O&P Fabrication Are We on the Same Page?

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By Garrison Wells

It's not if-it's when.

The move toward standardizing O&P fabrication procedures isn't new, but it's likely to trigger changes in how technicians are trained and educated, provide consistency in fabrication, and, some argue, boost profitability, improve patient care and outcomes, and set standards for insurance companies to consider for reimbursement. Indeed, the move is being driven by a mix of regulatory agencies, O&P associations, and a few dedicated and determined O&P technicians and business owners.

Ronnie Graves

"I think technicians of the future are going to have to accept standardization because I believe that Medicare and the insurance industries are going to demand it," says Ronnie Graves, BOCPO, LPO, CO, CTP, owner of Prosthetics Research Specialists, Bushnell, Florida. "I don't think there is any choice, and those of us who [have already] adopted some standardization and kept track of how we do things are going to be much further ahead of the curve."

Setting the Pace

Standardization begins with documentation, and there are already a couple of technician education manuals floating around. Graves has authored one himself that he says is about 75 percent complete.

"I started writing it over the last ten years, but a lot of it [still] pertains to what we are doing today," he says. "I wrote it because I didn't want to die and take all the knowledge I had in my head with me."

Graves started writing his manual after learning there was almost no consistency in how prostheses were designed, fabricated, and fitted-specifically in regard to the techniques associated with those processes. This realization hit him when he wrote a column about mixing plaster.

"That, to me, is like the very first thing we learn," Graves says. "I had techs from all over the country calling and thanking me. I was stunned. It was so basic, like, this is how you do it.

"If you asked somebody about laminating a socket," he continues, "you'd get 15 different answers depending on what area of the country you were in."

At between 50 and 75 pages in length, the text of Graves' manual is complete. All that he needs, he says, are illustrations, photos, an editor, and an interested publisher. The manual "would give us a foundation," he says. "The industry is not that complex. It's really not."

Brad Mattear

Another early-stage manual has already started making the rounds among technicians and O&P practitioners. The outline of the manual, written by members of the Orthotic & Prosthetic Technological Association (OPTA), was presented recently in Canada by Brad Mattear, CFo, central United States and national strategic account manager for Cascade Orthopedic Supply, Chico, California Mattear is also vice president of OPTA.

The response from members of the Canadian Association for Prosthetics and Orthotics (CAPO) was heartening, he says. "I've never seen so much enthusiasm and engagement for a talk," he says. "It was not just a groundswell of support but a massive dust storm of support."

OPTA hopes that technicians in the United States have the same enthusiasm, but Mattear says there's a difference between Canadian technicians and U.S. technicians. Canadian technicians are more involved in the clinical care process, while their American counterparts spend more of their time on fabrication.

However, the new-school practitioner in America, Mattear says, tends to want to be more clinically involved. Many technicians are seeking higher-level degrees and "want to do more than just...fabrication," he says. "They want to erase the image of 'give it to Johnny in the back. He can make anything.'"

The manual, Mattear continues, "gives techs the how-to. We are giving them the opportunity to look at the basics and build the foundation. We've never seen the manual as the Holy Grail."

Proponents liken the manual to Wikipedia. As new processes are developed and new materials are used, they will be added to the manual. As old procedures or materials fall out of favor, they will be removed.

"It's always going to progress," Mattear says. "Things change. The one thing that won't change is the...foundation...of O&P fabrication. It's like math, one plus one always equals two."

Science Versus Trade

Fabrication, says Rachel Friddle-Johnson, CPO, director of fabrication and product development at Friddle's Orthopedic Appliances, Honea Path, South Carolina, "is still sort of a craft, and everyone has their own personal touches they can make... but I think there's a great need for standardization, not just in training, but in the industry in general as far as fabrication."

Tony Wickman

Moving toward standardization won't be easy. Technicians, and indeed the entire industry, will have to see fabrication as a science rather than a trade. That means documentation- and lots of it-as fabrication becomes more evidence-based. "The general motion in the industry is toward legitimacy and becoming a science," says Tony Wickman, CTPO, CEO of Freedom Fabrication, Havana, Florida. "This [OPTA] manual is a stand-alone piece. It doesn't come with any agenda, long-range plans, or political views. It's...a document. That's it."

Indeed, one of the biggest obstacles to completing the manual, experts say, is time. Nobody has enough of it.

"The...sheer mass of work ahead of us is just daunting," Wickman says. "When I think about it, it is paralyzing."

OPTA is looking at anecdotal information, experience, and consensus as it develops the manual. After completion, it will have to pass muster of an editorial committee. Each module will have more than one author. Wickman shares his vision of the project: "My honest hope is this Darwinian dream-that people get interested enough to research it and find out I was completely wrong."

