Prioritizing Instrument Sets in a Lean OR

I know of no OR that has enough instrument sets to take care of all the cases within a surgeon's block time. This apparent shortage is aggravated by the way in which instrument sets are batch processed from the OR to the Sterile Processing Department (SPD) and back. In this article, we will discuss one case where simple low-tech tools were used to identify the priorities for SPD processing of instrument sets. This improvement was made as a Lean Kaizen event, where a team of knowledgeable people dedicated a week of time to address the problem.

After the team documented, analyzed, and re-designed the entire SPD, the shortages of instrument sets plummeted. Block time scheduling for surgeons, however, places a high burden on the instrument set inventory because the block demand is a very high spike of usage rather than a smooth curve. Assuming that block times would not be changed, we had to look for ways to prioritize the instrument sets returning to SPD after a case was finished and ways to flag and prioritize the various demands placed on SPD services.

The new design for the SPD started on the "dirty" side with a queuing area coming out of the return elevator, organized in first-in, first-out fashion. This organized the case carts and avoided "cherry-picking", i.e. selecting the easier carts first. There are several different conditions for processing instrument sets:

• Normal Processing. No special expediting is necessary.
• Rush: The instrument is needed sooner than normal. Move up in the queue.
• STAT: The instrument is needed on an expedited basis, but it is to be wrapped and sterilized in SPD.
• STAT FLASH: The instrument is needed on an urgent basis and it must be flash-sterilized in the OR for immediate use.

Knowing under which condition a set returns to SPD is very important. This is usually communicated via frantic calls and even trips from the OR to SPD. Put your Lean thinking hat on and tally the number of minutes spent on the phone chasing instrument sets. See the waste?

Following is the process that the Kaizen team developed, using the Lean tools of Visual Management. Based on the classifications mentioned above, every time a case is completed the following steps take place. These were documented for the Perioperative Services Team using Standard Work definitions:

• Return all instruments to their respective pans.
• Apply enzymatic foam to all appropriate instruments.
• Gather all refuse and place it on top of the case cart.
• Move case cart to the staging area in front of the "dirty" elevator.
• Apply a color-coded clip to the instrument set, according to how this set is to be treated in the SPD. This is normally done by the Service Line Coordinator.
• Return the case cart to the SPD.
• Process instrument set according to the clip color code.

The SPD Tech interprets the clips as follows:

• No clip: Normal processing. Process the cart via first-in, first-out (FIFO) priority all the way through the SPD.
• Yellow clip: The case cart moves to the front of the first FIFO lane. After that it is processed normally.
• Red clip: STAT processing. The case cart jumps to the front of the first FIFO lane. After that it receives expedited processing. The instrument set is sterilized in the SPD.
• White Clip: The case cart moves to the front of the first FIFO lane. After that it receives expedited processing. The instrument set is flashed-sterilized in the OR.

Simple Visual Management tools like the use of color-coded clips can eliminate the waste of calls and chasing by indicating what needs to be done visually. There are many other applications of visual management that are possible throughout any hospital. You can read about some other applications in our articles "Kanban in the OR", "Quick Changeover in the OR", and "7S in the OR".

Gerard Leone, MSIE, MBA, is the Lean Hospital practice leader with the Leonardo Group Americas. The Leonardo Group is based in Munich, Germany and Denver, CO in the USA. Gerard is has been a consultant to manufacturing companies for almost 20 years and to hospitals for 8 years. You can reach him at gleone@leonardo-group.com or visit the Lean Hospital Group website at http://www.leanhospitalgroup.com