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The Central Supply Processing & Distribution Department (CSPD) at Sanford Health, a Dakota’s health system of 43 hospitals and 250 clinics across nine states, was stuck in a vicious cycle. Its staff would spend all day stocking supplies and prepar-ing sterile instruments for surgical cases only to have that work wasted when a case was moved or cancelled. The process was long, disjointed, and exhausting.

Too often, surgical case carts were sent to the operating room (OR) incomplete or with errors. Trust was lacking: surgeons could not depend on CSPD to deliver the level of service that they needed.

“There was a lot of frustration on the part of the staff. And as a result of that, it was difficult to manage what item moved to what case,” said Susan Pfeifer, director of sterile processing at Sanford Health since 2009. “Not only were the staff frustrated with the environment they’re working in, but the outcome was that their work also ended up with defects, which frustrates the custom-ers—in this case the OR.”

Pfeifer believed that there had to be a better way. In 2008, Sanford Health CSPD implemented a Just-in-Time (JIT) case-pick-ing project to both reduce the time spent picking cases and improve quality of service. The project would impact not only the process of surgical case preparation at Sanford, but eventually the brick and mortar of the hospital system itself.

ChallengePfeifer and quality improvement engineer Jason Wilson began their work in April 2008 by evaluating ways to improve efficiency in case picking—the process of gathering and preparing supplies and instruments for surgery into a cart.

They started with the procedure card, which specifies the set-up, supplies, and surgical instruments needed for a given surgical procedure. They first sought to improve efficiency by preassembling supplies into standardized kits, which they could then add to for the needs of a specific surgeon. Working with the OR, Pfeifer and Wilson used analytics to find commonalities among different surgical specialties.

But after a year of work, they determined that the attempt to standardize with a kitting system would, in practice, only increase complexity. There were too many items specific to each surgeon’s needs, requiring an insurmountable amount of work that offset an estimated $12,123 in annual cost savings. But fundamentally, it was an attempt to corral factors that were outside CSPD’s control.

“The ‘aha’ moment for us was that the procedure cards are managed by the OR staff,” Pfeifer said. “We came to the realiza-tion that we’re trying to use external forces to make improvements versus looking at what are the opportunities internally. Instead, we started looking at what we could do to improve even some minor things internally.”

BRIGHT IDEAS

CSPD Department Wins Back Trust, Just in TimeGavin Stern

At a Glance

SUBJECTCentral Supply Processing & Distribution Department (CSPD) at Sanford Health, a Dakota’s healthcare system

LOCATIONFargo, ND

SIZEIntegrated health system including 43 hospitals and nearly 250 clinics in nine states and three countries.

STAFF27,000 employees (113 within CSPD)

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After a year of work, the kitting project was abandoned. However, the data collection uncovered other ways to improve case picking.

Starting over, Pfeifer and Jim Engelstad, process and improvement coordinator with Sanford Office of Continuous Improvement, developed a value stream map (a representa-tion of how all the steps in a process line up to produce a product or service, as well as the flow of information that triggers that process into action) to chart out the process of surgical case picking. They conducted time studies (with a stopwatch), produced spa-ghetti diagrams (where are resources going?), and brought in outside observers to tell where processes were breaking down.

It became clear that the whole case-picking process was “riddled with waste,” Pfeifer said. Data showed that the average case cart was being assembled piecemeal over the course of 22 hours, beginning at 9 a.m. the day before surgery. Carts in various stages of completion were parked and “babysat” for hours. Items were taken from some carts and given to others, with each step requiring documentation and increasing the possibility for error. Instruments currently in use could not be added. In the meantime, the present day’s cases were ongoing.

The OR schedule for the next day wasn’t finalized until about 5:30 p.m., which meant that much of the case assembly work contin-ued after normal working hours. That constrained the ability to get help when issues arose. And if there were any changes to the surgical schedule—which happened fre-quently—then much of the work would be lost.

“We learned that there was really no sense in starting to do work that would require additional rework until the surgery schedule was final,” Pfeifer said. “Things always changed. There was no value in doing the work in advance because we’re constantly moving things. You don’t realize all the additional waste you put into the process. Instead, let’s finish today and then worry about tomorrow.”

SolutionThe solution to the inefficiencies, the errors, and the frustration was to reduce the amount of time used to assemble the instrumenta-tion, and instead do that work at the right

time—in this case, just in time. In December 2008, Sanford’s new JIT system moved surgical case cart assembly away from an assembly line “push system,” where CSPD is reacting to the demands as they come in, to a proactive “pull system” similar to a deli counter where customers wait until their number is called.

