The rate at which surgical cases have grown in complexity is overwhelming. While in the past every procedure was an “open case,” with the advent of laparoscopic or “minimally invasive” surgery in the 1990s, and more recently the introduction of robotic surgery, procedures have escalated in complexity — as have the instruments required to perform them.
In this article, we explore the challenges around surgical kit/procedure tray planning. We also offer best practices from operating room (OR) and central sterile/sterile processing department (CS/SPD) professionals, as well as leading product/solution suppliers, on how to improve efficiency and reduce waste in this area.
Collaboration is critical
A surgeon doesn’t operate in a void. There are numerous parties that play a role in getting a clean and sterile instrument tray into his/her hands, including OR staff, the CS/SPD and supply chain. Efficiency and effectiveness in surgical kit/procedure tray planning requires collaboration among these parties.
“Collaboration between the surgical team and CS is critical when creating or altering surgical procedure trays,” said Weston “Hank” Balch, BS, MDiv, CRCST, CIS, CHL, Director of Sterile Processing Operations, University Health System. “Whether it is determining proper sterilization containers, gauging adequate inventory levels based on case volumes, or even something as simple as deciding to standardize your instrument manufacturer, the CS team can provide an important holistic perspective on these instrument related processes. But getting everyone around the same table is often the hardest part.”
Diane Betti, Director of Inpatient Surgery and Sterile Processing at Baystate Health in Springfield, MA, explains how her team participates in an “OR Huddle” every morning, which includes surgical staff and the CS/SPD manager. During this meeting, the participants can share potential challenges that need to be addressed with regards to tray and kit planning.
“For example, if we have a bunch of ENT cases scheduled for that day, the OR leaders can inform the room staff to make sure they get the kits down to CS/SPD as soon as possible so they can begin decontamination,” said Betti. “The OR huddle is a huge benefit to relay that type of information.”
Betti and her team are also working on another solution to ensure surgeons have the right kits/trays at the right times. The OR previously used a hand-written “turnover prioritization board” to communicate high priority kits/trays to the CS/SPD. Now they are transitioning to an electronic version where they can “red flag” when a kit/tray is high priority, such as when it is needed for a subsequent case that day.
Balch describes the value of collaborating with suppliers, including instrument manufacturers. He has worked at three facilities now that have collaborated on “Surgical Asset Management” projects with their instrument manufacturer Aesculap. At one stage of the partnership, the facilities hosted two-week long, hands on collaborative consultations with surgeons, OR staff, and CS/SPD representatives to look at each tray in their service for opportunities to reduce unused instrumentation, remove obsolete trays and create new, more efficient sets to meet their current needs.
To help facilities better manage their multi-million dollar surgical instrument fleets, Aesculap developed a Surgical Asset Management (SAM) program to analyze reprocessing practices and identify instrument and set standardization and optimization opportunities. Following a five-step process, it is the only end-to-end Surgical Asset Management model specifically designed to balance both clinical and fiscal outcomes, says the company.
“These kinds of partnerships and events can give facilities a great reason to bring all the decision makers to the table, and provide a platform for CS leadership to weigh in on opportunities the hospital may have to standardize procedure trays, better utilize current inventory and pursue continued communication with their surgical peers,” said Balch. When CS departments take ownership, not only of their role as instrument experts, but also as customer service advocates, this kind of collaboration becomes a natural outworking of their commitment to service excellence. They are then able to fill in the logistical gaps related to surgical tray planning and ensure what is proposed is also possible.”
“The SAM team had a fantastic engagement with the KentuckyOne Health system,” said Chris Abell, Aesculap CSSD Consultant. “The project entailed a combination of surgical assists from four different facilities: two main ORs and two surgery centers. The goal was to streamline and standardize as many set titles as possible among those four facilities. Additionally, we looked for potential options in instrument reduction, redundancy and obsolescence. The facilities were highly organized under their SPD and clinical leadership. This type of engagement was a key piece to the on-site success of such a large project. In summary, seven SAM Consultants were able to review 413 set titles and provide an overall instrument reduction of 6 percent, which more directly results in a net reduction of 6,000 instruments.”
Kit/tray standardization
“Many challenges are related to surgical kit planning, but the most defining issue is lack of standardization among the practitioners that utilize kits,” said Sue Champion, MBA, BSN, RN, CNOR and Perioperative Clinical Consultant at Cardinal Health. “When clinical practice and component usage is not standardized, it is very difficult to create a kit that meets the needs of the end-user while providing the labor efficiency and cost effectiveness expected from a kitting program.
“Facilities are looking to standardize, both in component usage and clinical practice,” she added. “They are seeking to gain acceptance from the end-users by making them stakeholders in the entire standardization process. Best practice facilities are also paying more attention to the maintenance of physician preference cards to enable better decision-making.”
The OR and CS/SPD teams at Baystate Health have done extensive work to standardize kits/trays in an effort to boost efficiency and reduce costs and waste. Through collaboration with multiple stakeholders, they have come up with “generic kits” within certain specialties.
“Service line leaders in the OR and the sterile processing department sit with the surgeons and come up with proposals that make sense in terms of kit standardization,” said Betti. “We did this in a few specialties, one is Bariatrics where we do many procedures laparoscopically, including gastric bypasses and bands. We gathered input from the Bariatric group and CS/SPD and used this information to develop a standard kit. We’ve done the same thing in Neurosurgery and Total Joint specialty lines. We have a real partnership among the departments and they truly do support each other.”
Driving standardization through data
Champion says data on instrument usage can help drive kit/tray standardization projects. She notes how many hospitals don’t have the accurate data they need to support their decision-making processes.
