“After the analysis was completed, we talked with our OR teams and surgeons, and every person we spoke with acknowledged the tremendous waste in the process.”
– Denise Dubuque, RN
When something is off-kilter in health care, the first to notice the problem – nearly always – are frontline workers. The people who do the work know the work, and recognize when something is askew. That was certainly the case in the Sterile Processing Department.
The pattern repeated itself day after day: Sterile Processing would send carts full of instruments to surgeons for a variety of procedures. And after virtually every procedure, most of the instruments sent to Sterile Processing for cleaning had not been used.
“The team members at the sink decontaminating surgical instruments noticed that a majority of the instruments coming back to us from the ORs had not been used, yet they had to re-clean, decontaminate and sterilize all of those items,” says Denise Dubuque, RN, administrative director, Surgical and Procedural Services.
This struck the workers as a huge waste of time and effort. So they acted. A number of team members proposed Everyday Lean Ideas (ELIs) intended to mitigate the waste of time and work. But the problem was so large and complex that they realized small fixes here and there weren’t going to help very much.
Sam Luker, director, Sterile Processing Department, knew his team members had identified a serious challenge, so he and Dubuque initiated a 3P improvement event (which occurred in February 2013).
“We were on a lean journey and, in our early years, we focused a lot on standardization,” says Dubuque. “We did that because we believed the best product for the surgeon was a standardized set of instruments, so we produced the same set every day for each specialty.”
But the essential question raised during the 3P was how could the team shift from standardization to customization? How could they give each surgical team just the instruments they needed – no more, no less – for a particular case?
The answer proved to be a build-to-order approach for surgical instrument cases. The initiative started with good data collection – asking scrub techs in the operating room to list every instrument a surgeon used during a particular procedure. Techs did this by checking a box on the instrument list that accompanies each set of surgical instruments.
This process would be repeated five times for each surgeon performing a particular procedure. Once the data had been collected and analyzed, the problem emerged in striking numbers:
- On an average day, Virginia Mason conducted 70 to 75 surgical procedures.
- For each procedure, the Sterile Processing team created 13 instrument sets.
- Each of the 13 sets contained 53 instruments.
- This amounted to 52,721 individual instruments scrubbed and sterilized per day.
And the analysis showed that 70 percent of these instruments were returned to Sterile Processing unused.
“After the analysis was completed, we talked with our OR teams and surgeons, and every person we spoke with acknowledged the tremendous waste in the process,” says Dubuque.
Armed with new data, the Sterile Processing team assembled new sets of instruments for each surgeon conducting a particular procedure. This was inherently complex since multiple surgeons on a number of different service lines all had their individual preferences for what instruments to use. They had been able to select their preferences from the large, standardized instrument carts, but the goal now was to provide them only with the instruments they needed – no more, no less.
And that is what the teams constructed – instrument sets tailored to the needs of a particular surgeon performing a particular procedure.
“In a lot of these cases, there were 70 percent fewer items going up to the OR,” Dubuque says. “It was really a great process that eliminated so much waste.”
From the start, everyone was concerned about a what-if scenario – what if something goes wrong in the OR and the customized set of instruments does not contain what is needed for unforeseen circumstances?
“Everyone shared the same concern – surgeons, techs, nurses, the Sterile Processing team,” says Dubuque. “Everybody wanted to make sure that every patient had the instruments needed for their operation. We needed to ensure that our surgical team had what they needed.”
The solution was a backup cart containing a full, original set of instruments – everything a surgeon might need in the most challenging situation.
“We created contingency plans to allow redundancy and still support the OR,” says Luker. “So if something is dropped on the floor, the surgeon just calls for the backup cart, which is in the OR on standby.”
The backup has not been used much. But over time the customized sets have been modified. “If the OR team sees a need for a certain item, they let us know and we add it back to the set. We can add and delete items as we go.”
What are the results of this initiative?
Greater efficiency, of course. “Previously, they had to set up so many instruments in the OR suite it was taking 24 minutes just for setup,” says Luker. “With the new build-to-order sets, setup now takes two minutes and 30 seconds. We are decontaminating many fewer instruments, assembling fewer sets, storing less, lifting less and transporting less.”
The average assembly time for a neuro instrument set decreased from 34 minutes to 22 minutes. The average number of instrument sets/case carts decreased from 13 to three (while the average number of instruments in each set increased from 53 to 60).
But something else was achieved with this initiative – perhaps less tangible than the efficiency gains, but just as meaningful. And that involved the issue of respect for people. When Dubuque first recognized the unnecessary burden of work on the Sterile Processing team, she saw it as deeply disrespectful to the workforce.
“We believe that the build-to-order initiative is about respect for people,” she says. “I have passion to come to work every day as a leader, saying: How can I help this team be successful? Because every day that goes on that we’re not getting to that goal of build-to-order we’re disrespecting the team.”
What work on your team could be done differently to improve respect for people?