University of Michigan Health Systems

Reduction in CSPD/OR Missing InstrumentationFinal Report

Submitted to:Jania Torreblanca, Manager, Central Sterile Processing Department

Kerstin Rider, Supervisor, Operating Room NursingMatt Claysen, Industrial Engineer, Operating Room

Nicole Farquhar, Industrial Engineer, Operating RoomDr. Mark Van Oyen, Professor, Industrial and Operations Engineering

Submitted by:IOE 481 – Team 2

Conner VanDeveldeTimothy O’Neill

Ivana KosirJacob Homan

Date submitted: December 13, 2016

Table of Contents

EXECUTIVE SUMMARY...........................................................................................................1

INTRODUCTION.........................................................................................................................4

BACKGROUND............................................................................................................................4Key Issues.................................................................................................................................................5Goals and Objectives...............................................................................................................................5Project Scope............................................................................................................................................5

METHODOLOGY........................................................................................................................6Observations and Interviews..................................................................................................................6Literature Search.....................................................................................................................................6Data Collection and Analysis..................................................................................................................8

Coordinator Data....................................................................................................................................8Decontamination and Sterilization Audit Data......................................................................................9

Surveys......................................................................................................................................................9In-service Pilot..........................................................................................................................................9

Two Truths and a Lie...........................................................................................................................10Marshmallow Spaghetti Tower............................................................................................................10Initial Findings.....................................................................................................................................10

FINDINGS AND CONCLUSIONS............................................................................................11Lack of Understanding between Departments....................................................................................11

Disconnected Team..............................................................................................................................11Lack of Transparency of Department Policies.....................................................................................11

Lack of Standardization in CSPD Search Process..............................................................................13Valuable Information Lost on Count Sheets.......................................................................................15OR and CSPD Frustrated with Count Sheets.....................................................................................15

Manufacturer Names............................................................................................................................15Substitutes............................................................................................................................................16

RECOMMENDATIONS............................................................................................................16Interdepartmental Relationship Maintenance....................................................................................16

Team Building.....................................................................................................................................17Restructured Accountability................................................................................................................17

Standard CSPD Search Process...........................................................................................................18Subject Matter Expert..........................................................................................................................18External Surgical Set Marker...............................................................................................................18Standard Search Process......................................................................................................................19

Decontamination Count Sheets.............................................................................................................19Common Name and Acceptable Substitutes Committee....................................................................20

Condensed Manufacturer Names.........................................................................................................20Allowable Substitutes..........................................................................................................................20

EXPECTED IMPACT................................................................................................................21

BIBLIOGRAPHY........................................................................................................................22

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APPENDIX...................................................................................................................................23Appendix A: CPSD and OR Surveys...................................................................................................23Appendix B: Surgical Set Lifecycle......................................................................................................26Appendix C: Excel Workbook for Expected Impact..........................................................................27Appendix D: Example of a Count Sheet..............................................................................................28

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List of Figures and Tables

Table 1: Literature search provides applicable information to project……………………… 7

Figure 1: Group 1 Working on Marshmallow Spaghetti Tower……………………………. 10

Figure 2: Group 6’s Finished Marshmallow Spaghetti Tower……………………………… 10

Table 2: OR and CSPD Audit Results………………………………………………………. 11

Figure 3: Reporting has dropped off substantially since May 2016………………………… 12

Figure 4: Lack of time is the main reason for CSPD processors not reporting missing

instruments………………………………………………………………………… 13

Figure 5: Missing instrument search order for CSPD processors…………………………… 14

Table 3: Count sheet provides very specific information on instruments needed

in surgical set……………………………………………………………………… 1

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EXECUTIVE SUMMARY

The University of Michigan Hospital’s (UMHS) Central Sterile Processing Department (CSPD) and the Operating Room (OR) Department are experiencing frustration due to instances of missing, incorrect, or extra instruments in surgical sets. For future reference, sets with missing, incorrect, or extra instruments will be referred to as incorrect surgical sets. Complete and correct surgical sets are essential to performing surgery, and an error in the surgical set can result in patient safety issues. When an incorrect surgical set returns to the CSPD, processors spend valuable time searching for the correct instrument. The OR and CSPD leadership asked Team 2 to conduct an analysis of the current situation and provide recommendations to reduce the occurrence of incorrect surgical sets and the time spent searching for correct instruments.

BackgroundIncorrect surgical sets lead to patient safety issues and increased processing time, frustrating both the OR and CSPD. The surgical set lifecycle is the repeated use of surgical sets in the OR, processing in the CSPD, and return to OR storage. The surgical set lifecycle begins with the OR opening the required surgical sets to perform the scheduled surgery, and afterwards returning the used surgical sets to the CSPD. In the CSPD, the surgical sets go through a decontamination area to be cleaned. A CSPD processor then assembles the surgical set according to a count sheet that lists all the instruments needed in the surgical set. Finally, the surgical set is sent through a sterilizer and stored in an OR storage room. The goal of this project is to recommend changes to reduce the occurrence of incorrect surgical sets and the time spent searching for correct instruments.

MethodologyTeam 2 used a variety of methods to conduct this project: observations, interviews, a literature search, data collection, analysis, surveys, and an in-service pilot.

Observations and InterviewsThe team conducted 25 hours of observations in both the OR and CSPD. After gathering information from the observations, Team 2 interviewed 15 relevant stakeholders in the surgical set lifecycle to gather firsthand information, including pain points and possible causes for incorrect surgical sets.

Literature SearchTeam 2 conducted a literature search to understand if other hospitals experienced similar issues with incorrect surgical sets, what actions were taken to alleviate the problem, and the effectiveness of each action. The most applicable source was the series of articles written by The Detroit News regarding the Detroit Medical Center’s (DMC’s) poor instrument cleaning process. The DMC was facing major public backlash after dirty instruments were used during surgery. Key findings include that communication and training were the leading cause of issues at the DMC. Team 2 took these findings into account when developing recommendations for UMHS.

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Data Collection and AnalysisThe project coordinators provided collected data on incorrect surgical sets from May to October 2016. However, findings indicated that the recently collected data was less representative of the current state due to underreporting. Therefore, Team 2 collected data in two areas of the process to audit for incorrect surgical sets: the decontamination area and the pre-sterilization area in the CSPD. This data gave information on the accuracy of sets exiting both the OR and CSPD.

