OR and CS were worlds apart - now they are inseparable
By Jamie Shimkus

It started with a promise from management to alleviate a space crunch in the operating rooms. It ended with a radical transformation of OR supply management - and a strong between the surgery department and central service. Along the way, Community Hospital of the Monterey (Calif.) Peninsula, which had lagged behind in supply management techniques, caught up in one giant step.

For years, Community's CS and OR existed in their own, separate worlds. "The OR director had isolated the department and kept total control of every aspect, including purchasing, inventory and replenishment. The only interaction with CS came when the OR said, 'This is what we need; please deliver it,'" says OR director Mariano Catbagan, who now manages both the inpatient and outpatient operating rooms. Over the past two years, however, the two worlds have grown much more interdependent. The surgery department has transferred control of supplies, many instruments and decontamination to the newly renamed central processing department. CPD now encompasses both materials management and central service.

That's nothing new for most hospitals, but it meant tremendous change for Community Hospital, a stand-alone entity with many long-timers on both surgery and CPD staffs. Change not only in the way things are done, but, just as important, in how people relate to each other.

The catalyst
Space had long been tight in the inpatient surgery department. Virtually all of the
supplies and instruments were stored in the ORs or nearby in the "sterile core" because the physicians wanted to have all of their preferred supplies close at hand. Ironically, many complained about the resulting cramped quarters. And inventory had grown wildly out of control. To appease the physicians - and to remedy inefficient and costly supply replenishment by the clinical staff - senior management laid out a rudimentary plan with the help of a project team and a consulting firm. The idea: interface surgical scheduling and inventory software with materials management software so that CPD could play a larger role in case cart management (see sidebar, below). But the project quickly evolved into something much bigger: a complete overhaul of surgery and materials. "Administration requested that materials management assume responsibility for all of the surgery department's materials functions - in essence, to be the 'owner' of all its inventory," says Ron Gaasch, an information systems manager who headed up the project. "All told the re-engineering affected about 100 people."

Surgical case carts: before and after
*Community Hospital of the Monterey Peninsula did use OR case carts before revamping its surgical/materials interface, but the system was rudimentary at best, says project consultant Sid Packer of Implementation Specialists for Healthcare, West Orange, N.J. This is how the case cart system worked before the reorganization:

• All of the instruments and about 60 percent of surgical supplies were kept in the OR department; the remaining supplies (mostly disposable items) were stored in central supply, as were the case carts themselves.
  
• For each case, an OR secretary would print out both a CS case cart supply list and a preference sheet with the patient's name, the surgeon's name, the type of procedure and the surgeon's preference items. The two pieces of paper - the list of standard supplies and the preference sheet - were clipped together and sent to central supply.
  
• With the supply list in hand, a CS technician would pick standard disposable surgery items such as packs, basins, gloves, dressings and anesthesia supplies. Because it was generated from the surgery department's database, the list did not include item numbers or locations. The CS tech would pull items based on his or her own knowledge of where they were stored.
  
• After placing standard procedure items on the cart, the CS worker would send the cart and preference sheet back to the OR, where nurses would add specialty preference items and instruments. But the computer system indicated locations for only about half of the supplies stored in the OR, so the nurses had to rely on their own experience and memory to pull the other items. If some items did not make it onto the cart, it was usually only a minor inconvenience because most everything was stored close at hand.
  
• When a surgical case was finished, unused supplies would be set aside and either put back on the OR shelves or eventually brought to CS, where workers would try to figure out what the items were and where they belonged.
  

• CPD now stores 90 percent of surgical supplies, as well as much of the instrumentation for inpatient surgery. For outpatient surgery, which has always done its own instrument reprocessing, case carts are for supplies only.
• With the new interface, scheduled cases are automatically loaded into the CPD system. Now, supply technicians can print out near-complete pick lists for the next day's cases. Each pick list includes the patient's name and all supplies and instruments - along with their location - that are to come from both CPD and the OR.
  
• A supply tech pulls all of the supplies and instruments that are now kept in CPD and places them on a clean case cart, along with the pick list. The cart is sent to the OR staging area, where a nurse checks the list. (Since implementation of the new system, the CPD fill rate is very close to 100 percent.) The nurse then adds those items and instruments that are still kept in the OR department.
  
• During the case, "time-of-procedure" items are pulled as needed, and the OR pick list is updated with the additional items that have been used.
  
• When the surgical case is compete, an OR nurse places any clean, unused items back on the cart along with the pick list, on which these clean items have been circled. The cart is returned to CPD, and a technician returns the unused items to the inventory shelves.
  
