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TABLE OF CONTENTS

PageExecutive Summary1.0 Introduction and Background 12.0 Approach and Methodology 23.0 Current Situation 54.0 Inventory Replenishment Process 6

4.1 Ordering of Supplies 64.1.1 Special Ordering 64.1.2 General, Ordering 84.1.3 Ordering of Supplies Findings 8

4.2 Delivery of Supplies 104.2.1 Sepcial Orders 104.2.2 General Orders 114.2.3 Delivery of Supplies Findings 12

5.0 Service Scheduling Process 135.1 Service Scheduling Process Findings 15

6.0 Additional Findings 167.0 Recommendations 21

TABLE OF APPENDICES

APPENDIX A. Flow of Weekly Placement orders (Special Items)

APPENDIX B. Flow of General Material Ordering Process

APPENDIX C. Order Arrival Process (Special Items)

APPENDIX D. General Materials Receiving Flow

APPENDIX E. General Materials Replenishment Flow

APPENDIX F. Service Scheduling System Flow(Picking of first case only)

APPENDIX G. Service Scheduling System Flow (Day of Surgery)

APPENDIX H. NeuroSurgery Inventory Count Form

APPENDIX I. OR Equipment/Supply Requisition Form

APPENDIXJ. Sample Pick List

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EXECUTIVE SUMMARY

The elimination of waste and inefficiencies of processes in the inventoryprocedure of the OR is important to improve the overall system. To evaluatethe inventory processes and general flow of items, it should first be noted thatthe key areas of inventory management are located in the OR and MaterielServices (MSE). The area is divided into three “cores”, named A, B, and Cand includes twenty-three operating rooms. Each department is allocated acertain amount of space within the cores to store its inventory. In addition,there is a main storeroom for MSE items in core A.

All stock items fall into one of two categories: general items from MSE andspecial orders from outside vendors. Some of the most expensive specialitems are also on consignment, which means that the item is not owned bythe OR until it is used. There are no special, designated areas for anyparticular item, as general items and special orders (and consignment items)are shelved together.

Implementation of the SSI Surgi-Server inventory software has resulted inthe program completely replacing the former preference card system in coreA. In cores B and C, the process of entering the preference cards into the SSIdatabase has already begun. Surgi-Server is used most frequently in theservice scheduling area. Surgeries are finalized approximately at 11:30 A.M.the day before, but an advanced schedule likely to change is generated a weekbefore.

Surgi-Server’s database is used to generate “pick lists” to indicate whichitems are needed for the next days surgeries. Pick lists are printed and sent tothe specific department at about 1:00 PM.

Key findings discovered during the inventory flow research include thefollowing:

• Dissimilarities between departments concerning the use of the Medical

Assistant

The job description for the Medical Assistant (M.A.) differed slightly

between departments. While all the departments allowed the C.N. ifi to train

the M.A., one department appeared to designate more responsibility to the

assistant. In this department, the M.A. is responsible for completely stocking

the items onto the shelves. Additionally, the M.A., upon receiving the SSI

generated pick list, picks supplies onto the bypods for the next day’s cases.

In another department, the stocking of items onto the shelves is a joint

effort between the M.A.’s and the R.N.’s. This department also had the M.A.

prepare the bypods, but it appeared that the R.N.’s took a more “hands-on”

approach with the items.

• Comparison of General Items vs. Special Items

General items and Special items are managed by different members of the

OR staff. General items are the responsibility of the stockkeepers, while

special items are the responsibility of the nurse coordinators or C.N. III. The

following table summarizes the differences among the two types of supplies.

Special Items General ItemsNumber of line 8,000 5,000

itemsPercentage on 80% 0%

ConsignmentNumber of Fed. -30/week 2/month

Ex. orders

Inventory on- 2 weeks 1-2 weeks

handTime to take 23 hours 20 min./ day

InventoryAverage orders 5 to 30 100

per weekNumber of —5 boxes 30

arrivals per dayAverage lead 3-7 days 5 days

time

C)

C

• Utilization of expensive equipment

One of the jobs of the circulating nurse is keeping track of items and price.

When an item of large expense comes into question, a discussion about its

use often arises. Nurses are often faced with a decision between using

supplies that a surgeon requests and the possibility of cutting costs for the

patient.