SurveysTeam 2 developed one unique paper survey for each of the OR and CSPD departments to gather more information on the search process for correct instruments and concerns with the surgical set lifecycle (Appendix A). Team 2 received 65 responses from OR staff and 36 responses from the CSPD staff.

In-Service PilotTeam 2’s findings indicated a disconnected community between the OR and CSPD staffs. Team 2 hypothesized that team building could encourage a sense of unity and improve communication. Team 2 tested this hypothesis during an in-service pilot on November 17, 2016. Between the OR and CSPD, there were approximately 100 staff members present. Team 2 facilitated activities that were designed for members to meet unfamiliar coworkers, promote collaboration, and encourage problem solving. Team 2 presented initial findings from the project, and a constructive dialogue between staff members ensued. Overall, the in-service pilot was well-received, and the feedback from clients, coordinators, and staff members was positive.

Findings and ConclusionsWhile carrying out the tasks described in the methods section, the team collected a number of findings and conclusions about the instrument set flow and the CSPD search process.

Lack of Understanding Between DepartmentsDuring interviews and observations, both staffs highlighted pain points in their department. Also, each staff mentioned that the other department was making their job harder. Through the audit the team conducted, the OR and CSPD had error rates 24% and 39%, respectively. Both departments attributed the missing instrument problem to the other department while having a significant error rate themselves was revealing. Neither department totally understood the relationship between the two departments. There is a lack of buy-in to being a team with the other department, and that is causing a breakdown in procedure and effort. In addition, reporting of missing instruments has dropped off significantly after being implemented. From observations and interviews it was found to be that nurses don’t report data because they are worried about punishment for processors, and processors don’t report because they don’t have time from a productivity quota. These are both caused by misconceptions of hospital policy, meaning better communication can improve this problem.

Unstandardized Search ProcessIn the CSPD, Team 2 observed an unstandardized search process for missing instruments. Processors looked for missing instruments in the storage cabinet, other surgical sets, peel packs (single packaged instruments) from the OR cores (the OR storage area), the down cart, or asked

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other processors for guidance. During observation and interviews with the OR, Team 2 found the closing of cases were rushed, causing instruments to not always returned to the correct set. Consequently, CSPD processors search for missing instruments in other surgical sets, but processors have no way of knowing which surgical sets were used together during surgery. Processors could find missing instruments easily if the processors knew which surgical sets were used together during surgery. Processors rely on a subject matter expert (SME) to provide guidance on searching for missing instruments, using substitutes, and providing clearance for surgical sets to be without all instruments. Team 2 found there are not always SMEs available or are not known.

Valuable Information Lost on Count SheetsFrom interviews the nurses often write notes on the count sheet about instruments that were missing or incorrect believing those count sheets were sent down to the CSPD where the processors could read the notes. In actuality, the count sheets are thrown out in the decontamination area and the notes are lost before processors see it. This loss of information hinders CSPD processors in fixing small mistakes and leads to incorrect sets being sent up to the OR with the same incorrect or missing instruments.

Gaps in Instrument Naming and SubstitutesData from Team 2’s surveys found that 85% of nurses and 37% of CSPD processors surveyed could not use the manufacturer name on the count sheet to identify the instrument. During observations, the manufacturer name and number were only used to confirm if an instrument was correct. This finding shows the overly technical manufacturer name used in the item descriptions is confusing.

Team 2 found that the OR and CSPD disagreed on substitutes for instruments. Generally, the OR nurses believed there are not many substitutes, and the CSPD processors believed there are many substitutes. In Censitrac (the electronic tracking system for surgical sets), there is an area under each instrument to list acceptable substitutes, but many have no substitutes listed. These observations showed that the OR and CSPD have not clearly communicated a list of substitutes for instruments.

RecommendationsTeam 2 provided four main recommendations to reduce the occurrence of incorrect surgical sets and time spent searching for correct instruments. The first recommendation is to strengthen the interdepartmental relationship through team building and communicated policy transparency. The second recommendation is to standardize the CSPD search process by using subject matter experts in the CSPD, attaching an external surgical set marker to sets used together during surgery, and implementing a specific order in the search process. The third recommendation is to develop a method to transfer OR staff’s count sheet notes to the CSPD processors. The fourth recommendation is to establish a committee responsible for shortening manufacturing names to a common name and developing a list of allowable substitutes for instruments.

Team 2 believes that implementing these recommendations will result in a more engaged workforce and an estimated productivity savings between $54,000 and $164,000 per year.

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INTRODUCTION

Within the University of Michigan Hospital (UMHS), two departments have a symbiotic relationship to ensure that surgical sets are properly used and processed: The Central Sterile Processing Department (CSPD) and the Operating Room (OR) departments. The CSPD cleans, assembles, and sanitizes surgical sets, which contain the instruments required to perform a surgery, and the OR uses those surgical sets. However, the OR and CSPD are experiencing problems with missing, extra and incorrect instruments inside of their surgical sets. For future reference, sets with missing, incorrect, or extra instruments will be referred to as incorrect sets. IOE 481 Team 2 was asked by the hospital internal quality committee to assist them in finding the root causes of the incorrect instrument sets by observing the inventory flow, interviewing hospital stakeholders, surveying hospital stakeholders, conducting audits, and performing statistical analysis on the data collected. The project’s purpose is for Team 2 to find the root cause of incorrect surgical sets. Consequently, the team will make recommendations to reduce the amount of incorrect surgical sets and reduce the search time for correct instruments. This final report provides a background on the project, a detailed methodology, findings and conclusions from the data, and recommendations to address causes of incorrect surgical sets.

BACKGROUND

A surgical set is a box of sterilized instruments that are used for a specific surgery. Recently, both the Central Sterile Processing Department (CSPD) and the Operating Rooms (OR) department have been experiencing incorrect surgical sets. Incorrect surgical sets have been causing frustration in both departments, because incorrect surgical sets can cause delays or other patient safety issues in the OR. In addition, incorrect surgical sets lead to increased processing time in the CSPD, because the CSPD processor must search for the correct instrument, and extra instruments can confuse processors.

