Optimizing Sterile Processing Workflow

A Roadmap to Success

Source: HealthCare Purchasing News, Nov 2006: A Roadmap to Optimizing Sterile Processing Workflow , Dan Johnson, SterilTek Inc.

Trends Pressuring Sterile Processing Departments

Higher surgical volumes Overburdened process capacities Inadequate instrumentation availability Reduced or under-skilled staff Viable sterile process outsourcing

alternatives

New View of SPDs as Factories

Lean Process

Concentrates improvement effort on workflow (value stream)

Identifies waste Eliminates waste Eliminates process variability

Processing Circular flow

Increasingly efforts are being directed toward improving the circular flow of reprocessing work from the O.R. through the SPD and back, with the goal to:

Produce more quality Produce higher quality Improve process efficiency Work with same resources

Workflow Optimization

Developing processing to promote rational, logical and efficient workflow

In a hospital SPD, you must determine: What is of value to customers How to deliver more value to them How to accomplish more with available

resources How to satisfy the supply needs of the O.R.

Why Does Workflow Matter?

Eliminates non-productive, repetitive tasks Cultivates an environment that seeks to

improve efficiency Strengthens customer relationships Reengineers processes to be leaner and

more productive Positions SPDs for growth

The Costs of Inefficiency

Ineffective and inefficient workflows often go unexamined, unmeasured and unmanaged.

Poor workflow compromises: Effectiveness of the operation Level of customer service Many areas of the healthcare facility

SPD staff OR staff Technologies

Efficient SPD Workflow

Incorporates reprocessing operation and related systems

Automates when possible Eliminates redundancy Eliminates process variability Reduces errors Increases speed Improves quality

Ultimate SPD Workflow Goals

Provide customer: Best quality product At the volume required At proper time At the proper cost

100%3

100% clean & sterile 100% complete instrument sets 100% on time delivery

Characteristics of Optimal Workflows

Compatible with current systems and they streamline existing methods

Applicable across similar functional departments

Consistent

What Managers Should Know

To ensure process improvement success: Take Action

Gather information Analyze it Determine action steps Implement them Then, do it again

“Now and better is better than perfect and never” –unknown

“Just do it.” –Taiichi Ohno, former vice president of Toyota Motor Corporation

What Managers Should Know

Actively involve employees and customers Staff understands pitfalls and makeshift

operations Staff is available, valuable, and willing creative

resource Customers will be happy to help you improve

product and service level Customers can identify potential change

impact Customers also creative resource

What Managers Should Know

Be prepared for resistance

Change is hard work in an organization People have a natural reluctance to change Change challenges comfort zones Proposed change is threatening

“It must be considered that there is nothing more difficult to carry out, not more doubtful of success, nor more dangerous to handle than to initiate a new order of things.”

---Niccolo Machiavelli

What Managers Should Know

Leading Change Show dedication to the improvement process Leading change is not a part-time job Change requires daily attention Don’t get caught up in daily distractions Engage the services of a knowledgeable

change agent Facilitate improvement process Plan and lead improvement activities Demonstrate and teach effective techniques

Another Day in CS!

Step 1: Mapping your Central Sterile Workflow

Optimizing the sterile processing functions first begins with a process flow and map. Visual representation of the reprocessing

cycle Focuses initially on the primary process steps Dives deeper into the process to uncover

process layers of complexity

Sample Process Map - Simple

OR Sets Up Case

Instruments PlacedIn Transport Cart

CSDecontamination

CSAssembly

Instrument StorageOR Performs

Procedure

OR Breaks DownCase

CS Sterilization

Value Added Activities

Process maps help in identifying value-added activities within the process

Characteristics of Value Added Activities Customer is willing to pay for Physically improve the fit, form, or function of

an item Performed correctly the first time

Non-Value Added Activities

Non-value added activities = Waste Characteristics of Non-Value Added Activities

Take time, resources, or space but do not add value to the product

Rework at any point in the process Searching or waiting for instruments or

supplies Waiting on machine cycles Double handling

Constraints / Bottlenecks

Process mapping also assists in identifying process constraints or “bottlenecks”

Process Constraint = Area where demand is greater than the current ability to supply

More on this later!

