While lean methodology has been used in many hospitals’ sterile processing departments, these areas remain largely untapped for advanced lean implementations. At Rouge Valley Health system in Toronto, Canada, the team undertook a transformational journey using lean tools to gain powerful improvements in efficiency, error reduction, cost savings and customer and team satisfaction. Rouge Valley Health System’s Jatinder Bains and Renate Ilse explain.
Sterile Processing Departments (SPD) are at the centre of nearly every patient transaction requiring medical instrumentation. They consider themselves the heart of health operations because they care for a great deal of instrumentation often worth millions of dollars, but rarely find themselves basking in the spotlight for their daily efforts. Usually found in a hospital’s basement, isolated until they make a mistake or become the target for budget cuts, SPD employees often complain about being forgotten, neglected or otherwise ignored.
In recent years, many hospitals have done at least some process improvement work in this area, lean or otherwise. However most hospital sterile processing departments have fundamentally changed very little during the past 20 years. This presents great opportunities for overall improvement in customer service, quality, safety and staff satisfaction. At Rouge Valley Health System Centenary Campus we undertook a multi-pronged approach to improving customer satisfaction, team engagement and overall efficiency by applying the concept of Heijunka, an advanced lean process of level loading and sequencing the timing of customer demand for products or services more commonly found on production with outstanding results.
Costs of delays and errors
In our current state, errors occurred at a rate of about eight per month. Some published and some anecdotal sources have pegged error rates at three per cent of total surgeries booked. Errors such as missing instruments, the wrong instruments, dirty instruments or delays in the production of instruments effectively interfere with patient care. The costs associated with errors such as opening additional trays to replace missing or dirty instruments, repacking or reworking unintended instrumentation, and delays in procedures while waiting for sterile supplies are high. The risk of litigation over sterilisation errors is also potentially high.
The challenge – SPD and lean
The department previously incorporated basic lean concepts to help with reducing error rates, improving team work, improving the flow of instruments to and from the department, reducing requested instrument returns, and improving instrument care. A lot of safety and equipment issues had been addressed with visual management setups and even improved lighting. Regular team huddles were created to discuss safety concerns, ideas for improvement, regular knowledge exchange and to improve overall communication. These changes were incremental and largely remedial, leaving staff wanting more. As in most healthcare organisati ons, there was also constant pressure to do more with less.
Leadership recognised the department played a vital role in patient safety and managed a large investment in instruments and machinery required to run many areas in the hospital. There was a recognition that intradepartmental, interdepartmental and relationships with end users were strained and there was a large degree of expected mistrust between these departments. The organisation and new leadership in the department set about to investigate the various options to further improve the department’s performance in reputation, patient safety (reduction in near miss errors), team work and efficiency. Options such as investigating outsourcing to investing in technology were explored. The organisation agreed that it would instead begin by engaging the CPD employees and, with the help of internal and external performance improvement staff, tackle all internal opportunities to improve the department’s overall performance.
With error rates similar to other departments in our catchment area and production bottle necks resulting in daily backlogs of work-in-progress (WIP), we decided that we would introduce a new way of thinking to the department to try to drastically improve both performance metrics. We invited a lean specialist and together with our Transformation Office (TMO), formulated a plan to hold a week-long event deploying the Heijunka (load levelling) tool kit.
We recruited staff from various customer departments (the OR, Labor and Delivery, the Catheterisation Lab) as well as staff and leadership from both our CPD’s with the following overall objectives for the event:
- Load levelling
- Modernise/digitise/embrace technology
- Engagement of stakeholders and customers in wanting to improve the “way its always been” (engage departments, charge nurses, managers and physicians to participate in ways to improve satisfaction).
The rapid improvement event was supported by one of the most detailed data mining projects the organisation had done for any department. The team undertook several sessions in the department capturing time trials of work being completed.
Our observations showed the current state had staff:
- Walking frequently to gather supplies
- Being left with incomplete work on shelves
- Waiting/ looking for items not immediately available
- Frequent distractions at assembly
- At odds with customer expectations
- Frustrated with their work environment.
