if a technician or practitioner spends 15 minutes digging around looking for something, effectively they've just bought what they're looking for-two and three times over-with the cost of their lost time.
Regulate your workflow. Too much work-in-progress will kill your business. If you have 30 jobs halfway started, you have absolutely nothing you can deliver to a customer, yet you have the expense of 30 jobs sitting in bins, and the confusion of 30 bins' worth of parts. You're eating up thousands of dollars worth of supplies, you're completely filling up a space, and you have more work to manage and to look at. While you're working on these jobs, there's nothing completed for six or seven days, then suddenly, you need to deliver 30 jobs all at once-which isn't possible.
It's much better to see one job through to completion and keep your work-in-progress very low. Strive for a regular flow of work that does not exceed what any part of the process can deliver.
Improve communication. During slow periods, I recommend that people work on work orders and business documentation. If you look at a company's books, one of the most expensive line items on the account is payroll. That means that your people are your most expensive asset, hands down. Nevertheless, a lot of businesses don't have work orders; they don't have due process for how they do their business. Every single job has many levels of communication to clarify details so that the job can be done correctly. If your communication isn't effective, you're reworking jobs or delivering substandard product.
Discover what your customers want. If you're delivering your idea of service and value without surveying your customers, you're probably over-delivering. For years, we made a really nice leather strap for every single AFO that went out the door. We probably spent 12-15 minutes making each one of these straps.... Our patient surveys showed that no one noticed it.... We consequently changed to a much simpler strap that probably saved $4,000 the first year. The product was the same, and our customers were just as happy.
Don't overstock; instead, purchase more often. Don't stock anything you don't have to. Create a purchasing process that is easy enough that you can place one or two small orders a week, just to cover your needs. OPIE's purchasing software makes purchasing very straightforward and helps track inventory.
A lot of people don't manage their inventory, so when it gets to zero, they have a knee-jerk reaction and order 100. When so many items come in the door, they must be stored piecemeal anywhere they'll fit. Since the items are scattered and no one's monitoring inventory, before they know it, they've used the last one and they're at zero again, and the overstocking cycle continues.
Don't sit on dead stock. If something you order doesn't work for a patient, send it back and get it out of the way, even if it requires a restocking fee-even if you take a loss. If it winds up on a shelf, it will probably never be used.
If you've been carrying inventory on your books for two years and you've got a stockroom that's worth $60,000, you probably can do some evaluating and get rid of some of it. Donate it to a charity, do what you've got to do with it. You're losing money every day it stays. If your warehouse is full of only what you need, you are much more likely to stay on top of it.
Find new ways to be efficient. If you really want to make profit-oriented differences in your business, then become more efficient by changing what you do every day. That's the free money in the business. All your other variables remain the same. However, if you figure out every single day how to get a minute's worth of extra work done, that's 365 minutes a year-and you can do the same thing next year.
You can always figure out how to do your job better, and those changes are the gold mines in the business. The componentry, the profitability, the billing structure-all of that stuff has real limits to it. The productivity doesn't.
Basic starting points include standardizing your product and processes, working off of written work orders that have standards, and standardizing your inventory, but there's really no ceiling on efficiency.
Knowledge Is Power in Changing Times
Like Wimberly, Brad Mattear, MA, CFo, general manager of O&P1, Waterloo, Iowa, believes that profitable fabrication depends on the effectiveness of the technicians, but rather than evolving methods to control waste, Mattear's primary "tip" for technicians is to pursue an education that leads to certification and beyond.
"In our field," Mattear points out, "everybody has access to the same equipment. There's no propensity to exclude or have exclusivity on a certain product or methodology. If there are 'trade secrets,' they have evolved from a regional location or are company-specific tweaks or twists."
In the case of O&P1, its business individuality developed through trial and error, he notes. Looking to tomorrow, however, Mattear foresees an urgent need for technicians who are highly trained and well equipped to take on increased responsibility.