For Mattear, the manual is "an opportunity to showcase the need for evidence-based work by technicians." "It's constant change from clinical outcome, development, and legislative action, from having the FDA [U.S. Food and Drug Administration] coming in and clamping down on fabrication," he says. "Medicare and private insurance are also decreasing reimbursement, and manufacturing is coming up with new products."

Another, lesser obstacle is the reluctance of some of the older technicians to share the techniques and secrets they've used for years. For some, it's a matter of job security. And companies that have developed their own procedures aren't likely to give them up for competitive reasons.

"The only threat they have to their job security is the watch on their wrists," Wickman says. "I certainly understand their point, but this is a science, not a guild. If we ever want to be taken seriously as an industry, we have to consider this a science."

The Benefits

One of the biggest benefits to standardizing fabrication processes is having the ability to quantify what constitutes a highquality device. You can't say I did a good job unless you know what a good job is," Wickman maintains. "If it can't be measured, it can't be controlled."

Standardization, which requires documentation and data, could change all that. Consistent production hours will help fabricators measure outcomes more accurately and provide a cost benefit as well as reduce liability.

"You will have a quality controlled, outcome-based operation," Graves says.

The drive toward standardization and documentation has other potential benefits. By keeping records, not only can technicians help improve their companies' profitability, they can also use that documentation to justify requests for pay raises. At least, that was a benefit for Graves.

"I kept a daily record on my bench. I also knew how many raw materials I was using," he says. "I was using my own documentation to challenge myself but also to demonstrate to my boss what I had achieved in making his bottom line better."

Education

As with most industries, standardization starts with documentation, but it is solidified in the classroom. Schools that teach fabrication are at a disadvantage without a current manual. Some teach with manuals from the 1950s, 1960s, and 1970s.

"As practitioners become more clinical in nature and less focused on fabrication, the knowledge and skills for fabrication and positive model rectification must be preserved to teach future technicians," says Joseph Young, CPO, director of the orthotics and prosthetics technician program at Francis Tuttle Technology Center, Oklahoma City, Oklahoma. Fledgling technicians "will have far more autonomy to make decisions in these areas. Well-trained, knowledgeable technicians are essential when creating devices that will allow patients to function at their highest-possible level...and it is essential to have an industryaccepted manual to train our next generation of technicians."

Friddle-Johnson says schools "do a fine job of teaching basic skills for a technician, but they may be using four or five different manuals from different manufacturers. Even tech schools don't have official training standards that they teach students," she maintains.

A manual, Young says, would allow technicians to "build and grow any way they want from a standardized base." OPTA and the American Orthotic & Prosthetic Association (AOPA) are also taking steps to provide more intensive training for technicians by offering hands-on seminars at industry conferences.

"OPTA has...partnered with AOPA to provide a totally different tack on tech education-a two-day summit," Mattear says. The summit was offered as part of last month's AOPA National Assembly. "It's not mundane education or recycled presentations," Matter says. "This is all cutting-edge stuff- new materials, new science. Don't stick technicians in a classroom- they are hands-on people."

"This is the first time we have done two days," says Tina Moran, CMP, senior director of membership, operations, and meetings for AOPA. "And the first time we've had the education as intense as it is. We feel like it's been taken to a whole new level."

One piece of the technician summit was a contest for technicians to create a swim prosthesis. "The committee putting together the tech summit thought it would be kind of neat to do something a bit interactive," Moran says. There were monetary awards, and the creations were on display at the assembly.

Ahead of the Curve

Andrew Micek

Some companies are already well on their way to standardization. Ottobock, Minneapolis, Minnesota, for example, created a fabrication manual as part of its move to lean manufacturing, says Andrew Micek, marketing manager at Ottobock.

"It enables us to document all of the steps involved with every product that we make," he says. "We are really in a good position to have standardized processes. We've already done it."

Benefits have included streamlining of processes, certainty of internal pricing and timing to customers, and better quality, all of which beef up the company's bottom line. "It creates an umbrella under which we know how we are going to operate," Micek says.

Quality has increased because there is less guesswork when designing products, he adds. Outcomes are predictable, and consistency is the rule rather than the exception.

"We know precisely what costs are involved, and it helps us to meet our commitments to our customers. We are not guessing. We have a solid understanding of how long it will take us to get a job out."

Friddle's has also gone with in-house standardization.

"We're able to fabricate a prosthetic socket that is engineered and standardized," Friddle-Johnson says. "It's repeatable and consistent and verifiable."

Having consistent processes has also enabled the company to streamline those processes, she explains.

"It's a way to not only streamline, but to ensure the quality of the product that you send out. And the bottom line, I think that we are starting to see that," Friddle-Johnson says. In many ways, the benefits are already being felt simply by the effort, Mattear maintains.

"This is a great time for technicians to get involved [and] for people who are looking for a career," he says. "The time for technicians is now."

Garrison Wells is an award-winning freelance writer and author based in Colorado Springs, Colorado. He has written for newspapers and magazines nationwide and authored five books on martial arts. He can be reached at