Following the change, CSPD staff began assembling case carts only after the final list of procedures became available from the OR. They work in four-hour blocks beginning the morning of surgery. After the first set of cases is ready (surgeries begin at 6 a.m.), another four-hour cycle of preparation begins until the day’s surgeries are complete. One employee handles a case from start to finish.

“Getting something the day before is almost too much time. You have too many different things you might be able to do. The four-hour time frame allows us to make decisions with the most accurate informa-tion,” said Stacy Lund, director of surgical services at Sanford. “I think that’s what has allowed us to be successful.”

Case cart assembly and restocking now take place entirely during the evening shift. During that time, staff focus all of their efforts on production, all instruments are available, and missing items can be addressed right away. With nighttime resources dedicated to finishing up the day’s work, the morning shift can begin with a clean slate.

“In our old process, there were many surgical trays left to be assembled at the start of the day that were needed for that day. We focused on making sure that that everything that was used the previous day was clean, reassembled, sterilized, and ready to go at the beginning of the following day so that it can be used again,” Engelstad said.

The reduced time frame necessitated new tools for keeping track of inventory, to ensure that instruments would be ready when needed. CSPD developed a tracking system using radio frequency identification and eventually began using handheld personal digital assistants for inventory management. In addition to getting the carts ready just hours before surgery, these enhancements allowed CSPD to retrieve new instrumenta-tion within minutes of a request from the OR.

About the Author

Gavin Stern is senior editor at AAMI. Email: gstern@aami.org

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“Previously, there was a lot of walking the shelves or picking the case and finding an error. We’ve been able to build out tools and also working with preference cards to get them as accurate as possible,” said Randy Merkle, supply chain director. “That give us that heads up as soon as things are scheduled what our inventory levels look like. It allows us to be a lot more proactive than ever before.”

The reaction from the OR was one of concern: If CSPD couldn’t get their instru-mentation correct in 22 hours, how were they going to do a better job in less than a quarter of the time?

“There was an element of fear, and I think that there was mistrust in the process we had developed. If we were unable to deliver successfully in our current state, what would the future hold by changing it so dramati-cally?" Pfeifer said.

Sanford committed to JIT for a 90-day study period, during which no changes to

the process were allowed. Implementation required a communications plan to bridge the trust gap between the OR and CSPD, Lund said.

ResultsThe metrics, though, spoke for themselves. Within the first two weeks, the number of instrument trays left to assemble by 7 a.m. (work left over from the day before) decreased from about 16 to two trays. After two months, hospital staff started to have faith in the new system—the surgical trays were sterile, correctly assembled, and on time. Over the long term, the lessons of JIT would spread throughout the healthcare system.

“Trust between the OR team and the SPD team is easily as important to the success of this work as any process is,” Lund said. “Susan was able to share with the OR team and the OR leaders that this is the right thing to do, and she was able to bring data that

Members of Sanford Health’s Central Supply Processing & Distribution Department in Fargo, ND, assemble surgical case carts with the instruments and supplies needed for surgery. A new system is saving staff time and making customers happy.

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made sense. The bottom line impact is that our patients are being served and the OR knows we’re going to have what we need. That creates confidence.”

Over the next four years, JIT catalyzed process improvement work throughout CSPD. Initiatives included eliminating wasted processes/systems, the creation of standardized processes for OR and CSPD communication/feedback, procedure card printing, sterilization wrapper defects, two-bin room stock, inventory accuracy using automation, sterilization wet loads, periop-erative inventory management using unique device identification, reverse case picking; and on-demand scanning.

Sanford is currently building a new $494-million trauma center, Sanford Medical Center Fargo, which is specifically designed to incorporate the tenets of JIT for surgical case preparation. Excess inventory will not be

stored, no cupboards will be built into the OR rooms for room stock, and the OR will have no capability for instrument processing. All processing will be completed by CSPD, on demand.

Ultimately, JIT improved not only the quality of surgical case preparation and the relationship between CSPD and the OR. It was a fundamental shift in culture that continues today.

“This project created a mindset for staff to understand the basic elements of process improvement,” Pfeifer said. “The beauty now is that this is so ingrained in our culture that when we hire people, they are immediately encouraged to speak up when they see something that might need to be improved.” n

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