• Nurses spend. large amounts of time with inventory

There exists the theory that “nurses are on the forefront”. If nursing is

involved in the inventory process, they can talk directly to physicians.

Nursing knows and understands the intricate details involved in surgical

equipment. This is an argument used against adding departmental

stockkeepers to the staff.

• Relative independence between inventory replenishment and services

scheduling

Ideally, the ordering, pick list generation, and inventory replenishment

: processes should be tied together. Based on flow research, however,

inventory replenishment was found to be accomplished weekly through

comparison with par levels. With rio apparent approach to link the processes

together, goals of a perpetual inventory system are contradicted. A new

scheduling system is currently being implemented which has interface

capability with the SSI system being used. This interface will allow for more

of cooperation between the two processes.

• Apathy towards implementation of inventory software

The current attempt for implementation of the SSI Surgi-Server inventory

software program is the fifth in eight years. The program is not currently

used for inventory purposes, but is primarily used as a database capable of

generating pick lists. Ideally, the software should replace the time-consuming

equipment requisition process, and form the basis for a perpetual inventory

system. However, inadequate coordination in the past, and an aversion to

change have led to an apathetic view to the current implementation attempt.

1.0 Introduction and Background

Material requirements for the numerous surgical procedures are managed

by the Operating Room (OR) and Materiel Services (MSE). The operating

room deals with a total of 8000 products which are bought from outside

vendors, and 5000 general items which are bought from Materiel Services.

The high levels of inventory reflect the high values of supplies. The value of

OR supplies is estimated at around $2,000,000 in consignment orders only.

Both the special orders and the basic supplies (i.e., gloves, sutures, gauze, etc.)

which are common to every service are stored within each of the three cores

(A, B, and C) of the operating room. Each service has a designated location

and space within the cores to store its inventory.

Currently, nurses (R.N.’s), medical assistants (M.A.’s), and stockkeepers are

involved in the inventory ordering and replenishing processes. The number

of nurses responsible for the ordering varies depending on the size of the

service. Due to all the different people involved in the ordering and

managing of supplies, confusion occasionally arises. Because of the

numerous types of procedures and surgeon preferences, difficulties also have

been encountered in the effort to establish standards for surgical materials.

Situations such as backorders and Federal Express orders are ones which the

OR is would like to reduce, if not completely eliminate. The OR is aiming for

a perpetual inventory system. The SSI inventory software, Surgi-Server, is in

the process of being implemented to establish an on-line inventory system.

This implementation in addition to standardization, would result in a

reduction of money tied up in inventory due to a reduction of inventory

levels,, better coordination between the nurses and stockkeepers, and

improved organization of the overall system.

In order to ensure that all resources in the OR are effectively utilized and

that the number of items in inventory is accurate, a systematic materials

management system is required. The purpose of this project is to effectively

analyze and describe the system currently used at UH and identify possible

areas for improvement.

1

2.0 APPROACH AND METHODOLOGY

As the inventory handling process involves a large number of people, the

approach taken by the project team was to interview the relevant parties, as

well as to allocate substantial time to observe actual examples of the flow of

supplies within the cores and the operating rooms. The team treated the

interviewing process as an opportunity to understand the role and

responsibilities of the various people involved in the ordering, replenishing

and management of inventory. By observing the staff on a regular day in the

OR, the team was able to discover potential areas for improvements and

make suggestions for recommendations.

The first interview was conducted with the inventory coordinator. This

provided the team with a general description of the problematic issues and

main areas to concentrate on. The inventory coordinator exposed the team to

existingparadigms and prevalent attitudes among the staff. Many of the

nurses who have been responsible for the inventory system for many years

were very comfortable with the flow of the current system and expressed

resistance to any possible changes. The difficulty of learning a new

computerized inventory system was also noted as a concern by the nursing

staff. Also discussed were previous efforts made in addition to UH research

and studies conducted to improve the current system, such as the

establishment of a case cart system. With this information, the team was able

to understand the main areas of concern and the type of approaches already

considered. Subsequently, the team toured the three OR cores to get a more

accurate picture of how supplies are handled. This was the first opportunity

to see the equipment requisition forms, the shelving of stock, and the

preparing of bypods.