Step 2: Improving Functions and Workflow Optimizing Workflow

Streamline Identify Waste Work Process Simplification Capacity Line Balancing

Streamline

Eliminating and minimizing non-value added steps in the process

Quick hits to produce quick results Not all non-value added can or should be

eliminated

Identify Waste

Labor Waste Quality inspections after the set is complete

versus IT solutions and certification to ensure proper set preparation the first time

Time spent looking for an item that should be readily available

Improperly staffed SPD or other reprocessing areas

Identify Waste

Overproduction Excessive stat washes or flash sterilization in

the OR when instrument set is not used for an immediate procedure

Space Non-linear workflow from requiring storage

racks and transportation routes Excessive movements, poor ergonomics Non-reprocessing supplies stored in

reprocessing work areas

Identify Waste

Defects Sets put up with missing instruments, extra

instruments, or wrong instruments Improper Count Sheets or documentation Instruments not returned to decontamination in

their original container/tray Sets returned with instruments missing

Identify Waste

Time Work schedules that do not align with

workload requirements (too many technicians too early in the day as an example)

Assembly staff waiting for instruments from decontamination

Instruments arriving from the OR with extra items, missing items, or non-instrument items that slow down decontamination process

Work Process Simplification

Deep dive into detailed process steps Increase process utilization and capacity Develop smooth flow of materials, work and

communication Eliminate

Unnecessary work Rework Fatiguing motions Long transports and complicated paperwork

Work Process Simplification

Prioritize Select activity that benefits the entire process Select activity that a lot of time is currently

spent on - greater benefit than smaller tasks Select activities that currently require a lot of

chasing or looking for items, hard work, inspections, or non-desirable work conditions

Work Process Simplification

Prioritize – Instrument Assembly example Provide all needed materials within the

technician’s reach Eliminate unnecessary materials from

instrument sets Remove unneeded instruments from set to

reduce the set size and simply the assembly Provide accurate count sheets, IT solutions, or

pictures to assist in the assembly process

Work Process Simplification Steps

Keep an open mind and no work process can be taken for granted – question everything!

1. Select the job or function to be improved 2. Process chart the job in detail

All operational steps Transportations Inspections Storage Delays Time and Distance

Work Process Simplification Steps

Sample Instrument Assembly Process Chart

Extra instruments in

set

Set is complete

Instrument requires repair

or maintenance

Set missing instruments

Extra belongs in another set

Extra is determined to be a common peel pack item

Ente in IMS Repair Log and place in

IMS Bin

Set Complete?

Yes

Place instrument in Peg Board inventory

Place instrument in Peel Pack Bin

QUALITY CHECK* In correct basket* Properly Cleaned* Properly sent through washer

Add internal indicator and

fill out external load card for

container

Sign, document and

date Count Sheet

Keep tray at table area for

pick-up

Supervisor checks log and enters into PC

Instruments given to IMS

for repair

Instruments returned and logged into IMS Repair

Log

Instruments placed in

Return Repair bins by

specialty

Assembly entire set firstbefore looking for missingInstruments.

Find Missing Instrument1. Look at Repair Log at table2. Look in Today’s Extra Bin3. Call OR if applicable4. Check Returned Repairs bin5. Use Peg Board if common non-marked instrument is needed

Yes

If specialty item is out for repair, place on Hold Shelf

Place set on Today's

Incomplete ShelfNo

Missing Itemout for Specialty

Repair?

No

Supervisor checks Hold

Shelfdaily

Fill out Hold Ticket and place in set

Assigned person tries to complete sets

at 8pm and 2am

May use Peg Board or

substitutes for marked

instruments

Set Complete?

Yes

No Hold or Send?

Hold

Send

Fill out Missing Instrument

sticker

Set Complete?No

Yes

Peel Pack instruments at

regularly scheduled

times

Place instrument in Today’s Extra

Bin

Instruments used to

complete sets

Assigned person empties

Today’s Extra Bin at 6am

Peel Pack?

Yes

No

Peel Packs taken to

sterilization area

Work Process Simplification Steps

3. Question each detail 4. Develop a new method

Reduce the number of steps Arrange the steps in the best order Make the steps as efficient as possible Reduce handling Combine steps Shorten moves Provide the most economical method

Work Process Simplification Steps

5. Implement the new process 6. Review, measure, and repeat

Work Process Simplification Steps

Sample Instrument Assembly Are instruments brought to the assembler? Are extra instruments readily available to

replace missing? Are all needed materials within reach? Is the walking and transporting minimized? Can sets assembled per hour be increased? Can time to assemble each set be decreased? Are clear procedures available to handle non-

conforming situations?