“Physician preference cards are the repository for surgeon practice/preference, but they can be inaccurate or not maintained on a consistent basis,” said Champion. “This lack of accurate data leads to making decisions with anecdotal information rather than a true data-focused approach. To compound these issues, the merging of facilities is greatly affecting the ability to create surgical kits that support a wide range of facilities and end-users.”
Available exclusively from Cardinal Health, PackManager is an interactive online tool that helps facilities make informed decisions by providing valuable information, including inventory and forecasting details, cost reduction opportunities, reporting tools and video images of packs and pack components. A new standardization tool is available in PackManager, which provides valuable data and analytics enabling users to evaluate and implement standardization opportunities at a hospital, surgery center or across the entire integrated delivery network (IDN).
“Facilities are recognizing the need to take a data-oriented approach to procedures, so they can identify cost improvement opportunities and optimization of procedural practice,” said Champion. “Standardization of surgical supplies, procedure packs and ultimately the procedure itself, is something many facilities are evaluating today. Pulling together and gaining access to meaningful data can be challenging; however, there are new tools available to help facilities in this area.”
The rate at which surgical cases have grown in complexity is overwhelming. While in the past every procedure was an “open case,” with the advent of laparoscopic or “minimally invasive” surgery in the 1990s, and more recently the introduction of robotic surgery, procedures have escalated in complexity — as have the instruments required to perform them.
In this article, we explore the challenges around surgical kit/procedure tray planning. We also offer best practices from operating room (OR) and central sterile/sterile processing department (CS/SPD) professionals, as well as leading product/solution suppliers, on how to improve efficiency and reduce waste in this area.
Challenges of loaner trays
The use of vendor-owned inventory (loaners and consignments) is another area where collaborative planning is critical to efficiency, effectiveness and safety according to Keerthi Kanubaddi, Founder/CEO of ReadySet Surgical.
“Loaners and consignments are typically delivered or replenished by the medical device manufacturer just-in-time so the hospital and surgeon are subject to the logistical constraints of the manufacturer and manufacturer’s reps,” explains Kanubaddi. “Implementing strong policies around the delivery, sterilization and overall preparation of vendor trays is the first step. Creating a collaborative environment with the vendor by providing early notice of case details and requirements can also drive improved procedure tray planning.”
ReadySet is a cloud-based surgical coordination platform for the management of vendor inventory (loaners and consignments). According to the company, it drives a new level of transparency in the surgical supply chain by relaying surgical details and requirements to the vendor in advance of the procedure. Vendors are asked to provide details about what is coming, when it is coming and how to properly sterilize it. The platform consolidates logistics and communication through one dashboard accessible by all members of the surgical team to ensure that every patient has the right equipment with the right sterilization parameters at the right time.
Kanubaddi points to New England Baptist Hospital (NEBH), which was experiencing “major headaches” from the increasing number of surgical cases using vendor-owned inventory. To manage, the CSS and surgical staff participated in a weekly, all-hands meeting to discuss upcoming surgeries that would require vendor inventory.
After the installation of ReadySet’s Vendor Inventory Software platform, NEBH’s CSS staff can now readily see what scheduled surgery cases require vendor equipment. And, a calendar view timeline shows how many trays will be needed and when the trays will be dropped off. Armed with full, ongoing visibility, the CSS/Perioperative weekly meeting has been canceled, recovering the time formerly used on vendor inventory management. Day-to-day communication between the departments has also been streamlined.
Minimizing waste
In August 2015, researchers tracked every disposable supply that went unused in neurosurgical cases at University of California, San Francisco. In a study published in the Journal of Neurosurgery, the study authors estimated that the hospital’s neurosurgical department was wasting $968 in OR waste per case, $242,968 per month and $2.9 million per year on unused disposable supplies.1
Betti says her organization has put a “rigorous” process in place to reduce waste of disposable items. To prevent waste in procedure-based packs, they hold an annual review and work across the organization with service line leaders and their purchasing department, as well as the procedure pack suppliers, to reevaluate their contents.
“We make changes so that we are only using what we feel would support the majority of the caseload,” said Betti. “Also, quite a few years ago many of the doctors had their own packs and that’s wasteful so we’ve made more generic packs.”
During each case briefing, the surgeon speaks with the entire surgical team and tells them which products he/she plans on using, where he/she might experience challenges and any additional products that should be on hand if he/she needs them. During the case, the OR team asks the surgeon before opening any disposable item that is not contained within a procedure-based pack. Considering some products designed to stop bleeding can cost close to $4,0001, having these checks and balances in place can have a significant financial impact on an organization.
“Certainly any implantable item, like mesh for a hernia, we would absolutely ask first,” said Betti. “It would be part of the briefing prior to the case.”
“Medline is committed to helping our customers achieve both clinical and financial success. Some of the most common questions we field address efficiency and waste reduction,” said Kim Haines, RN, certified OR nurse and Vice President of Clinical Resources at Medline. “In order to avoid building too many or too few packs, you have to walk a fine line to balance production demands. If we overbuild production and a customer has a practice change, it can create waste in utilization if the components in the custom pack aren’t used. If we build too few in production, we risk the chance of back ordering a customer if procedure demands spike.
“Analyzing your annual surgical volume mix by procedure and by surgeon will baseline your true utilization requirements for both instrument sets and surgical pack needs,” she adds. “Monitoring this information closely for changes will increase accurate utilization that will help drive decisions for waste reduction, improved efficiencies and standardization opportunities.”
Reference:
Kara Nadeau | Senior Contributing Editor
Kara Nadeau is Sterile Processing Editor for Healthcare Purchasing News.
