Practitioners use central fabrication facilities for a variety of reasons: to cut operating costs, to reduce expenses, to increase cash flow, to help with overflow during busy times or to complete rush jobs. Regardless of the reason why O&P practitioners choose to use central fabrication services, understanding how work flows through a facility is crucial in ensuring that the process flows smoothly from start to finish.
Instruction forms
The first step in the fabrication process actually begins before a central fabrication facility even receives a job. Before a job can be fabricated, practitioners must provide instructions detailing specifications for the orthosis or prosthesis. Most central fabrication facilities have devised their own work order forms that are available online and can be downloaded by practitioners. However, unless the device to be fabricated is unique to a specific facility, most work order forms can be interchanged because they generally contain the same basic information needed for fabrication.
Work orders should be as specific and complete as possible, and include as much detail as possible concerning the job, noted Brad Mattear, general manager of O&P1.
“A comprehensive, completed work order form is a key to getting that job completed right the first time and out the door on time,� Mattear said. “If practitioners can take the time to fill out that work order with all the information they need to get that job done right first, then it will go out on time.�
As an aid in completing work orders, practitioners should consider science versus subjectivity, said Scott Wimberley, technical sales manager and lean implementation officer for FabTech Systems LLC.
“Instead of using the word ‘thin,’ use ‘one-quarter inch thick,’ because I have lots of rulers at the facility, and none of them say thin on them anywhere,� Wimberley said. “The ones that seem to make sense and you do not ask to get an actual measurable value, those are the ones that can get interpreted later as ‘no, I said I wanted it lightweight, and this is not light.’ Much like the ruler, the scale does not say light, so subjectivity and science are something we are trying to clearly separate.�
Evaluating work orders
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Depending on whether practitioners use computer-aided design (CAD) or conventional methods, jobs are either shipped as cast molds or transmitted electronically as digital files. Some facilities offer both conventional and CAD fabrication services, while other facilities only offer conventional fabrication services.
Once a job is received by a central fabrication facility, either as a cast mold or a digital file, work orders are reviewed, classified as orthotics or prosthetics and entered into the facility’s system. Evaluating work orders often is completed by one of the facility’s most experienced staff.
“Usually it takes the highest degree of skill to do the initial assessment, so it is always our most skilled people who are evaluating work as it comes in and making phone calls to see exactly what is needed for fabrication,” Wimberley said.
In some facilities, an experienced clinician will check and evaluate orders. At Tidwell’s Orthotics, a licensed, certified pedorthist evaluates each job by reviewing the casts and paperwork to determine whether all of the required information is included or whether the practitioner will need to be contacted with questions, noted Chris Tidwell, RTO, president of the company.
In other facilities, an experienced technician or shop manager will review work orders. PEL Central Fabrication’s shop manager Sharon Dolly noted she evaluates all work orders, handles the paperwork, writes up and distributes the orders, and calls practitioners with any questions.
When jobs are received at Freedom Fabrication Inc., one of the company’s technicians evaluates work orders as they are received, said chief executive officer Tony Wickman, RT, OP, which he described as “triage.”
“In our particular instance, it is a technician, and he is one of our more experienced technicians,” Wickman said. “The reason we do that is because he has a good understanding of what goes into making each device, so if any red flags come up in the input end, he can immediately contact the practitioner involved and work out any design or materials issues.”
Fabrication and modification
After work orders have been evaluated and entered into a facility’s system, jobs are then ready to be modified and fabricated. This stage often proceeds in an assembly-line fashion through different departments, with technicians working on individual steps rather than completing a job from start to finish.
For instance, with conventional casts, one technician will seal, pour and strip the mold. Another technician will modify the molds, and a different technician then vacuum forms the plastic on the plaster mold.
“After that, it goes into trimming, and somebody cuts off the plastic and does whatever trimming and buffing needs to be done,” Tidwell said. “Then from there, it goes right over to strapping, and they do the necessary strapping, or if there is metal to be bent, it goes to the metal section where we have technicians who do all conventional bracing, metal and leather, and add any kind of metal to the brace if needed.”
In most facilities, technicians are cross-trained and can perform more than one step.
“I think it is a matter of having primary and secondary duties,” said Andrew Steele, MBA, CPO, vice president of O&P1. “Everybody has their primary duty, and then we try to look at a secondary duty that they can have, be that working in the other lab, or it may even be helping with checking jobs in, reviewing inventory, and things like that, so it goes beyond just the technical aspect of it too. We try to pull people in so they have some idea of what is going on with the business side of things as well.”
