1. Missing Instrumentation in Surgical Sets
Final Presentation: December 13, 2016
Team 2
Team
Clients
Coordinators
Jacob Homan
Jania Torreblanca
Matt Claysen
Ivana Kosir
-Manager, CSPD
-Industrial Engineer, OR
Timothy O’Neill
Kerstin Rider
Nicole Farquhar
Conner VanDevelde
-Supervisor, OR

2. Agenda Introduction Background Current Process Key Issues Methodology
Findings & Conclusions
Recommendations

3. Identify root cause of missing, extra or incorrect instrumentation
Introduction
Surgical sets have missing, extra or incorrect instruments
Central Sterile Processing Department (CSPD)
Operating Rooms (OR)
GOAL
Identify root cause of missing, extra or incorrect instrumentation
OBJECTIVES
Improve CSPD assembly process
Reduce number of incorrect surgical sets
Reduce search time for missing instruments
Increase data reporting rate

4. 16K+ instruments assembled per day
Background
32 operating rooms
20K+ cases per year
16K+ instruments assembled per day
We’ve already laid out the problem- the background could now go into how we want to approach it. We can also add numerical values
We can make it visually appealing by using bubbles or some form of table- Ivana can do it, but I just want to have the final count of how much info we want to talk about here.
$1.03M in instrument costs

5. Current Process OR runner searches for missing instrument OR
OR opens instrument set
OR uses instruments
CSPD

6. Current Process OR runner searches for missing instrument OR
OR opens instrument set
OR returns instruments into the set
OR uses instruments
CSPD
CSPD sends instrument sets through decontamination

7. Current Process OR OR runner searches for missing instrument
OR opens instrument set
OR returns instruments into the set
OR stores instrument sets
OR uses instruments
CSPD
CSPD searches for missing instruments
CSPD sends instrument sets through decontamination
CSPD sends instruments set through Sterilization
CSPD assembles the instrument sets

8. Decreased Satisfaction
Key Issues
Missing Instruments
Patient Safety
Decreased Satisfaction
Resources Wasted
Satisfaction of Three Department Staffs & Physicians OR
CSPD
Supply Chain

9. Observations and Interviews
Methodology
Observations and Interviews
Literature Search
25 hours of observations
15 Interviews
2 previous IOE teams
6 Detroit News articles about Detroit Medical Center

10. Data Collection and Analysis
Methodology
Data Collection and Analysis
Surveys
12 hours of audits
75 cases analyzed
36 responses from CSPD
65 responses from OR

11. Marshmallow spaghetti tower
Methodology
In-service Pilot
Two truths and a lie
Marshmallow spaghetti tower
Initial findings

12. Findings and Conclusions

13. Lack of Understanding between Departments
Interdepartmental Relations
Lack of Understanding between Departments
Errors attributed to other department
Both departments contribute to issue
CSPD OR
Grand Total
Incorrect Cases 8 16 24
Total Cases 34 41 75
Error Rate
24%
39%
32%
Source: November Audit Data (N = 75)

14. Lack of Understanding between Departments
Interdepartmental Relations
Lack of Understanding between Departments
Source: Provided Qualtrics Data (N = 403)

15. Lack of Understanding between Departments
Interdepartmental Relations
Lack of Understanding between Departments
Drop-off of reporting due to policy misunderstanding OR does not want CSPD to get disciplined
CSPD is trying to meet quotas

16. Interdepartmental Relations Maintenance
Increase procedural integrity, communication, and data reporting to reduce incorrect surgical sets
Increase positive interaction between departments
Team Building
More buy-in to policies
Restate Departmental Policies

17. Unstandardized Search Process
Source: CSPD survey data (N = 30)

18. Unstandardized Search Process
Search Area
Benefit
Problem
Ask another processor
-Other processors have more experience and knowledge
-Tough to know who to ask
-Processors are low on time
Check other instrument sets
-Instruments are mixed during surgery
-Missing instruments are likely in sets that were used concurrently
-No way to track which sets were used together

19. Standard CSPD Search Process
Unstandardized Search Process
Standard CSPD Search Process
Reduce search time & improve CSPD assembly process
Provide guidance on shifts without service leads
Subject Matter Expert
Help find instrument sets used together
External Surgical Set Marker

20. Communication Breakdown
Manufacturer names
Confuses nurses and processors
No substitutes
More incorrect instruments

21. Communication Breakdown
Are you able to identify instruments using the manufacturer name?
Source:
CSPD survey data (N = 30)
OR survey data (N = 60)

22. Common Name & Allowable Substitutes Committee
Communication Breakdown
Common Name & Allowable Substitutes Committee
Improve CSPD assembly and OR return processes
Provide useful name for OR staff
Common Names
Fill gap between OR and CSPD
Allowable Substitutes

23. Valuable Information Lost on Count Sheets
Decontamination Count Sheet
Valuable Information Lost on Count Sheets OR
Notes added on count sheet
Non-vital information
Decontamination
Count sheets thrown out
Information lost
CSPD
May miss small mistakes
Re-identify already known issues

24. Decontamination Count Sheets
Improve CSPD assembly process
Notes written in permanent marker
Stored in bin in OR
Short Term: Tags
Populate notes when set is scanned
Preferably through Censitrac
Long Term: Electronic

25. Expected Impact CSPD OR Yearly Lower Upper Current Productivity Loss
$175K
$400K
$25K
$350K
Future Productivity Loss
$133K
$320K
$13K
$264K
Savings
$42K
$80K
$12K
$86K
Total Savings
$54K - $166K
Findings based on CSPD survey data (N = 35) , OR survey data (N = 61) and salary data

26. Expected Impact Qualitative improvements
Improving Interdepartmental Relations
Reduces the number of incorrect surgical sets
Standardizing Search Process
Reduces the time spent searching for instruments
Qualitative improvements
Happier, and more productive workforce
Improved patient safety
Reduces the number of incorrect surgical sets
SMEs, Common Name, Decontamination Count Sheets
Improves the CSPD assembly process

27. Thank You!
Questions?

28. Expected Impact CSPD1 OR Lower Upper Lower2 Upper3
Current Productivity Loss
$175,000
$400,000
$25,000
$350,000
Future Productivity Loss
$133,000
$320,000
$13,000
$264,000
Savings
$42,000
$80,000
$12,000
$86,000
Findings based on CSPD survey data (N = 35) , OR survey data(N = 61) and salary data
Assumed 10% reduction in search time and 1 less expected incorrect surgical set
Assumed 0% reduction in search time and 0.5 less expected incorrect surgical set
Assumed 0% reduction in search time and 1 less expected incorrect surgical set

29. Project Scope In-Scope Out-of-Scope Sets missing instruments
Sets marked incomplete
Inventory flow in OR
Clinic sets
Quick turnaround & main CSPD
Loaner sets
Set transportation between floors
Surgitech sets
Search process for missing instrument
Implantables
Cleaning, packaging, and sterilization