Advocate Christ’s dream team pursues SPD quality, ‘March to Zero’ defects

Out with the old

Armed with a spaghetti diagram illustrating SPD workflow that resembled a cord-strewn, 1970s-era sound studio for a heavy metal album recording, Theodule’s team recreated the technician’s workspace with marked floors to improve travel paths, cart assembly and supply searches in sterile storage.

Simple changes led to significant improvements. SPD standardized the tools and resources at each workstation with easy visualization cues. Floor and priority carts sport visual cues and alerts, too, so that SPD knows when rapid turnovers occur and one-of-a-kind trays are needed quickly. SPD also categorized and rearranged what had been disorderly storage areas, using clear labels and pegs with Kanban cards.“Creating this work space provided increased accessibility to help achieve increased efficiency and accuracy when comprising instrument trays,” Theodule said. “It provided all equipment and items necessary for the technician to work within their workspace, eliminating the need to leave.”

SPD organized loose inventory on pegboards and in bins. The peg boards and bins are displayed in category and alphanumeric order, making it easier to replace instruments when needed.  SPD’s Non-Conforming Technicians maintain the pegboards and bins, conducting daily inventory and ordering as necessary.

If an instrument is on back order, and a tray becomes incomplete, the tray is tagged with an orange dot and placed on the Non-Conforming cart, which alerts the Non-Conforming Technician that a critical instrument should be replaced. When critical instruments are missing from a tray and a rapid turnover isn’t achievable, SPD may use a “gold tray” instead, Sikora explained. These trays were created as supplemental PAR levels or as a necessary back-up for high-volume or specialized trays. SPD’s gold tray system enables the department to provide complete and functional trays to the OR, despite instrument backorders, without delaying surgeries, she added.

SPD established a two-bin system with Kanban cards for a visual replenishment cue to reorder product. To assist the OR upstairs the team created an immediate-use safety stock zone accessible to the OR staff to eliminate the opening of full trays for one or two items that may be dropped during a case.

Sikora noted that Supply Chain already had been using the two-bin Kanban system in the patient care areas with some degree of success so implementing a higher-cost software system wasn’t considered as a potential and preferential solution.

“The two-bin Kanban system was found to be an optimally efficient method to control and create continuous replenishment of stock through a visual cue — empty bin — that communicates the need to replace stock in a cost-effective manner prior to it being fully depleted,” she said. “It was determined that software was not necessary, as the two bin Kanban system is a truly effective and optimal method.”

Loaner trays represent more than 20 percent of the trays SPD sterilizes, so the team uses an electronic Casechek Loaner System to link loaner technicians, vendor sales representatives and OR staffers when checking these trays in and out. SPD color-codes and wraps these trays with appropriate identification for surgical cases, which gives the OR its own visual indicator, according to Theodule.

“We hope to reduce the percentage of loaner instruments through continued partnership with our surgeons to create standardized tray system availability,” Sikora indicated.

Marching to zero

The SPD Workgroup, composed of OR, SPD, Nursing, Finance and Project Management executives and associates, launched its “March to Zero” drive toward high reliability, quality and safety with zero defects in April 2016. Sikora represented the administrative and financial resource liaison with the C-suite and worked with Cindy Mahal-van Brenk, Vice President of Surgical Services for Advocate Health Care, to explore savings opportunities, staffing to demand and building relationships. Theodule oversaw day-to-day SPD issues and long-term OR-SPD strategic goals, while Yasmin focused on project management between the two departments. The group met weekly to target rapid improvement, Yasmin indicated, and as goals were met over time the frequency tapered to monthly reviews led by Matthew Balog, Director of Business Finance for Surgical Services, and Lenore Williamson, SPD Non-conforming Technician.

The SPD Workgroup defined “defect” as any quality issue within a tray that is avoidable, such as a missing instrument, broken instrument, bioburden or hole in the wrapper. “As we all know, a defect within a tray can be disastrous for patient outcomes, both with risk of infection and possible procedure delays,” Sikora noted. “This all could result in extended periods of surgical time for patients under anesthesia, as well as an increased length of stay and complication rate; all which directly affect the cost to the institution vs. reimbursement rates.”

To generate useful data for pursing zero defects, SPD replaced its “antiquated” electronic tracking system with a Censitrac electronic monitoring system to collect and update instrument defect reports and review and assist with necessary countermeasures and interventions, according to Sikora. The new system opened an immense opportunity to monitor many other sub-processes that were in the works for quality improvement, including instrument maintenance, case cart pulling, newly designed rapid turnover protocol, tray updates and physician preference card updates, she continued.

“We needed to hardwire protocols and processes before we implemented an updated electronic instrumentation monitoring system in all attempts to do it right the first time!” Yasmin said.