The future clinician will have very little or no fabrication experience, Mattear predicts, because their objective is to be recognized as a clinician, serving as part of the allied healthcare team. Their training will have prepared them to deliver excellent patient care and high-end technology rather than performing the mechanics of pulling a prosthesis or laminating a socket correctly. That's why technicians are destined to play such a significant role, he believes.
"The technical field in itself is the driving force for the future," he says. "Without the bullet, a gun is useless. The practitioners have the gun; they need the technicians to carry forward their aim and follow through with accurate service to impact their targets."
Times are changing faster than O&P business operators can complain, he notes. "The old adage, 'I'll have to see twice as many patients today to make the same money I did five years ago' is no longer relevant because by the time you say it, you'll need to see three times as many patients!"
Mattear believes that increased use of CAD/CAM along with greater dependence on outsourcing are sounding the death knell for traditional methodologies of fabricating, making this an exciting time for technicians.
"Successful practices are realizing that with the rising costs of healthcare and benefits, lean manufacturing, outsourcing, and central fabrication are the right ways to get the most bang for their buck," he says. "Having technicians in-house to perform minor modifications or finish jobs is also a standard that we're starting to see practiced more."
To gear up for that future, Mattear advocates developing stricter standards for aspiring clinicians to enter school, increasing the proficiency of those who succeed in completing their education rather than flooding the market with an overabundance of possibly underqualified COs, CPs, and CPOs.
"In theory," Mattear says, "if it's harder to get the education, it creates greater value for the finished product."
As a member of the ABC technicians' certification committee, Mattear reveals that tech exams will be changing in the very near future, affording more technicians the opportunity to become ABC certified-a credential that should be pursued much more avidly than it is at present.
"We're worried about why 70 percent or greater of the practicing technicians around the country are not seeking certification," he comments. "If making examination opportunities more accessible to those technicians already practicing does not encourage them to take steps to become a part of ABC, what value is it?"
The answer, of course, is that there is tremendous value to becoming an ABC-certified technician-Mattear's question is simply, "What's holding them back?"
By pursuing excellence-or what the industry regards as a measure of excellence in that field-the technician not only achieves acclaim and recognition but increases his or her own confidence and self-worth, Mattear notes. Although many veteran "bench jockeys" never really felt the need to be ABC certified, he says that the new wave of technician graduates are recognizing the value of accreditation and pursuing that goal.
Mattear also predicts that technicians' everyday work will be significantly different in five years, and drastically different within ten. "With the rising costs of petroleum-based products, thermoplastics, and resins, and the emphasis on the green factor, we all need to be vigilant. Unfortunately, many companies are realizing that a green label provides a license to increase the price.
"Smaller, boutique-style outsourcing centers are going to find themselves in a pinch, while larger outsourcing centers will find opportunities through growth and perhaps mergers with the smaller companies, offering both the mutual benefit of increased buying power.... We're going to see a total shift in materials management and also a drastic difference in the way prosthetics are fabricated in order to serve patients who want results quickly. There will soon come a time when we'll see a healed amputee who's ready for a prosthesis clock out within a day or two, as is already happening in Europe.... It's all about education and staying ahead of a very fast-paced game."
Tools for Success
Tony Wickman, CTPO, Freedom Fabrication, Havana, Florida, has been a leader in understanding and refining the role of the technician and spearheaded the transition from technician registration to certification. However, for this article, he emphasizes the material fundamentals of efficient, economical fabrication-the technicians' physical tools.
"In this industry, people see tools as an expense; they almost never see a tool as an investment, which is just nuts," he says. "In every other industry I've ever been involved with, your tools are just everything-invest in good tools and you'll get the return on your investment."
Wickman notes that it seems to be characteristic of O&P technicians in particular to prefer to make their own versions of tools they see-and to seldom create tools as successful as the original model, for various reasons. What drives otherwise sane people to saddle themselves with such self-imposed handicaps? It's not that the tools are exorbitantly priced, he believes.
"I think one common trait among technicians is that we like to freehand, to 'commonsense engineer' things. We love thinking on the fly, making something that wasn't in the box when we came to work. Everybody wants to try to make a better, faster, cheaper widget-it's a part of our job that we love to do. But sometimes you just have to let it go-just order it and be done with it."