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Digital files
For jobs that are sent to central fabrication facilities as CAD files, the process differs slightly. Digital files are sent by e-mail, entered into the company’s system and sent into production. Frequently, the digital files have already been modified by the practitioners themselves.
“We avoid as much as possible making any modifications to the CAD program,” said Greg Mattson, RTPO, BA, chief executive officer at FabTech Systems LLC. “We really want to leave that up to the practitioner who saw the patient.”
Typically, digital files are checked for format to ensure compatibility and sent to a carver for output. The model is then manufactured by a technician in a traditional fashion, said Adam Finnieston, CPO, LPO, a prosthetist and orthotist for BioSculptor Corporation. He noted BioSculptor’s digital services are unique in that the company has created a Web portal where customers can upload digital files in multiple file formats that are not restricted to just orthotics and prosthetics.
“What we have been working on, and is currently up and running, is a Web portal for digital central fabrication services, and what that means is that anybody who has a CAD system, anybody who has our system or some of the other systems, can become a member or a user of our Web site and upload their files through the portal,” Finnieston said. “The portal can handle multiple file formats and then it can convert those files to something that we can use or that one of partners can use.”
Finnieston describes the portal as being similar to a “digital clearing house” in that BioSculptor has partnered with other manufacturing companies that can fabricate items such as custom-made shoes from files uploaded to the Web portal. The data is formatted or configured to the appropriate model in preparation for fabrication, and then devices are either fabricated internally by BioSculptor or sent to one of its manufacturing partners for fabrication.
At O&P1, all prosthetic jobs are digitized. Digital images are created for any casts that are received, the file is sent to a carver, a foam model is output and a check socket is fabricated.
“The reason that we digitize all of those models, all of the impressions that we receive prosthetically, is so that we have a complete record of modifications of the model and so that we have a digital image of the original model and the modified model,” said Dennis Clark, CPO, president of Point Health Centers of America, president of Clark and Associates Prosthetics and Orthotics, president of O&P1, and executive director of Orthotic Prosthetic Group of America. “All of those digital images are saved. They are actually the property of our clients, but we save them here in a database so that they can refer back to that digital image 6 months, a year, or 2 years later when that patient requires a socket replacement.”
The digital files provide objective documentation of the physical changes that occur in patients that can then be used to justify to the insurance company the need for a socket replacement, Clark said. In addition, the files can ensure that the same technique is used when a socket is modified for socket replacement so that it is clear the difference is just a volume change and not a completely new socket shape.
For prosthetic jobs that are already received as digital files, Clark noted that while some of the digital images are raw digital images of the patient’s limb that need to be modified by a technician, the majority of the digital images have already been modified by the practitioner.
“We are receiving something that we can whip in, prioritize, put into production, classify and then we can download it to our carver and start the process, so it is basically shortening that time from hitting our door or our server to being in production,” he said.
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Building relationships
For central fabrication facilities, the ability to successfully complete orders revolves around building a relationship with practitioners. One way that facilities work toward achieving this goal is by becoming familiar with a practitioner’s personal preferences. Some facilities accomplish this informally by taking notes and remembering the particular likes and dislikes of practitioners.
“I know some of our customers only like certain parts, certain manufacturers of certain parts, so I will not give them those manufacturers’ endo parts or whatever they are requesting because I know they do not like that manufacturer’s product,” Dolly said. “Or they do not like a certain trim line or they do not like a certain build-up, so you just make notes, and after you deal with them for a while, you just remember that they do not like this and they do not like that.”
Other facilities track preferences more formally, creating profiles and even templates that specify various styles used by practitioners.
“Basically, a template is a preference that the practitioner has developed that they like to use on a consistent level so if they send us a job and they would like their style of brim or their style of modifications to that socket, they just write down that this is an xyz style,” Mattear said. “It can be named after them; it can be named after their company; it can be named after a geographic location. It just depends on what they want to name it. But we keep that form.”
By creating and maintaining practitioner profiles and templates, facilities can give practitioners consistency every time a device is fabricated, which he noted is something practitioners look for.
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Another key aspect necessary in forming any relationship is good communication. With central fabrication, the more information practitioners provide about a job initially, the more likely they will be satisfied with the completed job.