The current process begins with the OR opening the required surgical sets to perform the scheduled surgery. If a required instrument is missing, then a nurse has to search for the instrument in other surgical sets or single use packaged instrument, known as a peel pack. After the surgery is complete the nurses return the used instruments to the surgical sets, and the sets are transported to a quick turnaround CSPD. The quick turnaround CSPD has two main functions: the first is to spray down all used instruments to begin cleaning off bioburden, and the second is to expedite the cleaning and sterilization of sets that are urgently demanded. Once instruments are sprayed down and are not urgently needed, all surgical sets are sent to the main CSPD for processing. In the main CSPD, the surgical sets go through a decontamination area to be thoroughly cleaned. A CSPD processor then begins assembling the surgical set according to a count sheet that lists all the instruments needed in the surgical set. If a required instrument is missing, then a CSPD processor searches for the instrument in the storage cabinet, other surgical sets, peel packs from the OR cores (the OR storage area), the down cart, or asked other processors for guidance. If there are extra or incorrect instruments in the surgical set, then a CSPD processor has to return the instrument to the storage cabinet or an extra instrument bin. Finally, the surgical set sent through a sanitizer and stored in an OR storage room, known as the core. A flowchart of the process can be seen in Appendix B

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In response to the missing instruments problem, the hospital has formed an internal quality committee called the Instrument Care Team, consisting of members from both the OR and CSPD. The purpose of the committee is to find the root cause of the missing instruments in surgical sets. The committee has begun collecting data on incidents of missing instruments in the OR and CSPD. Data collected from May 2016 to October 2016 shows that 89 sets have been opened in the OR with a missing instrument, and 354 sets have returned to CSPD with missing instruments. These missing instruments have caused 109+ hours of search time for missing instruments in the CSPD. Missing instruments and increased search time directly affect patient safety and satisfaction of the OR, CSPD, and Physicians. The goal of the project is to use the provided data and the team’s independent observations to identify the root cause of incorrect surgical sets that are being delivered to both the OR and CSPD. Consequently, the team will make recommendations to reduce the amount of incorrect surgical sets and reduce the search time for correct instruments.

Key IssuesThe following issues have been identified as drivers for the project:

Missing or incorrect instruments in surgical sets have the potential to cause case delays Case delays can pose a patient safety hazard, as patients have a limited time under

anesthesia Resources are wasted searching for instruments Frustration with incorrect surgical sets are decreasing the satisfaction of the OR, CSPD,

and Physicians

Goals and ObjectivesThe primary goal of the project is to identify the cause of incorrect surgical sets that are being delivered to both the OR and CSPD. The team will achieve this goal by performing the following tasks:

Observations of current surgical set lifecycle Interviews and surveys with stakeholders about the current surgical set lifecycle Audits of surgical sets leaving the OR and CSPD Statistical analysis of surgical set and survey data

From this information, the team will develop recommendations to:

Reduce the number of incorrect surgical sets that reach the OR and CSPD Reduce the amount of time spent searching for instruments Improve surgical set assembly process in the CSPD

Project ScopeThis project’s scope includes surgical sets that have missing, extra or incorrect instruments. The scope includes the entire surgical set lifecycle which includes: the use of surgical sets in the OR, the transportation process of surgical sets to either the quick turnaround CSPD or the main CSPD, the surgical set cleaning and reorganizing processes in the CSPD, the search process for correct instruments, the surgical set sterilization process, and the transportation process of surgical sets back to the OR.

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Anything that is not a part of the regular OR surgical set lifecycle was not in scope. In particular, sets with an orange sticker indicating a missing instrument were not in scope. Also, clinic, loaner, and Surgitech sets were not in scope. Finally, any items classified as implantables for operations are handled by a separate group of employees and therefore were not in scope.

METHODOLOGY

Team 2 used a variety of methods to conduct this project: observations and interviews, literature search, data collection and analysis, surveys, and an in-service pilot. Each method is explained in further detail below.

Observations and InterviewsEvery member of the team has observed both the OR and CSPD. During the observations, the team members were paired with an employee who explained the process and answered the team member’s questions. These observations, a total of at least 20 hours across the team, have provided the team with a better understanding of the surgical set process and raised possible problem areas that the employees see.

With those observations and input from the processors and nurses, the team interviewed 13 relevant stakeholders in the surgical set process. Specifically, the team interviewed eight nurses, the OR and CSPD educators (who are responsible for training new employees), the nurse liaison, three service leads (who are responsible for the stock of surgical sets and peel packs), and two CSPD supervisors.

Through these observations and interviews, the team received a firsthand account of the surgical set process, the pain points in the surgical set lifecycle, and some of the possible causes for incorrect surgical sets. From our observations, the team noticed that the OR and CSPD staffs do not understand the pain points of the other staff. As a result, the team led two team building activities with the OR and CSPD to help increase comradery.

Literature SearchThe team used two final reports from previous IOE 481 teams and five articles from The Detroit News to gather a broader understanding of why instruments go missing, compare actions and results from other hospitals experiencing similar issues, and ultimately help develop recommendations. The two IOE 481 teams’ final reports gave background on methods that were previously implemented in the CSPD to track the most commonly used instruments [1], reasons why materials go missing, and ways to reduce time spent searching for missing materials [2].

The Detroit News articles were a relevant, timely, and local reminder that UMHS is not the only hospital that faces the issue with instruments. The Detroit Medical Center (DMC) is currently undergoing extensive measures to improve their instrument cleaning process to avoid losing federal funding [3]. Previous efforts failed to improve the process at DMC [4], but the largest area of opportunity was to restructure the employee training process [5]. The DMC submitted a five-page plan to state regulators with details on their action plan, most of which included plans

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to increase training, oversight, and infection control practices [6]. After implementing some of the changes, the DMC passed the inspection and is no longer at the risk of losing federal funding [7]. However, recent emails showed that the state and federal agencies conducting the investigation have doubts about their expertise, which triggered a longer investigation for both the government and the DMC [8]. UMHS’s ORs and CSPD do not face as extreme issues as the DMC; however, it is useful to see the measures the DMC is taking to improve the instrument sterilization process.

Below is a summary of the sources and how the team used the information to improve the results of this project:

Table 1: Literature search provides applicable information to projectSource Summary Takeaways

[1]. IOE Team 5, 4/21/15

The CSPD has experienced a variety of problems such as lost and broken instruments, items sent to wrong location, and a lack of standardization since the merger of the OR and CSPD.

CSPD instruments need a better tracking process and requisition form process.

[2]. IOE Team 4, 4/27/09

Nurses spend a lot of time obtaining missing medical and surgical materials.

The most frequent missing materials were materials that were most frequently used, and the time to find missing materials was increased because nurses did not know where to find the materials and were busy with other tasks.

[3]. The Detroit News, 10/11/16

The DMC has failed to implement effective policies and procedures, and unless progress is made by Dec. 2016, the DMC is at risk of losing federal funding.