One of the most essential tools required is a quality oven. "That's a huge one," Wickman says. "They're expensive, and people will try to avoid buying a quality oven for a long time."
Another necessary item is a Trautman router. "There are many different models, most of them less costly than the original Trautman, and many have been made by their owners -which are usually junk!"
A tool that is small but vital to a fabrication shop is a stirrup bender for making metal braces.
"It's an $850 tool that people do anything not to buy, but it's a tool that delivers real value and increases your quality of life. It doesn't take many ruined stirrups at $50 apiece before this item has earned its keep."
The key, Wickman concludes, is seeing tools as an investment and recognizing that sometimes it's best to let others do the tool designing.
"Labor is what will kill you in this business; labor is the big item on any bill. Simply having and using the right tools can make an immense difference in your labor costs."
Some unique time-savers Wickman has developed himself (and describes in detail in the column he writes for The O&P EDGE-check the archives at www.oandp.com/edge) include the following:
- The hold-fast jig-a simple way to grip an arch-support mold.
- A powered surform file-it looks like a cheese grater, is used to file plaster casts, and is motorized to "move a lot of real estate." Wickman is unabashedly attached to this item: "If the building caught fire," he says, "I'd grab my powered surform file and run out the door!"
- The Arch-Xpress-a vacuum press for forming foot orthoses is another item that many people feel compelled to reinvent and build for themselves, often with limited success.
- The bean box-"a really wacky, wacky tool" in the form of a six-cubic-foot tank filled with Beanie Baby "guts" that allows the little plastic pellets to hold an entire mold while the removable inserts of walking soles are vacuum formed around a neuropathic walker.
Tricks of the Trade
As the level of technology being employed in the O&P industry has grown in sophistication, so too have the skills and knowledge required of the O&P technician. The occasional cross-pollination of duties between clinicians and technicians also means that many techs can use expert advice on providing patient care, while any clinician who fabricates can use the advice of seasoned technicians. The following collection of tips and tricks runs the gamut from nuts-and-bolts shortcuts and solutions to adjustments in basic tech- management philosophy. Some recommendations encourage you to change a tool, method, or technique; others advise you to change your thinking and your way of doing business.
Garry Owens, CO, LO, LPed, of Snell Laboratory, Little Rock, Arkansas, has seen a lot of changes and learned a lot of patient-care tricks during his 42 years in the business; here are just a few of them:
- Listen to your patient. Textbooks aren't always right-the patient is the one who knows how it feels.
- Don't give patients too many choices-you'll just confuse them, and they're less likely to be happy with their final choice.
- Don't suggest that the option you're offering may not work; if you do, the patient will believe it surely won't.
- Don't say, "this may hurt." If you tell them that, it's going to hurt.
Patrick Myrdal, RTPO(c), FCBC, Myrdal Orthopedic Technologies, Winnipeg, Canada, shares his top ten tech tips:
- When vacuum-forming, use Volara (aliplast 4E) foam instead of duct seal for sealing plastic to the vacuum pipe. Use double-sided tape to adhere a strip of foam to your vacuum pipe, and make sure that you have an adequate vacuum channel established at the end of the pipe. It's a cleaner alternative to duct seal and other commonly used putties, which tend to be messier and require more cleanup.
- Use roped or twisted nylon hosiery, which is commonly used in the industry as a vacuum channel, to assist in achieving distal vacuum for orthotic applications. It will help to acquire a better seal at the distal end of a long KAFO cast. We'll pull one piece of nylon hosiery over the cast, then rope or twist a length of hosiery and staple it at the anterior or outside of the required trim lines to enhance the vacuum channel.
- To place an abrasive sleeve on a rubber-shaft arbor, use your vacuum pipe to compress the rubber arbor. Place one end of the rubber-shaft arbor over the vacuum pipe and plug the open end with an appropriate-sized disc. Compressing the rubber-shaft arbor makes it easier to apply and remove abrasive sleeves.