• Soiled instruments and trays are placed in a closed cart to transport to the CPD, where they are cleaned, decontaminated and sterilized. Sterile instruments, trays and sets are then stored in CPD.

Wheels in motion
The initial plan evolved into an integrated supply replenishment model with four components: materials consolidation, including the case cart computer interface; instrumentation system improvements; remodeling of the central processing department; and a computer system upgrade.

But first a lot of prep work had to be done. The project team spent four months assessing the status quo and analyzing inventories in all areas involved. From there team members determined which of the 1,800 items should be moved to CPD and which should remain in the OR. The goal was to shift as many items as possible, but a handful, such as sutures, were designated "time of procedure" items since their usage can't be predicted. A small inventory of such items is now kept near the OR.

All the while, a handful of OR and CPD staffers dug into a tedious but essential task. An interface between the two departments' automated inventory systems would serve little purpose unless all of the items in the databases matched each other.

"That was the most crucial thing," says Gaasch. "It took months and months, but if we hadn't synchronized and cleaned up the databases the materials system wouldn't have been able to identify nine out of 10 items on a case cart pick ticket." Due to this effort, the "hit rate" has been nearly 100 percent on the 40 or so cases sent across the interface daily.

* The project also provided a perfect opportunity for much-needed project standardization and inventory reduction. In the first year, onetime inventory reductions will contribute to total inventory savings of more than a million dollars, says project consultant of Implementation Specialists for Healthcare, West Orange, N.J. That sum is offset by start-up costs for construction, equipment and information systems, leading to a net loss in year one, but Barrett projects a cumulative return of nearly $4 million after five years.

Another key to the project's success: an instrument tracking system and standardization, which meant instrument processing and storage also had to be examined. Previously, instruments were decontaminated by OR techs, sent to CS for sterilization, and then returned to surgery for storage. Now CPD handles processing for all instruments and storage for most of them (some specialty instruments and emergency sets remain in the OR), and adds instruments to the case carts along with supplies.

Attitude shift
Clinicians also became acquainted with a concept that was completely new to them: par levels. "It was a real education for us," says Patricia Cal, a surgical nurse who joined the team midway through the project and served, as Catbagan says, as a reality tester. "At first we were reluctant to let go of things, to cut back to 20 of each item to maybe two. But the more I learned, the more I realized that we didn't need that much stock on the selves," Cal says. Her comments hint at one of the most gratifying outcomes of the project: an appreciation for the cultural changes that accompanied procedural ones. "This project stimulated staff to realize that change was coming and that they had to break out of the old mode," says Catbagan.

Cal, who's worked in the OR for more than 20 years and is highly regarded by the surgeons, started out a skeptic. "Everyone said that if they could convince me, they could convince everyone. I was resistant, but they've educated me and shown me it can work. Yes, our department had to relinquish control, but we've learned to depend on CPD to furnish our supplies. It's been a very positive relationship." In turn, Cal's good rapport with the surgeons helped quell their concerns about giving up turf.

Surgeons and other OR staff weren't the only ones shaken by the changes, says materials management director Dorothy Crosby, who co-directs CPD with Catbagan. CPD also was tight on space. It needed remodeling to accommodate additional stock items and two new washer-decontaminators to handle the increased workload. The OR instrument techs moved to CPD, and three FTEs were added for the new night shift when the department increased its hours of operation from 16 to 24. CPD staff also had to learn the computer upgrades and how to set up case carts with the new OR supplies.

One world
Physical and operational changes were bound to happen no matter what, but success was by no means a sure thing. It would come only if physicians and staff accepted and complied with the changes. Naturally, the project didn't get immediate, unanimous acceptance from all quarters. But team members were committed to these new ideas and worked closely to ensure that they would be well received by most of the people affected.

Team members emphasize that constant communication and education helped win acceptance and make the transition as smooth as possible. "We knew that materials was taking over sacred ground, so we worked aggressively to communicate with all the staffs at every step and gain their cooperation," says Gaasch. There were frequent meetings, and the team posted a weekly newsletter on bulletin boards in each department.

The educational efforts have paid off. A recent report to senior management shows strong financials for year two and beyond, as well as positive cultural changes, including a "spirit of cooperation, trust and interdependency; an ingrained sense of thrift; and a heightened awareness of cost reduction potentials."

"At first people wondered why we should change the system when it seemed to be working," says Catbagan. "But as we move into managed care, we must reduce excess and become more efficient. We're still fine-tuning our par levels and case carts and staffing patterns, but we've accomplished some great things."

*Reprinted from MATERIALS management in Health Care
Volume 7 Number 1 January 1998

Published by American Hospital Publishing Inc.
Printed in USA