Investigations found problems in both the OR and Central Sterile Processing (CSP) departments that relate back to improper training.

[4]. The Detroit News, 8/25/16

The Detroit Medical Center (DMC) are experiencing issues with dirty and missing instruments in multiple hospitals.

The biggest concern at both the DMC and UMH is compromised patient safety.

[5]. The Detroit News, 9/15/16

The DMC is under investigation for using dirty and missing instruments in surgery and had 60 days to submit a plan to fix the cleaning and

Findings show that there is a lack of training and communication for employees and management

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sterilization issues. at the DMC. Attendance at a training session was recorded at 50%; UMH does not experience this extreme of a lack of attendance at training sessions.

[6]. The Detroit News, 10/18/16

The DMC submitted a five-page plan to increase training, oversight, and infection control practices in efforts to fix the dirty instrument problem and ensure federal funding.

Reports showed that the problems stemmed from both the CSP and the ORs. The action plan addresses both areas for improvement.

[7]. The Detroit News, 11/11/16

The DMC passed an inspection and will not lose federal funding. Changes were made at the DMC, but the root cause of the problem still needs to be addressed.

Changes in the CSP include more employee training and meetings. Changes in the ORs include using a different floor cleaner in the ORs and all personnel must wear foot coverings. Changes to come include training to soak tools post-surgery and to use proper instrument-use procedures during surgeries.

[8]. The Detroit News, 11/29/16

Released emails show that the leader of the state and federal agency investigating the DMC questioned the expertise of the staff in the DMC investigation.

The DMC’s instrument issues are not resolved, and the released emails showed additional surgeon complaints and the DMC’s lack of recommended practice of sterilization of surgical sets.

Data Collection and AnalysisThe team analyzed two data sets: data previously collected by the coordinators and data collected by Team 2 during an audit of the decontamination and sterilization areas.

Coordinator DataThe project coordinators have been collecting data on incorrect surgical sets since May 2016. The team planned to analyze this data for factors that contributed to incorrect surgical sets, but the data illustrated a steady decrease in the number of reported incorrect surgical sets. Consequently, the data has become less representative of the incorrect surgical set issue. From the team’s interviews, processors and nurses did not believe that the time and effort needed to properly report the incorrect surgical sets outweighed the benefits. With this information, the

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team decided that the previously collected data could not be used to determine an accurate rate of missing instruments.

Decontamination and Sterilization Audit DataThe project coordinators suggested that the team collect supplement data on the accuracy of surgical sets at different points in the surgical set lifecycle. This data was necessary to provide information on the accuracy of surgical sets exiting the OR and CSPD. The team analyzed this data to see if any services, surgery types, operating rooms, or surgical set types are more likely to encounter issues. The team collected data in two points of the surgical set lifecycle: after exiting the OR in the decontamination area and before exiting the CSPD in the sterilization area.

The first point for data collection was when the surgical sets left the OR and were sent to the decontamination area. A team member would partner with an OR nurse and check the accuracy of surgical sets coming from the OR.

The second point for data collection was after the surgical sets were assembly in the CSPD and before the surgical set entered sterilization. These sets were checked for missing, incorrect, and extra instruments. The team collected 75 data points between the two locations.

SurveysFinally, the team distributed two unique paper surveys: one survey for the OR staff and another survey for the CSPD staff. These surveys were distributed by the coordinators to the proper staffs. The team designed the OR survey to determine the level of current reporting of missing instruments, the average amount of time spent searching for missing instruments, the areas searched most often for instruments, the importance placed on sorting the instruments into their proper set, the current pain points, and areas for improvement.

The team designed the CSPD survey to determine how much time is spent searching for instruments, the most frequently used search methods and areas for missing instruments, how often missing instruments are currently reported, assembly pain points, and areas for improvement.

The team tabulated the surveys in Excel and analyzed the results to determine the following: Average search time in the OR and CSPD for missing instruments Estimate for the number of incorrect sets in the OR and CSPD Current instrument search preferences process in the OR and CSPD

In-service PilotThe team had the opportunity to share some of its initial findings and perform a pilot of the team building recommendation on November 17, 2016 at an OR and CSPD in-service meeting. Approximately 100 staff members from both the OR and CSPD attended the in-service. One of the team’s recommendations was to increase the frequency team building opportunities. Therefore, Team 2’s goal for the in-service was to provide the OR and CSPD staffs with the opportunity to meet each other and build camaraderie by performing team building activities. The team also shared initial findings during the in-service. Based on Team 2’s personal experiences as well as conducted research, the team proctored effective activities for the in-

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service. Overall, the in-service was well-received by the staff, and feedback and dialogue were positive. The agenda for the in-service was as follows:

Two Truths and a LieThe in-service began with the introductory activity “Two Truths and a Lie.” “Two Truths and a Lie” is an activity that begins with volunteers sharing three statements, two of which are true and one is a lie. Other members are then responsible for guessing which of the statements was a lie. Due to the size of the in-service, the audience was divided into 12 teams and asked to respond as a unit. The goal of the activity was to increase staff interaction and buy in for future activities. Also, the activity allows for staff members to learn more about coworkers in other departments.

Ten volunteers were asked to provide three statements and prior to beginning the activity, Team 2 created teams of people from different departments and friend groups. Staff members were given a number 1-12 for their assigned team. Team 2 created separate number teams for the OR and CSPD to make sure there were members from both staffs in each team. As an incentive to participate, the group with the most number of correct responses won candy.

Marshmallow Spaghetti TowerAfter the “Two Truths and a Lie” activity, Team 2 proctored the “Marshmallow Spaghetti Tower” activity. The goal of this activity was to build the tallest free-standing tower that could support a marshmallow with the provided spaghetti, tape, and string. Teams were competitive, innovative, and engaged. Figures 1 and 2 show the staff interacting during the team building activities.

Initial FindingsTeam 2 explained its project and discussed its findings up-to-date at a high-level, which later sparked a respective and constructive conversation between OR and CSPD staff members. The

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Figure 1: Group 1 Working on Marshmallow Spaghetti Tower

Figure 2: Group 6’s Finished Marshmallow Spaghetti Tower

OR and CSPD staffs understood that the incorrect surgical sets were frustrating all staff members at different parts of the surgical set lifecycle.