The stockkeeper was interviewed next. The responsibilities and work

sequence were described to the team. Correlation between the stockkeeper’s

ordering system and the nurses’ ordering system were identified. The

stockkeepers were determined to be responsible for ordering and replenishing

all the items bought from Materiel Services. In rare instances, special orders

were also placed by the stockkeeper.

2

Interviews were conducted with nurses (C.N. III) in charge of inventory to

gather information on the precise nature of the flow of materials. Three

C.N.’s III were interviewed, each from three different services (Neuro,

Cardiac, and ENT). The UH OR Head Nurse was interviewed so that a

standard inventory process could be determined. Issues discussed included

inter-departmental differences and current vs. proposed usage of the

computerized inventory software. The individual department nurses

provided a description of their department’s ordering and scheduling system.

The nurses were very cooperative in providing the most detailed

information on the inventory flow, from when supplies are ordered to when

they are stored and ultimately used and discarded. Issues regarding the

possibility of implementing a new “on-line” inventory system were

mentioned in the interviews in order to investigate on the nurses’

perspective about the effectiveness of the current system. The information

gathered from the department nurses was compared to the standard flow

provided by the Head Nurse in order to locate inconsistencies, if any.

Furthermore, the three specific departments were compared to determine the

consistencies and inconsistencies between the inventory control processes

because standardization of all departments was an issue of concern.

A tour of the operating room during a surgery further aided in analysis of

the inventory process. The team observed first-hand the responsibilities of

the nurse engaged in the preparation of a case. The circulating nurses were

observed bringing materials in and out of the operating room and keeping

track of all the extra supplies used in the case. Interviewing the circulating

nurse was also done at this time.

An OR ordering clerk was interviewed next to develop an understanding of

the ordering flow involved with material that is ordered from outside

suppliers. All of the items that are considered for ordering are listed within

the SSI Surgi-Server system. This includes detailed information about the

vendor and the expected cost of the items to be ordered. Some of these items

are purchased on blankets, which are estimated usage contracts with vendors

to help negotiate the price of the units. Further negotiating with the sales

representatives allow for discounts on early payments.

3

The team then interviewed a representative from the Med. Center

Information System department to understand previous attempts at SSI

implementation. The current state of the software and issues regarding

implementation were noted.

From the information received, an accurate overall flow was determined

and key issues were highlighted. Several of the staff members interviewed

also indicated what they felt were potential areas of improvements.

4

3.0 CURRENT SITUATION

Organization:

The inventory in the OR, including the ordering and storing process, is

managed by many people. For each department, multiple people such as the

C.N.’s III and medical assistants are involved in the OR materials

management program. Each staff member involved in the inventory process

has various responsibilities. This results in an intricate coordination and

organization among all the people involved . To analyze the current

situation, the flow of inventory should be separated into two independent

stages: the inventory replenishment process and the service scheduling

process.

5

4.0 INVENTORY REPLENISHMENT PROCESS:

The inventory replenishment process differs between special order items

and the general items. Special order items include all of those which are

ordered from an outside vendor and are specific to each service. General

items are those that are ordered in-house from Materiel Services and are

common to each service. These have different ordering, delivery, and storing

systems. Each department has a designated day of the week in which to take

inventory of all the supplies shelved in the core. The designated day is

consistent week after week. Through a system of checks and balances the

appropriate amounts of the specific items will be ordered.

4.1 Ordering of Supplies

General items and special items are managed by different staff members

and use different ordering systems.

4.1.1 Special Items

Specialty items are the responsibility of the nurse coordinators (C.N. III).

They are in charge of making sure that all supplies needed for each surgery

are on hand. Depending on the service, medical assistants also have

various responsibilities and aid the nurses on the day of inventory to

check which items are available and which are out of stock. The

inventory flow is as follows (Appendix A):

• On the designated day of inventory the C.N. III will look at the case

schedule that has been proposed for the following week to determine

the key items to look for when taking a physical inventory.

