It is widely known within the healthcare industry that variation drives errors, inefficiencies and waste. Many health systems and hospitals are engaged in efforts to standardize products and processes with the goal of improving patient care quality while reducing costs.
Included in that goal is the standardization of kits, packs and procedure trays. This includes initiatives to establish standard product sets for specific procedures, standardized processes in the central sterile/sterile processing department (CS/SPD) and operating room (OR), and standard protocols for managing loaner trays and for instrument storage and transport.
A story of standardization: Munson Healthcare
Munson Healthcare, a nine-hospital system in Northern Michigan that is affiliated with Trinity Health, launched an effort to standardize custom packs and kits across its organization. “Standardization in clinical practice is key but this is something that is often missed or not supported up front by clinical leadership at the system level,” said Munson Healthcare’s System Director of Supply Chain Flavius Toader.
Toader explained how Munson Healthcare has many clinicians who cross from one hospital to another within the system; therefore, custom packs ensure clinicians are using the same products no matter where they are performing procedures. Standardization also impacts the patient experience since patients transferred from one facility to another encounter the same products regardless of where they are treated.
Over the course of two years, Toader and his team collaborated with Trinity Health and clinicians on standardizing 80 custom packs down to eight across Munson Healthcare hospitals, including two for OB/GYN (vaginal and C-section deliveries) and six for surgical procedures (e.g., lap chole).
But they discovered an unanticipated challenge. The custom pack standardization has been largely based on data analysis from 95 hospitals (Trinity Health sites and Munson Healthcare), including clinical representation from across these hospitals, and took almost two years to implement. As new standardized custom packs began showing up in the hospital procedure rooms, clinicians complained about the custom pack contents, explaining how the standardization had taken place before they joined the health system or with none of their involvement, which generated waste of product and time.
“This prompted us to come back to the table, open the packs and start talking about them,” said Toader. “We are getting current clinicians around the table and letting them have their say so that we can agree to new packs that are the same across all of our facilities. We need to standardize quickly because the longer it takes, the greater the chance new clinicians will come on board who were not part of the decision-making process.”
Toader notes how the next step in their journey will be working with clinical leadership to standardize the procedures themselves, as well as processes around these procedures for a more consistent clinician and patient experience.
“Standardization must be two-fold: The product and the practice,” said Toader. “It must go beyond product standardization to standardizing the practice so that clinicians in each hospital are doing things the same way.”
Physician preference cards and count sheets
Physician preference cards and count sheets are the two most important written communication tools that are used between CS/SPD and perioperative personnel, and ones that need systematic attention at every level of a healthcare organization, according to Erin Kyle, DNP, RN, CNOR, NEA-BC, Perioperative Practice Specialist, Association of periOperative Registered Nurses (AORN).
“As new surgeons join an organization and others leave, instrument trays in particular can become very cluttered,” said Kyle. “If there is no systematic way to approach review of instrument count sheets and preference cards then items are added based on physician preference but nothing is ever taken away.”
Kyle said in most healthcare organizations, a systematic review of these communication tools is not built into staff productivity measures and expectations; therefore it rarely gets done. For that reason it is important for leaders in the OR and CS/SPD to educate the executive leadership team on the importance of this process so that it is viewed as an ongoing improvement project where needed resources, including dedicated time is budgeted and measured.
“It simply comes down to the organization providing resources to make it happen, communicating the importance of the project and making it part of the team’s standard daily work,” said Kyle.
Streamlining OR turnover
With regards to process standardization, Sue Champion, MBA, BSN, RN, CNOR, Director of Clinical Operations at Cardinal Health, points to how standardizing components across procedural kits can reduce procedure and OR turnover times.
“Time is critical in the OR,” said Champion. “The biggest challenge is being able to turn the room quickly and efficiently. Therefore, having all the necessary equipment and supplies ready for the next procedure via kits is essential to efficiency and patient safety.”