Work Process Simplification Steps

Streamlined and Simplified in Assembly

Work Process Simplification Steps

Streamlined and Simplified in Decontamination

Capacity Line Balancing

Capacity: The amount of work a person, equipment, or process is capable or producing during a given amount of time

Capacity Requirement: The amount of work a person, equipment, or process is required to produce during a given amount of time

Capacity Line Balancing: Matching the capacity of each operation within a process to the requirements of the next

Capacity Line Balancing

Optimize the capacity of the entire process! First, perform a Capacity Analysis

Determine customer workload – often considered OR soiled instruments entering decontamination

Establish the arrival pattern or timing of workload

Utilize cycle times and work standards Determine needed resources to provide the

required capacity to handle the workload

Capacity Analysis

Instrument

Washers

Assembly

Sterilizers

Cart Washer Cycles for Case Carts and Containers

Cyc

les

Instrument Washer Cycles for Instruments, Containers, Singles, and Basins

0

5

10

15

20

6a 7 8 9 10 11 12p 1 2 3 4 5 6p 7 8 9 10 11 12a 1 2 3 4 5 6a 7 8 9

Cyc

les

Cycles Started Minimum Cycles Backlogged

Assembly Hours: Instrument and Linen

0

5

10

15

6a 7 8 9 10 11 12p 1 2 3 4 5 6p 7 8 9 10 11 12a 1 2 3 4 5 6a 7 8 9

Ho

urs

Inst. Assembly Hours Inst. Backlogged Hours Linen Assembly Hours Linen Backlogged Hours

Sterilizer Cycles: Instruments, Singles, Basins, and Linens

0

1

2

3

4

6a 7 8 9 10 11 12p 1 2 3 4 5 6p 7 8 9 10 11 12a 1 2 3 4 5 6a 7 8 9

Cyc

les

Cycles Started Cycles Backlogged

Capacity Line Balancing

Second, balance the capacity Identify the capacity restraint or “bottleneck” Ensure that the bottleneck operation is

properly scheduled and staffed to handle the reprocessing workload that is coming into it

Ensure that the operation and it’s equipment is functioning at it’s peak performance

Acquire additional pieces of equipment or staff to meet demand

Capacity Line Balancing

A typical balanced reprocessing cycle

A typical non-balanced reprocessing cycle

Washers SterilizersAssemblyOR65 Items 64 Items 60 Items 73 Items

2005 Upgraded Process

Items/Hour

Washers SterilizersAssemblyOR65 Items 56 Items 38 Items 73 Items

2005 Upgraded Process

Items/Hour

Step 3: Workstation and Operations Sequence Layout Linear flow for operational efficiencies but

also necessary to separate soiled, clean, and sterile items

All necessary and frequently used items are available within arm’s reach

Properly designed seating, fatigue mats, and ergonomically workstations

Step 4: Standardize Work Practices

Determine best practice and standardize to it Involve the people doing the work Document practice in procedures and work

instructions Train, train, and train Follow-up to ensure compliance Encourage continuous improvement and

change

Step 5: Scheduling Process

Ensure the sequence of CS operations are logical and easily understood

Schedule people, equipment, and processes to ensure smooth flow without interruptions or delays

Schedule to support the capacity line balancing except for the “push” of decontamination

Step 5: Scheduling Process

Push: Decontamination should “push”

instrumentation as quickly as possible to assembly without regard to capacity balancing

“Push” ensures instruments are quickly cleaned and identified as being in CS

Pull: Assembly and sterilization can then “pull” the

instrumentation through according to capacity restraints and customer requirements

Step 6: Measuring Process Performance Measure what you value Differentiate between perception and reality Measure based on facts Identifies process issues and bottlenecks Evaluates customer satisfaction level Provide a baseline to monitor improvement

Measuring Process Performance

Two purposes for developing consistent metrics and measurements within CS Ensure performance meets expectations while

driving accountability To measure the impact of any improvement

while driving additional improvement efforts

Measuring Process Performance

All measurements require a “goal” Sustainable goals reflect current process

performance such as hitting your budget Stretch goals focus people on changing the

process rather than tweaking the existing one

Measuring Process Performance

“We can’t change what we don’t measure.”

“Don’t measure what you won’t change.”

Focus your measurements on what you value and what you want to improve.

Measuring Process Performance

Track, post, discuss, and take action based on the performance factors being measured

Timeliness of measurement and feedback is of utmost importance

Employees should have a clear understanding of what the customer and management expects of them for every task they perform – both quality and productivity

Measuring Process Performance

Key CS measurements Quality: Defects per total items produced Customer Experience: Positive experiences

per total experiences CS Labor Hours per Procedure Productivity Skill mix and competency

Step 7: Active Management / Supervisory Techniques Communication

Continuous cycle Effective assignment giving and follow-up Regular interaction to ensure processes are

being followed Leads to problem identification and resolution Nothing in the process or work practices

should be taken for granted

Active Management / Supervisory Techniques Problem Resolution and Documentation “If it isn’t written – it isn’t done.” Use an Action Item tool or at least a simple

To-Do list.

Summary

It Doesn’t Take A Crisis – But It Helps… Change is usually a response to negative

circumstances – but this doesn’t have to be the reason

Start today by mapping and understanding your process and identifying your first opportunity for improvement