FINDINGS AND CONCLUSIONS

While carrying out the tasks described in the methodology section, the team collected a number of findings on the surgical set lifecycle. These findings were then organized into four main conclusions:

There was a lack of communication and understanding between the OR and CSPD The CSPD search process was not standardized Valuable surgical set information was lost when count sheets were thrown away in the

decontamination area The count sheet includes the manufacturer name which confuses the OR and CSPD staffs

and does not include a list of allowable substitutes

Lack of Understanding between Departments

There are two root causes for lack of understanding between departments: a disconnected team and a lack of transparency on department policies.

Disconnected TeamDuring interviews and observations with both the OR and CSPD staff, a common theme that emerged was how the other department could be doing a better job making sure instrument sets are correct. Both departments pointed out the issues that their own department had, but also attributed much of the error rate to the other department. The audit data showed, however, that both departments had errors. The error rates of the OR and CSPD were 24% and 39%, respectively, as shown in Table 2.

Table 2: OR and CSPD Audit ResultsN=75. Collected November, 2016. Audit

CSPD OR Grand TotalIncorrect Cases 8 16 24Total Cases 34 41 75Error Rate 24% 39% 32%

Both departments had a significant error rate, but attributed a significant amount of the missing instrument errors to the other department. This data and the team’s interviews with staff from both departments showed that the relationship between the two departments was not fully understood by either side. This relationship is based on the improvements in one department positively impacting the other department, and therefore requires teamwork and trust between the two departments. Since the departments are on separate floors and do not interact with each other often, a cooperative relationship is hard to build.

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Lack of Transparency of Department PoliciesIn addition, the team found that reporting of missing instruments dropped off significantly after the missing instrument reporting process was implemented in May of this year (2016). Shown below in Figure 3 is the number of filled out missing instrument reports by month.

May June July August September October0

20406080

100120140160 152

121

63

3418 15

Month

Tota

l Cas

es R

epor

ted

Figure 3: Reporting has dropped off substantially since May 2016N=403. Collected May-October 2016. Provided Data

As the data above shows, soon after reporting started, it dropped off significantly.

In interviews with the nursing staff, three nurses said that they did not report missing instruments because they were worried about getting the CSPD processors in trouble. While corrective action is taken when a missing instrument is found, it is used as a teaching process and multiple incidents must occur before any kind of punishment happens. The nurses did not know about this policy because disciplinary policies are not shared between the departments. In addition, three CSPD processors expressed frustration at the lack of accountability for OR nurses. They believed putting instruments back incorrectly or failing to clean instruments properly did not trigger any discipline for OR nurses. The clients informed us that there is a disciplinary process in the OR, but it very much varies on a case to case basis and the discipline is never made public. So while there was accountability in the OR, it was not made available for all to see. From this, the team concluded that lack of transparency on department policies has led to misunderstanding between the departments.

On the other hand, the survey results showed that the main reason for not reporting missing instruments in the CSPD was the time it took to do so. The survey results are shown in greater detail below in Figure 4.

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0

4

8

12

16

6

16

8

3 3

Responses

Res

pons

e Fr

eque

ncy

Figure 4: Lack of time is the main reason for CSPD processors not reporting missing instruments

N=36. Collected November, 2016. Survey

Four processors indicated to the team that they were worried about reporting missing instruments because it cut into their time to actually assemble sets. Processors are expected to complete approximately 18 sets per day and want to meet the quota in order to receive a positive evaluation. Processors are also expected to help unload instrument sets from the washer, place instrument sets in the correct shelving units prior to processing, and record any instances of missing instruments. The team inquired about the quota and learned that it is not strictly enforced, but is meant to be used as a general guideline. In addition, while determining the quota, time was set aside during the shift for reporting missing instruments. Processors appear to be taking the quota more seriously than it was intended to be used, therefore dis-incentivizing them to take the time to report missing instruments correctly even though there is time built into the day for them to do so.

Lack of Standardization in CSPD Search ProcessIn the CSPD, all six processors observed by Team 2 used a different search process for correct instruments. While talking with processors, Team 2 heard four main areas where processors look for instruments: the cabinet unit storage area, other surgical sets, peel packs from the OR cores, or the down cart. Also, processors ask other processors for advice on where to find the correct instrument or if there is another instrument that can serve as an acceptable substitute.

To determine if there is a standardized search process in the CSPD, Team 2 asked processors through a survey to rank the order in which they search for missing instruments. The results are shown below in Figure 5.

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1st 2nd 3rd 4th 5th 6th05

101520253035

Back cabinet units Ask other processor Peel packs from OR coresDown cart Other instrument sets Other

Position in Search Order

Res

pons

e Fr

eque

ncy

Figure 5: Missing instrument search order for CSPD processors.N = 36. Collected November, 2016. CSPD Surveys

As Figure 5 above shows, almost every processor first checks the cabinet units for a missing instrument. Checking other surgical sets and asking another processor were the most likely second options, with no clear third through fifth options. The “Other” option, when selected, was often not accompanied by a corresponding specification of what the “Other” was. When surveys did specify an “Other”, there was no clear trend to indicate another frequent search area.

Next, Team 2 examined the next two most used search locations, other instrument sets and asking another processor, to see how and why they were used. With regards to looking in other surgical sets, all six processors felt the OR does not always put instruments back in their proper sets before sending the sets down to CSPD. Therefore, the processors try to check other sets that they think were used together for a missing instrument. Processors told Team 2 they would check other surgical sets more often but they had no way of determining which sets were used together in the OR. In the team’s five OR observations, the nurses placed a number of items on trays, in water to soak, and other areas during surgery. These observations showed there was a possibility of items getting placed in the wrong set, since they were being mixed together during the surgery. During the team’s interviews, five nurses indicated that while they do their best to sort things into the correct trays, they are expected to close the case as quickly as possible so the proper time required for counting is not always available. This finding, along with the observations of instruments getting mixed, indicated that many missing items were most likely placed in a different tray and could therefore be found easily if the CSPD processors knew which trays were used together.

Additionally, during observations, three processors indicated to the team that at least one other processor knew the items better than them. However, due to the busyness of everyone in the CSPD, the processors did not always have the time or feel comfortable asking another processor for the location of an instrument, if the instrument could be substituted for a similar instrument, or if the instrument is vital to the set. Instead, processors ask the service lead when they have questions on substitutes or whether an instrument can be excluded from a set. However, service

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leads are only available on the day shift, so afternoon and evening shifts have no such resource. The team concluded that processors struggled without a service lead to confirm incomplete sets and help find correct instruments.