To address this challenge, Cardinal Health recently launched a comprehensive, standardized OR clean-up and room-turnover kit portfolio including table sheets, lift sheets, armboard covers, headrest covers, mop heads, kick bucket and can liners, and washcloths. The offering is designed to:
- Help staff reduce the cost of turning over the OR after surgery
- Streamline preparation for the following procedure
- Protect equipment from fluids and other wear and tear
- Increase billable procedures that can be performed in a single day
- Support hospitals’ goals to reduce surgical site infection and improve patient care via the one-time, single-use nature of the products
Foundation for change: Data access and interoperability
In order to standardize kits, packs and procedural trays, those involved in the decision-making process must understand their current contents. According to Weston “Hank” Balch, BS, MDiv, CRCST, CIS, CHL, principal consultant of Beyond Clean Consulting, accessing this data is no simple task.
“A root cause for many of the breakdowns between these two teams comes down to a lack of clean, consistent data regarding which instruments should be in the surgical kit, what they are called, and the most efficient way to make them available to the OR,” said Balch. “Historical trends in most ORs have shown surgical kits growing in total numbers of instruments requested, yet utilization of these instruments is only a small percentage of the total kit. This means CS/SPD staff members are processing countless instruments that aren’t needed and never will be due to dirty data.”
Balch explains how there is “no easy fix” for cleansing surgical kit data and making it accessible for procedure planning, stating how it can take months and years to recover depending on the current state of a hospital’s database. He adds:
“While some facilities may have resources to do this internally, most do not. Utilizing external surgical instrument data specialists to bring in high-powered analytical tools and data visualizations will not only help jump start these projects, but can also assist in disrupting ‘cultures of complacency’ among OR/SPD teams which can be difficult to overcome without robust data showing the true value of clean data.”
Marie Fournier, Director, Product Marketing at TECSYS, agrees that accessing the data required for educated decision-making on tray planning can be a significant challenge and points to a number of contributing factors, including disparate/disconnected systems, too many manual paper-based processes, short product lifecycles and lack of modern inventory practices.
“As a software solutions provider, we have witnessed exceptional results for customers that have completed transformational initiatives with a focus on cost, quality and outcome,” said Fournier. “Through this lens, healthcare networks looking to modernize operations realized their legacy systems were not built for interoperability. Healthcare CIOs recognize the importance of interoperability in order to unlock data and enable smart decision-making. They are looking for solutions that are transformative, proven and easy to use.”
Fournier stresses, “Procedural tray planning is still performed via a series of periodic audits and/or reviews rather than through a strategic, data-driven optimization exercise.” By continuously monitoring the data, healthcare organizations can avoid the trap of falling back into wasteful, inefficient practices, such as high variability across physicians for the same procedure, product waste due to obsolescence in preference card content, product waste due to expiration, and preference card cost creep by manufacturers that substitute for higher margin items.
“Having the right information at the right time is a foundational element to driving improvements within the OR not only in terms of planning for today’s procedures but also planning for the future,” said Fournier. “When your data is reliable, and your systems talk to each other, your analytics will only get smarter over time.”
Loaner tray protocols
Planning and preparing instrument trays for surgical procedures is challenging enough when the healthcare organization owns the instruments, but what about when the trays are outside of their four walls — and outside of their control?
The use of loaner trays is a common practice and one that makes good sense from a financial and operational perspective for instruments that are used infrequently. But as Kyle points out, relying on vendors to deliver trays when needed can add complication and stress to those in the CS/SPD and OR. Kyle describes the significant challenges that occur when a vendor delivers a loaner tray without its instructions for use (IFU):
“Most healthcare organizations require the vendor to send the IFU with the tray but that doesn’t always happen,” said Kyle. “It is an even greater challenge when the vendor does not deliver the tray well in advance of the case as defined by each organization. When CS/SPD staff members do not receive the IFU with the tray, and don’t have adequate time to inspect and process the loaned items, they are required to process the tray to the best of their ability based on their professional knowledge. It’s a really big deal.”
To help address this issue, Kyle recommends that healthcare organizations put into place a standardized process for managing loaner trays that is followed at every level of the organization. This should include specific requirements regarding tray delivery timing and accompanying IFUs that are clearly communicated by the health system or hospital to the vendors.