- Try Fabtech's 60-second adhesive for component setups; it's a very good product that makes people's lives a lot easier. It speeds things up, saves you time, and is much cleaner than the traditional "gunk." Use Fabtech's 60-second composite adhesive to repair broken casts- it's quick and works very well on plaster.
- Use a coping saw to cut plastic trim profiles that have a tight radius-it works great for tight cuts.
- Use PVA bags to separate liners from plastic. This also works well to separate formed thermoplastics. Make sure to establish a vacuum channel when using this technique. Many already use this helpful trick, which allows you to remove your liner or inner plastic easily from your main structure.
- De-gas resins prior to lamination by using a vacuum chamber to remove air from the resin, scooping out excess air bubbles that surface in the cup. This provides a higher-quality, relatively air-free lamination.
- Use a steel O-ring or harness ring over your PVA bag to reduce the reservoir volume and reduce air contamination. Saving on the resin needed within the smaller reservoir is the major advantage.
- Use an off-cut of old foam cover material on the end of your Trautman for buffing and finishing urethanes and silicones. This technique results in a higher-quality finished surface.
- Use a brush to paint on plaster slurry for your final plaster modifications; it will make it easier to smooth out the plaster for a superior finish.
John Huster, prosthetic technician and co-owner of PSL Fabrication, Fulton, Missouri, has been fabricating for 15 years and says his all-encompassing tip is very simple: "The key is using technology. I've grown up in the business-been around it since I was seven years old. I've seen and done it all using the old methods, plaster molds, etc.... Now we use CAD/CAM exclusively, digitizing casts received from our clients and modifying the image on TracerCAD. We are very tech savvy when it comes to shape capture, modifications, shape storage, and management. The model is then carved in foam and we use our thermoformer or other traditional methods to create the custom socket.
"The customer then fits and makes necessary adjustments, which are made simpler and faster by the use of Dimdim technology, which provides a web-based platform for real-time collaboration between the practitioner and our PSL fabrication tech. We can pull the practitioner in as needed, allowing him remote access as we share desktops, show slides, chat, talk, and broadcast via webcam.
"It's great-using our technology is like having a technician in your back room. The practitioner can send their cast and have their finished product the next day. Since we archive all shapes and patient files, the practitioner can access them any time for use, or if they need empirical data for billing purposes.... CAD/CAM just speeds up the process immensely. It's cleaner and quicker-there's just no comparison. The more technologically advanced we get, the better it is for everyone-practitioner, fabrication technician, and patient."
The price for such technology may be high, but "it's worth it," Huster concludes.
Prosthetic Fabrication Finesse
Todd Hall, CP, works in a Center for Orthotic & Prosthetic Care (COPC) fabrication facility that specializes in prosthetics. He noted two tips that save his team major time and money:
- We have a carver and use it for carving blanks on the prosthetic side. We try to save our bigger molds-say for a larger above-knee that we carve- planning to carve out another, smaller-diameter BK mold from it later, and perhaps even a third mold for a still smaller prosthesis, eventually. (Think of them as being like the little nested dolls that contain a family of five or more, one within another.) There are times the plan doesn't work out, but you've lost nothing by trying.
- We create what we call a "black ice" finish on our laminated sockets. Rather than use an inner PVA bag for lamination, we pull a thin layer of check-socket material; then we take sand and rough up the outside of that and laminate right over the top of it. The result is zero leaks.
Although the process takes about the same amount of time and costs the same as applying an inner PVA bag, the socket that has been laminated with check-socket material presents a clear plastic inner surface with a mirror finish. It looks great and actually allows the patient to don the prosthesis more easily because of the glass-like smoothness of the socket.
Jason Eddy, BOCP, LPO, Snell Laboratory, suggests using a carpenter's laser level to align prostheses.
"They do make a device specifically for aligning prostheses," Eddy says, " but this is much, much less expensive and works really well."
Snell's Dale Baeten, LP, RPA, advises taking special care with test sockets: "If you make sure to get your trim lines on the proximal attitude exactly the way you want them, the definitive socket is more likely to have a better trim line."