“Often, the result practitioners get is a function of the information we get,” Steele said. “And while we will call and ask questions if there are gaps in their instructions or there is something we do not understand, if we can get pictures, drawings, or as many measurements and things as we can, that really is where you are going to get the ideal outcome.”
In addition to the initial contact, communication must continue throughout the central fabrication process to further relationships with practitioners and ensure the fabricated device meets expectations.
“Our primary job here is to interface with the practitioner,” Wickman said. “Every time we get an opportunity to discuss anything with a practitioner, it is a point of contact; it is another opportunity for us to get involved in their practice.”
At some facilities, communication with practitioners flows primarily from one or two contacts. At other facilities, technicians can stop a job and contact practitioners directly at any time in the process when questions arise and more information is needed.
“We dealt with telephone skills and communication activities early on so that if the technician needs to contact a practitioner who sent a job, a cast, a digital image, they are all trained to make that call themselves,” Clark said. “They become the customer service representative at that point to clarify what needs to be done and then you have got the technician speaking directly to the practitioner and going from there.”
Another aspect to good communication and developing a mutual relationship is for practitioners to view central fabrication in the same light as they would view an in-house technical staff. When minor differences occur in the way things are produced, rather than going to another facility, O&P practitioners should work to help the current facility understand what they want.
“The more you can tell us what you want, the better our opportunity to give it to you,” Wickman said. “Almost every central fab that I have run across so far can do a good job at a great number of things, and the more you help them understand what you want, the better your opportunity to get it.”
Future of central fab
With today’s continuing emphasis on controlling and containing health care costs, more practitioners can be expected to turn to central fabrication in the future as a way to lower their expenditures and increase profits.
“With the lowering reimbursement rates that are happening in the field, you have to become more efficient and spend less time making products and more time with the patient and increasing your business,” Finnieston said. “That is what the whole concept of central fab allows you to do: to be that much more efficient and profitable.”
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Central fabrication also is an attractive model for new practitioners who want to start their own business. In addition to helping keep start-up costs down, new practitioners with little or no hands-on fabrication experience can turn to central fabrication services, which Wickman noted represents “an efficient, effective model for them.”
The role of central fabrication services also can be expected to increase as the use of CAD continues to grow. In the past few years since FabTech Systems acquired the ability to carve orthoses, Mattson noted the number of CAD jobs they receive has jumped considerably. He estimated the percentage of CAD jobs that currently come is roughly 45% – only slightly lower than the number of jobs that come in traditionally. In the next few years, that ratio may shift to 80:20 or even 90:10 CAD jobs to conventional jobs, Wimberley said.
By using central fabrication facilities to output CAD files, practitioners can realize both cost and time savings. In addition, the use of CAD can widen the area that central fabrication facilities serve.
“Central fabs have traditionally been regional or very regional in some cases, meaning local, and now the world is shrinking because you do not have to ship one way, so that saves a bit of time,” Finnieston said. “There is also obviously fabrication time savings as well and efficiency savings. It is a different approach than the traditional central fabrication. I know central fabrication is picking up all over the country, and we think that this takes it to the next step.”
Finneston said that traditionally in the O&P field, there has only been CAD with limited CAM and the CAM portion has been limited to the milling of a positive shape. At this stage, traditinal fabrication takes over. He said Maramed Orthopedic Systems is developing solutions for “one off” custom products for the O&P field.
Finally, central fabrication facilities can allow many practitioners to make the use of CAD a reality rather than just a dream by serving to take on the bulk of the cost of acquiring the carving equipment and absorbing the learning curve needed for incorporating new technology in their practices.
“The opportunity that larger central fabs like ourselves have is that we have gone to great detail and great expense to invest in the future of orthotics and prosthetics,” Mattear said. “As the field grows, we are seeing more clients come over to the central fabrication route and using these techniques and CAD/CAM. They are using the opportunities we have invested in, and I think that as time goes by, you will see this is a consistent trend.”
Mary L. Jerrell, ELS is a correspondent for O&P Business News.
Editor’s Note:
This story includes a small representative sample of individual companies and products. O&P Business News does not intend to promote individual companies or their products, nor to achieve an industry-wide consensus on the issue. Companies contacted in developing this story were randomly selected. Additional companies were contacted for information but had not responded prior to press time.