Furthermore, the process should include standardized steps for when the unexpected occurs, including trays that arrive late. Kyle recommends that the healthcare organization designate a role where specific leaders make the determination on whether or not it is safe to accept and process the tray in the shorter timeframe than is expected.
“The decision should rest in the same place every time,” said Kyle. “The same role should be making that determination so there is no question about whether or not all of the benefits and risks to the patient were considered in making that decision. Leaders needs to step in and make their contact known so that that vendor can get in touch with them, they can come up with a game plan, and then communicate that to the rest of the team. This requires a very close partnership between the OR and CS/SPD, very strong communication patterns and a focus on a culture of safety.
“In defense of vendors, they deal with multiple health systems and hospitals and sometimes over time the expectations from different organizations regarding loaner trays can vary and may not always be enforced,” added Kyle. “If we can encourage a standardized, systematic approach where IFUs and a strict timeframe for delivery become expected in every organization then that will benefit all parties involved, most importantly the patient who needs the correctly-processed specialty loaner tray in the operating room.”
Storage and transportation standardization
As discussed in HPN’s October 2018 article, Safe and Battle Ready, instrument storage and transport are critical to safe and effective patient care. When it comes to maintaining sterility the battle rages on between rigid containers and sterile wrap.
Joseph Hannibal, Marketing Director of Sterilization at Halyard, points out how multiple studies—including “Sterility maintenance study: Dynamic evaluation of sterilized rigid containers and wrapped instrument trays to prevent bacterial ingress,” published in the American Journal of Infection Control, have demonstrated that sterilization wrap is more effective than rigid containers at maintaining sterility post-sterilization. However, even if a CS/SPD standardizes on sterilization wrap, the reality is that wrap can run the risk of tearing without proper storage and handling.
“When it comes to sterilization wrap, it’s no secret that storage and transportation have been long-standing pain points,” said Hannibal. “In an effort to reduce tears and maintain the integrity of sterilization wrapped trays, Halyard and Belintra launched the SMART-FOLD STERISYSTEM, a system of specialized sterilization wrap, and optimized storage and transport, to help organizations adhere to the Association for the Advancement of Medical Instrumentation (AAMI) Standard 79 guidelines for maintenance of the sterility of processed items until the point of use.”
This solution is designed to maximize space in the CS/SPD, increase efficiency workflow and streamline transportation from the CS/SPD to the OR, reduce cost and eliminate the need to stack wrapped surgical instrument trays, thereby reducing CS/SPD touch points and the amount of reprocessing required. To ensure the sterility of surgical instruments all the way from sterilization to storage to surgery, this solution provides a critical visual confirmation that sterility has been maintained post-sterilization and through handling and transport to the OR.
Beyond the hospital
In an effort to deliver quality patient outcomes at a lower cost, healthcare organizations are increasingly moving patient services from high-cost, acute care facilities (e.g., hospitals) into more affordable non-acute locations (e.g., physician offices, clinics). As a result, there is a growing need for safe, effective and efficient reprocessing technology that can be used outside of the hospital setting.
The new Olympus OER-Mini tabletop endoscope reprocessor allows busy ear, nose and throat (ENT) facilities to improve reprocessing efficiency by removing some manual reprocessing steps. Designed specifically for Olympus endoscopes, the OER-Mini has a quick reprocessing time at just 16 minutes.
“In ENT, we see many facilities that are still manually reprocessing their flexible endoscopes,” said Dana Currier, Business Unit Vice President, ENT at Olympus America, Inc. “Given the diligent attention to detail needed for manual cleaning, as well as the increasing demands for efficiency at today’s ENT clinics, our customers have been asking us for a viable infection control solution for flexible ENT endoscopes. We’re very pleased to provide that solution in a compact, package designed that addresses the aims of value-based care.”
Kara Nadeau | Senior Contributing Editor
Kara Nadeau is Sterile Processing Editor for Healthcare Purchasing News.