That’s why Yasmin worked within the huddle to validate daily defects, tallied finalized monthly outcomes in collaboration with the SPD team, completed real time one to two weeks post-month for full review with the SPD Work Group, and reported out monthly to the Governance Committee for discussion, Sikora noted. “The SPD Leadership team reviewed, coached and created counter measures in real time at every daily huddle with their teams input,” she added.

Because of the success SPD experiences with Censitrac monitoring, the OR areas are implementing the system this year, too, according to Sikora, as a way to take optimal patient care to the next level. “SPD is always reviewed for instrument defects, but [defects] also needto be reviewed in all operative/touch point areas as well,” she continued. Sikora called the handling and reprocessing of instruments a “living, breathing process, constantly being reviewed for improvement.” In fact, perioperative staff ensures all instruments are free from blood, tissue and bone during each operative procedure as well as spraying all soiled instrumentation with an enzymatic foam to help decrease bioburden and biofilm before transport to the SPD decontamination area, she added.

“A good and engaging relationship with SPD and the OR is vital to successful patient outcomes and quality instrumentation,” Theodule insisted.

The OR sterile core houses a number of “tickie racks” that hold individual peel packs as part of the OR “safety stock,” much like a retail outlet will display product.

“We call them ‘tickies’ as they are a catchy name,” Yasmin said. “These tickies on the safety stock of the OR are the high use and/or rare instruments necessary for procedures, just an arm’s length away from the OR. Having these available decreases the need to open additional trays, IUSS, and the valuable procedural time it could take to replace one surgical item on the field.

Through the SPD Workgroup’s efforts and staff performance, SPD slashed their average tray backlog to 20 last year from roughly 650 unsterile trays on average two years earlier. SPD defines a tray backlog as any tray awaiting sterilization prior to 8 a.m. Backlogs, of course, generally elevates IUSS rates. Courtesy of the considerable backlog reduction, SPD has reduced IUSS rates to 1.8 percent last year from 8.3 percent the year before, which also decreases the amount of time the patient could be under anesthesia related to instrument needs during a case, Sikora noted.

Productivity has soared, too, starting with staff turnover dropping to 10 percent last year from 45 percent the year before due in part to consistent workflow, clarity of work functions and a team-centered environment that created a more content staff, according to Sikora. Prior to the process redesign, SPD infamously maintained the highest staff turnover rate of all departments at Advocate Christ, Sikora admitted.

“We currently utilize a productivity measure that looks at budgeted FTEs to number of items processed per day,” Sikora said. “Our goal is to be 99 percent to 102 percent productive per day. In 2017, SPD ended the year at 116.8 percent productive and nearly 6,000 hours under expected labor hours for the year while still continuing to provide safe quality trays. We have increased tray productivity by approximately five trays per hour per technician.”

Pulling teams together

SPD counts communication as the key to customer service so the team starts each shift with a “communication huddle.” During the huddle, the outgoing shift debriefs the incoming shift on the needs of SPD and the OR. The huddles also serve as an interaction point between team members working on different shifts, further cementing the entire department as a unit and prepping for upcoming surgical demand, asking clarifying questions and providing support for one another.

SPD created four liaison roles with the OR where two work in SPD on the communications team and the other two work in the OR. The surgical liaison also communicates to the SPD liaison when surgeries have been added for the day, and if specific trays need rapid turnover based on the OR schedule.

Solidifying SPD’s partnership with the OR definitely improved the customer service relationship, Sikora insisted. “SPD leadership and associates round in the ORs,” she said. “They have a visible presence with both the OR team and physicians. The OR team sends down trays when they are not used and houses less in the OR cores since we have made these changes. They are confident that SPD will have what they need for them when then call. We are all one team working together to provide care to our patients, and it is a noticeable difference from years prior. As one of our SPD leaders always says: One team, one dream!”

Sikora assures that Advocate Christ’s SPD-OR fusion can be replicated by those departments looking to emulate their example.

“First, I would highly suggest pulling together all of your key stakeholders to determine what processes do you need to work on,” she advised. “At ACMC, we realized that we had several opportunities for improvement. The most important was to fix our foundation. If the SPD associates could not find the tools they needed to do their job how could we expect anything else to change? Your house is only as strong as your foundation. Second, it is very important that you listen to your key stakeholders and your front-line associates. They are at the sharp end of the process.

“Far too often leaders make changes because they think they know what the customer or associate wants,” she continued. “Take time to hear your teams, engage with your teams and create a plan together. After the plan is created and implemented, review that plan daily in huddles for opportunities to improve on it. If you get it 80 percent right when you first implement a plan, then that’s a success. Each hospital will have different opportunities for improvement. Remember as you do implement change to celebrate your wins no matter how small. Celebrating these moments as a team only helps to sustain the momentum.”

Sidebars:

• SPD-OR teamwork calls for personal engagement
• Advocate Christ SPD fertilizes the mind
• Elevating the SPD profession