Bracing for Success
Owens also offers a number of insights into creating top-notch orthoses:
- When fabricating a metal leg brace, always put it together with aluminum rivets. If you have to make adjustments after the fitting, those aluminum rivets will knock out easily, saving you a lot of time. If it does work without adjustments, just remove the aluminum rivets and replace them with steel ones and you're ready to go.
- Never attach leatherwork to a brace until after the brace is fitted. Have it cleaned up and ready; lay it in the brace, making sure the shape, including the diameter and circumference, is right, then bring it back and put it together. This can save you half a day's work if you have to redo the brace. (This tip is similar to the carpenter's old adage, "Measure twice, cut once!")
- The proper evaluation of the patient is very important. When making a drop-foot brace; make sure that the patient's ankle inverts or everts. If it doesn't, just build a simple drop-foot brace; but if you build a simple drop-foot brace without evaluating the patient's ankle, you could be wasting your time. You may need to add something to hold the ankle straight.
- Keep it simple; the simpler the device you can put on patients, the better off they are-and the more likely they are to be compliant.
- Find out from the beginning whether your patient is allergic to leather, glue, or plastic. Knowing this could save you a lot of time in the long run.
- When you're measuring a brace and tracing a patient's leg on a piece of paper, remember that because the leg is lying flat on the table, it has spread out and become wider medial-laterally. If you pick up the leg and measure it while it is suspended above the table, it's going to be between a half inch and a full inch narrower.
- Always build the brace according to the measurements, not the pattern, as far as the size goes.
Mike Parker, CO, LO, CPed, also of Snell, offers advice for creating better foot orthoses and therapeutic shoes:
- People who make foot orthotics often use crushed foam to take an impression. Because some patients' feet elongate a bit under weight bearing pressure, we also make a standing, weight bearing ink print using an old pedograph machine. The ink print offers us a comparison with our non-weight bearing foam impression.
Sometimes the foam impression can be deceptively short.
Such an ink print will also give you a much more precise measurement for the placement of a metatarsal pad if you plan to include one in your insert.
- When taking a foam impression, don't allow the patient to put his or her foot in the foam and pull it back out immediately. This will invariably result in a higher arch than necessary in that cast, which will be uncomfortable for the patient. Instead, put the patient's foot into the foam, then back up the foam containment box until the patient's heel starts to lift, which simulates toe-off in gait pattern. This allows a more accurate crushing pressure than what is achieved when the patient simply inserts and withdraws his or her foot.
- When doing a shoe elevation of more than a half inch, broaden the base of the shoe for stability, particularly on the lateral aspect. It's a common error for inexperienced or untrained techs to grind the sole until the heel and sole are narrower than in a normal shoe; that's opposite of the way it needs to go.
- On any buildup that thickens the sole to the extent that it will no longer bend, be sure to roll the toe-off on the shoe, rather than leaving it the same thickness all the way to the tip. The rolled toe, or rocker toe, allows the wearer to toe off more naturally from a sole that's too stiff to flex. Without the rocker toe, the patient will tend to stub his or her toes on a big hump of material they'll have to consciously compensate for with every step.
Owens chimed in with his own pedorthic tips:
- When fitting shoes, again, it saves time to offer fewer choices. Patients are probably going to complain that a corrective shoe is ugly. Face this squarely and admit that it is ugly, but it's the best-looking shoe in the house. You may make them laugh, and it saves you from spending an hour and a half dragging out every catalog and showing them every shoe in the place-only to have the patient tell you that they're all ugly.
- When fitting shoes, never tell a patient what size you're fitting. Once they've agreed that it fits well and feels good, then you can let them know it's two sizes larger than the size they've been wearing.
- Match the shoe shape to the patient's foot shape. A person with a square foot won't be comfortable in a cowboy boot or a pointed-toe shoe. It's like putting a square peg in a round hole.
Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.
Editor's Note: More tips and tricks are coming in the September issue of EDGE Direct.