All of the above issues lead to a total average search time for missing instruments of 7.9 minutes in the CSPD, according to the survey that CSPD members fill out when they encounter an incorrect surgical set. The search time is a result of the following issues:

Processors not following a standard search process. Processors not knowing which instrument sets were used in surgery together Processors spending unnecessary time searching for instruments that could be easily

located by asking another processor or that are non-vital to the surgical set

Valuable Information Lost on Count SheetsIn interviews with nursing staff, all seven nurses mentioned that they often write notes on the count sheet about instruments that were missing or incorrect. These notes took the place of actually reporting a missing instrument if the instrument was non-vital or not used. The nurses were under the impression that those count sheets were sent down to the CSPD where the processors could read the notes. In actuality, the count sheets are thrown out in the decontamination area because they were exposed during the surgery and could hold dangerous materials or bacteria. Due to the count sheets being thrown out, the information and notes that the nurses leave on the count sheet are lost before processors see it. This loss of information hinders CSPD processors in fixing small mistakes and leads to incorrect sets being sent up to the OR with the same incorrect or missing instruments.

OR and CSPD Frustrated with Count SheetsDuring observations, the team noted that the OR and CSPD staffs were frustrated with the following: the manufacturer names were difficult to use and there was a gap between the OR and CSPD on substitutes.

Manufacturer NamesThe OR and CSPD staffs use the information provided on the count sheets to return and assembly surgical sets. Table 3 shows the columns of information provided on count sheets.

Table 3: Count sheet provides very specific information on instruments needed in surgical setColumn Name Information ProvidedItem Description/Size Brief text description of the itemManufacturer Manufacturer name of each instrumentManufacturer Catalog Number Unique identifier of each instrumentQuantity Quantity required of each instrument

Prior to 2015, count sheets included the common name used by most nurses and surgeons for the instruments instead of the manufacturer name. Due to inconsistency in the naming conventions between and within the OR and CSPD, the common names were replaced with the manufacturer names and number.

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The seven interviewed nurses informed the team that the nurses were unable to use the manufacturer name to identify an instrument when counting instruments before and after a surgery. The data from the team’s surveys validated this claim, as 85% of nurses and 37 % of CSPD processors surveyed indicated they could not use the manufacturer name to identify an instrument. The team then observed how nurses and processors counted the instruments of a surgical set if the manufacturer name could not be used. Five of the processors used key phrases from the item description to identify most items, and the manufacturer name and number to confirm any instrument they were not sure of. If neither of those approaches worked, processors used the pictures provided in Censitrac to identify the instrument. In the OR, all 11 of the nurses the team interviewed and observed counted the instruments using a name that was similar to the item description, and only used the manufacturer name and number to confirm several instruments. However, if the nurses do not know what the manufacturer name is referring to, the nurses do not have access to Censitrac and the instruments’ pictures.

These observations led the team to conclude that the manufacturer names include too many technical terms which are often unnecessary and confusing. Employees typically refer to an instrument by key phrases from the manufacturer name, and only use the manufacturer names and numbers to confirm the instruments. The lack of usability of the manufacturing names has led to nurses returning instruments to the incorrect surgical sets and processors not knowing which instrument is correct when they do not have an exact match or picture.

SubstitutesTeam identified a discrepancy between how the OR and CSPD handled substitutes for instruments. Currently, the count sheets include one manufacturer name and number for each instrument. The six processors the team observed would first try to find the item listed on the count sheet with the exact manufacturer. If the processors were unable to find that instrument, they would find another instrument of the same description made by a different manufacturer and substitute that instrument. In the OR nurse interviews the team held, all seven nurses said items are un-substitutable and must match the count sheet exactly due to surgeon preferences. The team was informed there is an area in Censitrac, under each instrument to list all acceptable substitutes. Certain instruments do contain this list, but many instruments have no substitutes listed. These observations showed the OR and CSPD do not agree on or have not clearly communicated with each other what is an acceptable substitute for instruments.

RECOMMENDATIONSFrom these team findings and conclusions, the team developed recommendations to reduce search time for missing instruments, reduce number of incorrect surgical sets, and increase data reporting.

Interdepartmental Relationship MaintenanceThe missing instrument problem has frustrated both the OR and CSPD staffs. Given that the surgical sets are handled equally by both staffs; the findings showed each staff believes it is the

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other that is causing the missing instrument problem. Therefore, the relationship faded between the OR and CSPD, and tedious procedures, such as instrument counting, have not been followed.

Another factor affecting the interdepartmental relations is the misunderstanding of departmental polices. Nurses are reluctant to report missing instruments because they fear it will mean discipline for a CSPD processor. In addition, CSPD processors feel as though OR Nurses have no accountability even though there is a policy in place to discipline nurses for missing instruments.

Team BuildingThe team recommends the clients conduct regular team building exercises to improve interdepartmental relations. The team building exercises should be conducted with groups with members from both the OR and CSPD. The purpose of the team building exercises is to increase the interaction between departments, and also teach lessons about teamwork and comradery. The team building exercises should include an open conversation where procedures are restated and discussed. By improving relations and restating procedure, the two staffs are more likely to count instruments correctly and communicate more.

The team conducted a pilot test to determine if the OR and CSPD staff would actively participate and learn from the team building exercises. The team facilitated two team building activities and an active discussion during the November in-service. From the staffs’ and clients’ reactions, the in-service was successfully engaging and well-received by both staffs.

Restructured AccountabilityThe team recommends the clients communicate details of department policies for missing instruments to both staffs. Even though both departments have policies that Team 2 feels are fair, the policies are widely misunderstood by both departments.

Additionally, both OR and CSPD staffs should be reminded of general department policies quarterly. Team 2 found that incorrect instrument data reporting has decreased because the processors feel that it takes too much time to complete, and they are preoccupied with meeting the productivity quota. If processors know that there is time built into the day for them to report missing instruments, and that the quota is not a strict number they have to meet, they will be more willing to report missing instruments they encounter.

Making policies more transparent will increase buy-in from both departments and help the departments understand the impact their actions have on the other department. Furthermore, an increase in accurate data reporting will lead to better tracking of missing instruments in the OR and CSPD.

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Standard CSPD Search ProcessTo reduce the average search time for correct instruments in the OR and CSPD, the Team 2 recommends the following changes:

Include a subject matter expert (SME) on every CSPD shift without a service lead Implement an external marker on surgical sets used together during surgery Standardize the search process

Subject Matter ExpertProcessors unfamiliar with a service have less confidence in recognizing instruments which may result in an unnecessary search. Service leads decide if the surgical set can be completed without the missing instrument or if there is an acceptable substitute for the instrument. However, the Service leads are only scheduled for day shifts on weekdays. Therefore, there is a gap in expert knowledge and processors are at risk of wasting time searching for missing instruments.