Change management cold turkey
Our Staff responded with incredible energy. The event ended on a Friday with the staff involved in the event settling on a new structure of doing work:
- Three dedicated assemblers that share in all the assembly work of the day
- One Float that distributes work and supplies to each of the assembly stations
A trial of this new work cell alignment took place during the Heijunka event with the involvement of others in the department. Unanimously, SPD staff voted to initiate the new system for the coming week. Some redesign of the department’s layout was done over the weekend and the level loading was launched as planned. Three key findings were quickly evident:
1. Staff satisfaction improved.
Immediate feedback from Staff was: “This event and the changes we have made is one of the best things that ever happened to this department” “We are capturing missing instruments in real time, instead of waiting 60 trays later, and we are getting to trays quicker” “You feel, as well as see, more teamwork” The overwhelming perception was that everyone was working more cohesively as a team and contributing equally to the work being done. The opportunity to recognise the priorities for the day, where the department was in its production target for the shift (leaving zero or minimal WIP) and other communication between team members and our customers improved.
2. A drop in our error rate
Since the Heijunka, our CPD department has experienced an error rate of >1.0% of total surgeries performed. While data collection is still early, our error rates dropped dramatically to a streak of zero errors over 39 days and then zero over 53 days. We would have expected 12 errors per month over this time period
3. Spring cleaning
The department has recognised a greater production throughput. Assembly work was a constant frustration for each shift change. A noticeable amount of WIP would remain in the department for the next shift. After our new work flow was instituted, our WIP was non-existent after every shift. Staff was required to walk less (less ‘hunting and gathering’). The new process resulted in a 75% decrease in waste of motion in the process. The assembly bottleneck was cleared up. The department felt neater and looked cleaner with less clutter evident.
The net result was there were no additional staffing complements required to achieve our great productivity and efficiencies.
Recognition and reward
The participant’s energy and enthusiasm (and some savings) made such an impression on the program leadership that they supported a CPD request for workstation computers. The program has now grown its footprint into the technology forefront by installing touch screen computers at each of the assembly stations. While technology has its learning curves and risks of creating redundant or parallel work flows, the installations have created options for staff to have access to resource materials required in inspection and assembly of instruments right at their fingertips. Recognition also culminated in a staff recognition ceremony with our board of directors.
We instituted weekly huddles with our OR nurses, less frequent huddles with other department nurses and managers, and periodic visits by surgeons. Generally, the teams responded with creating new ideas to minimise operational issues (nuances in assembly, better delivery times). The teams have anecdotally grown in respect for each other’s work and addressed challenges together (implemented a notice board in the OR to avoid over delivery of case carts). The physician visits have been a huge hit with the CPD staff . They brought with them frustrations and expectations and left with a better understanding of the area and developed collaborative solutions to minimise false assumptions (e.g. Understanding flexible endoscope turn around times (TAT) to manage patient bookings.)
The CPD departments at Rouge Valley Health System have long recognised the department still offers many process improvement opportunities. Having leveraged some lean methodology with some success prior, the team committed to a more vigorous effort to fundamentally change work flow, work life and patient safety.
Our approach has improved the efficiency, quality, team engagement and customer service. For example, tray assembly time for complex trays was reduced by 31% and for simple trays 43%. There are many ways to organise the functions in CPD (exchange cart system, central dispatch and a case cart system). Our innovative approach leverages the gains our department has made using the case cart system (Just in Time (JIT) logic) and enhances team work and productivity by using work cell units for production. By using this
approach, no staff member or table in the department becomes overburdened (depending on the types of surgeries performed that day) or a bottle neck to the department’s successful support of its customers. The customers have experienced less production errors and have been able to engage in productive and constructive dialogues to continue the momentum in improving both the service and relationships between departments. Physicians and front-line clinicians have lent to a constructive dialogue which has led to further quality improvements while reducing work load by cancelling work-around.