To provide guidance on shifts without service leads, the team recommends the clients include a list of SMEs in the CSPD. The SME would be responsible for answering questions from other CSPD processors regarding missing or confusing instruments. Each service would require their own SME. Given certain staff members experience with the CSPD, the team recommends the clients look to utilize their current staff to fill the SME role.

External Surgical Set MarkerAs laid out in the findings, a majority of OR staff believe that missing instruments are returned to the wrong surgical set during the surgery’s closing. Currently, there is no way for the CSPD processors to determine which surgical sets were used together during surgery. To reduce the search time for missing instruments in the CSPD, the team recommends that the OR attach an external marker on surgical sets used together during surgery. The external markers should have the following properties:

Use both color and written cues to group surgical sets Be relatively small (approximately the size of a quarter) to not inconvenience the staff,

not interrupt the current instrument lifecycle, and fit on all surgical sets Be purchased in bulk at once and be replenished as necessary to reduce time spent on

managing external markers

The external marker can group surgical sets by following attributes:

Day surgical sets were used Operating room where surgical sets were used Surgery number for surgical sets

Of these attributes, the surgery number provides the most precise grouping of surgical sets. However, it is impractical to design an external marker based on the surgery number, because the surgery numbers change daily and are too long to fit on a small external marker. The team recommends that the external marker group surgical sets by day and operating room.

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Specifically, the team recommends the external markers differentiate each day with different colored external markers and differentiate each operating room with different numbers (1 to 32). The external markers would allow for CSPD processors to know which surgical sets had the higher probability of being used during surgery together.

Given that there are approximately 384 surgical sets used per day, the team recommends the clients provide the processors with specific scan data from the OR of surgical sets used together. The external markers allow for the processors to have a higher probability of finding surgical sets used together during surgery. However, scan data from the OR would allow for confirmation.

Due to the time constraints, Team 2 does not feel comfortable recommending a specific pilot test. The team recommends the clients or a new student team perform a pilot test with external markers. The external markers should come in seven colors, one for each day of the week, and include numbers 1 to 32 on both sides, corresponding to each of the operating rooms. Possible external markers could include: tags, book rings, stickers, or digital tags.

Standard Search ProcessThe CSPD processors are not following a standard search process when looking for missing instruments, which is leading to longer search times. The team suggests that the CSPD staff implement the following search process flow:

1. Check back shelving unit2. Use external markers to find other surgical sets used during surgery together3. Ask service lead or SME if missing instrument is necessary or if there are acceptable

substitutes4. Check peel packs in OR core5. Put the surgical set on the down cart

Decontamination Count SheetsDuring the surgery’s closing, the OR staff will write comments on the count sheet before sending the surgical set down to decontamination. The surgical set is then taken down to decontamination where the count sheet is disposed of and the instruments are cleaned.

The team recommends that the notes from the OR staff are transferred to the CSPD processors next processing the surgical set. The CSPD processors will be able to make the adjustments necessary based on the OR’s comments, and in turn reduce the number of incorrect instruments in the surgical set.

The team recommends that the OR staff input their notes online, and then the CSPD staff be informed via a reminder. Preferably, the notes from the OR should be inserted into Censitrack and the CSPD staff would be reminded with a message to read the new notes. Unfortunately, the project coordinators have informed the team that currently there is no way of implementing this

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process in Censitrac since the Censitrac developers are focusing their efforts on a new version that is expected to be released in the coming year (2017). Once this version is released, Team 2 recommends the clients look into finding a way for the notes to be communicated electronically.

In the meantime, the team recommends the notes are transferred via white instrument tags that the hospital already own. These tags attach to the surgical sets and can be written on using permanent marker. The tags, along with a permanent marker, would be stored in each of the OR rooms so that nurses could easily attach one to a set and write the count sheet notes. The tags can then be sent through decontamination and the washing process without the information on the tags being washed away. Once in CSPD, the processors would remove the tag, if one was attached, read the necessary information, and dispose of the tag.

Common Name and Acceptable Substitutes CommitteeTo reduce confusion on instrument names and substitutable instruments, the team recommends that the clients establish a committee to condense the instrument’s manufacturer name and list the acceptable substitutes for each instrument in each surgical set.

Condensed Manufacturer NamesAs described in the findings, processors and nurses use key phrases from the manufacturing names on the count sheet to determine instruments. If that failed, the processors and nurses use the manufacturer name and number as a unique identifier. Since using the manufacturer name and number is impractical for hundreds of instruments when a surgery is closing, many instruments are returned to incorrect sets. The CSPD processors then must spend additional time correcting the surgical set and searching for missing instruments.

To improve the accuracy of surgical sets after the surgery’s closing and during the assembly process, the team recommends the clients form a committee to decide on shortened manufacturer name for each instrument that include all necessary identifying information. This name would replace the current manufacturer name and allow for faster identifying of instruments while still leaving the manufacturer name and number as an exact check.

Allowable SubstitutesIn addition to the manufacturer names confusing employees, the findings showed a discrepancy between the OR and CSPD on acceptable substitutes. CSPD processors frequently substitute instruments when the instrument listed on the count sheet is unavailable, while OR nurses want no instruments substituted. There is an area in Censitrac for substitutes to be listed, but it is currently not filled out for most instruments. This gap in allowable substitutes leads to increased search time in the OR when substitutes are used, which leads to time away from patients.

The team recommends that the clients form a committee to form a list of acceptable substitutes for each surgical set. The list of acceptable substitutes should be incorporated into the Censitrac

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system to allow the CSPD processors to access the information from their computers. The acceptable substitutes should not be printed on the final count sheets, as that will increase the size of the count sheet and further slow-down the count process in the OR. The acceptable substitutes should include the different manufacturer names and (if possible) manufacturer numbers.

A list of acceptable substitutes is necessary if the manufacturer name is to be shortened. A risk of including shorter names is the ambiguity of instrument definition, which can lead to including unacceptable instruments when they share a similar name with the acceptable instruments. A list of acceptable substitutes with exact manufacture names and numbers allows for the CSPD processors to complete a set correctly and the clearer manufacturer name allows for the OR staff to return instruments to surgical sets correctly. However, the team recommends that the clients avoid shortening the manufacturer name without a list of acceptable substitutes.

EXPECTED IMPACTUsing data from the surveys Team 2 conducted and salary data provided by the hospital, the team determined that the hospital currently loses between $175,000 and $400,000 of productivity a year in the CSPD, and between $25,000 and $350,000 of productivity a year in the OR due to searching for instruments. Team 2 estimated a conservative assumption for improvement in the CSPD is a reduction of expected incorrect surgical sets by 1, and a reduction of expected search time by 10%. Consequently, Team 2 expects savings between $42,000 and $80,000. In the OR, Team 2 assumed a reduction of expected incorrect surgical sets by 1 in the upper bound and 0.5 in the lower bound, with no reduction in search time. Consequently, Team 2 expects savings between $12,000 and $86,000. Along with improvements to productivity, Team 2 expects other qualitative improvements such as a more engaged workforce and improved patient safety. Team 2’s recommendations address the objectives for project:

Improving interdepartmental relations reduces the number of incorrect surgical sets that reach the OR and CSPD

Standardizing the search process reduces the amount of time spent searching for instruments

Adding SMEs, changing the manufacturer name to a common name, and using the decontamination count sheets improves surgical set assembly in the CSPD

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BIBLIOGRAPHY

[1] J. Kurth, "Emails: DMC probe head iffy on staff’s expertise," in The Detroit News, 2016. [Online]. Available: http://www.detroitnews.com/story/news/special-reports/2016/11/28/emails-dmc-probe-head-iffy-staffs-expertise/94580404/. Accessed: Nov. 29, 2016.

[2] J. Kurth and K. Bouffard, "DMC submits plan to state to fix dirty instrument woes," in The Detroit News, 2016. [Online]. Available: http://www.detroitnews.com/story/news/local/detroit-city/2016/10/18/detroit-medical-center/92382716/. Accessed: Nov. 29, 2016.

[3] J. Kurth and K. Bouffard, "DMC’s fed funds at risk if issues not fixed in 90 days," in The Detroit News, 2016. [Online]. Available: http://www.detroitnews.com/story/news/local/detroit-city/2016/10/11/dmc-feds-dirty-equipment/91917860/>. Accessed: Oct. 24, 2016.

[4] J. Kurth and K. Bouffard, "State probe: Lax training at DMC violates health codes," in The Detroit News, 2016. [Online]. Available: http://www.detroitnews.com/story/news/local/detroit-city/2016/09/15/state-dirty-instruments-dmc-violate-health-codes/90430466/>. Accessed: Oct. 24, 2016.

[5] K. Bouffard and J. Kurth, "Dirty, missing instruments plague DMC surgeries," in The Detroit News, 2016. [Online]. Available: http://www.detroitnews.com/story/news/special-reports/2016/08/25/dirty-instruments-plague-dmc-surgeries/89303582/>. Accessed: Oct. 24, 2016.

[6] K. Bouffard and J. Kurth, "DMC avoids loss of federal funding," in The Detroit News, 2016. [Online]. Available: http://www.detroitnews.com/story/news/local/detroit-city/2016/11/10/dmc-funding/93609210/. Accessed: Nov. 29, 2016.

[7] M. Mark, M. Priesand, and V. Zhang. Recommendations to Improve the UMHS Procedure for Obtaining Missing Materials. N.p., 27 Apr. 2009. Web. 24 Oct. 2016.

[8] O. Jones, D. Klippel, M. Mehta, and H. Perlmutter. Analysis of the CSPD Floorside/Non OR Workflow. N.p., 21 Apr. 2015. Web. 24 Oct. 2016.

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APPENDIX

Appendix A: CPSD and OR Surveys

CSPD ProcessorsHow long have you been with the CSPD including training? _______________

What shift do you work?Day Afternoon Midnight

How many sets per shift do you see with missing, extra, or incorrect instruments?0 - 3 4 - 7 8 - 11 11 - 14 15 - 18 18+

When a set is incorrect, how often do you report it on the CSPD survey website?Never(0%) Rarely(~20%) Sometimes(~40%) Frequently (~60%) Almost Always (~80%) Always(~100%)

What is the main reason that prevents you from reporting a missing instrument on the survey website?Don’t have time Able to find instrument quickly Website is confusing I forget Other _____________________________________

How long do you search on average for an instrument before finding the instrument or putting the set on the down cart?<5 min 5 - 10min 10 - 15min 15 - 20min >20min

Provide the order (1 - first through 6 - last) in which you search for missing instruments:Back cabinet units _______________Other surgical sets _______________Down cart _______________Ask other processor _______________Peel packs from OR cores _______________Other (specify ______________) _______________

What percent of instruments can you easily identify for the service you are most familiar with?0 - 25% 26 - 50% 51 - 75% 76 - 100%

What percent of instruments can you easily identify for the service you are least familiar with?0 - 25% 26 - 50% 51 - 75% 76 - 100%

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Are you able to use the manufacturer name (current name on count sheet) to identify an instrument? No Yes

Is there anything you would like to say about possible causes or solutions to the missing instrument problem?

OR NursesHow long have you been with the OR? _______________

What shift do you work?Day Afternoon Midnight

How many sets per shift do you see with missing, extra, or incorrect instruments?0 - 3 4 - 7 8 - 11 11 - 14 15 - 18 18+

When a set is incorrect, how often do you report it on/to ___________________?

Select one per row Never (0%)

Rarely (~20%)

Sometimes (~40%)

Frequently (~60%)

Most Always (~80%)

Always(~100%)

CSPD Supervisor

Debrief

Patient Safety Form

What is the main reason that prevents you from reporting a missing instrument on/to ______?

Select one per row Don’t have time

Able to find instrument quickly

Website is confusing

I forget Other

CSPD Supervisor

Debrief

Patient Safety Form

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How long do you search on average for an instrument?<5 min 5 - 10min 10 - 15min 15 - 20min >20min

What percent of instruments can you easily identify for your service?0 - 25% 26 - 50% 51 - 75% 76 - 100%

What percent of instruments can you easily identify outside of your service?0 - 25% 26 - 50% 51 - 75% 76 - 100%

Are you able to use the manufacturer name (current name on count sheet) to identify an instrument? No Yes

Is there anything you would like to say about possible causes or solutions to the missing instrument problem?

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Appendix B: Surgical Set Lifecycle

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Appendix C: Excel Workbook for Expected Impact

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Appendix D: Example of a Count Sheet

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