• All the data regarding quota levels, changes in quota levels, and

placement of orders for each individual item are kept in a binder. This

binder is retrieved for taking the inventory. Depending on the service,

the nurse(s) or the medical assistant(s) check the inventory on a

qualitative basis to determine if the level on hand complies with the

quota of what should be kept on hand, usually a two week supply of

inventory is held. When an item reaches a level below the set quota a

6

requisition order form is filled out and the binder is updated to indicate

the amount that was ordered on that given date.

• The nurses record what they are ordering on an inventory count form

Appendix H). This form lists item name and current quota levels and

the date that inventory is taken. Typically, two months worth of

inventory ordering records can be tracked. In the date columns, two

numbers are written down. One represents current on-hand

inventory, and the other represents the amount ordered.

• The requisition form contains three copies (Appendix I) The top two of

these copies, one white and one yellow, are delivered to a folder

outside of the OR Head Nurse’s office for approval to verify that no

unusual or extremely expensive items are being ordered. The third, a

pink copy is kept in another binder by the C.N. Ill who placed the order.

In the case of a new or expensive item being ordered, the Head Nurse

inquires with the C.N. III or surgeon who proposed the item as to valid

reasons why such an item is necessary. If the item is new, justification

must be given for the item to be added to the pick list. Otherwise, the

Head Nurse will refuse the order of the new inventory and an order

will be placed for an equivalent existing item already on the pick list. If

there is another problem, such as quantity, the Head Nurse will make

notes on the copies of the requisition form and then pass the forms on

to the ordering clerk.

• Upon receiving the requisition forms the order is double checked. If

the item on the order form is not part of the existing pick list then the

C.N. III is contacted as mentioned above. Additional notes may be

added to the requisition form to indicate any changes that the ordering

clerk has made. If the order is correct it is placed and the yellow copy of

the form is sent back to the respective C.N. Ill. The white copy is filed

by the ordering clerk for later use.

• Upon receiving the yellow copy of the requisition form, the C.N. III

will check any noted changes in the order. If no changes were made or

if the changes are acceptable it is noted that the order has been placed.

7

However, if an incorrect change has been made on the ordering form,

the ordering clerk or Head Nurse will be approached to discuss these

changes and make the final appropriate order.

4.1.2 General Items

The stockkeepers are responsible for managing the general items. They

place orders daily from Materiel Services based on stock units which are

available for each item for each core. The flow is as follows (Appendix B):

• The stockkeeper checks the inventory levels within each of the

operating room cores. For each item, the stockkeeper approximately

checks the quantity and notes if the quantity is low and by how much.

The inventories within the cores are filled from both the main store

room and from Materiel Services.

• The stockkeeper next returns to the Operating Room storeroom. The

stockkeeper then checks the inventory levels within the storeroom to

ensure that they can satisfy the requirements obtained from the

previous search of the OR cores. If inventory levels are adequate, the

item(s) are loaded onto a cart for later distribution in the core. If

inventory levels are inadequate, the quantity available is stocked to the

cart and the remainder is noted to be ordered from Materiel Services or

an outside vendor.

• Once the carts have been filled the quantities in the main storeroom

are qualitatively checked. If the quantity of the designated item is

determined to be below that of the par level, it is noted to be ordered.

The stockkeeper will then call in the orders to Materiel Services and

the appropriate outside vendors. These orders are placed once per day

to Materiel Services and once per week to outside vendors.

4.1.3 Ordering of Supplies Findings:

• Several variances have been noted throughout each of the services

within the OR. In some of the departments the C.N. III takes the

inventory and decides what to order. In other departments the medical

8

assistant is trained and trusted to keep track of the inventory levels and

fills out the order requisition forms for the necessary orders. (• In some departments the C.N. Ill or the M.A. will look at the surgery

schedule in advance to get an idea and an estimate of what items will

be needed for the next two weeks. In some cases, the C.N. ifi will have

to contact the surgeon(s) secretary to request the schedule, and in other

services a schedule of cases for the following week is provided on the

day the take inventory.

• When the medical assistant takes the inventory on the designated day

of the week it is more likely to be an exact count as the M.A. is

instructed to count every item shelved in the core for that specific

service. In the circumstances where the C.N. III takes the inventory it

is more likely to be an educated guess by eyeballing what is on-hand on

the shelves.

• When a requisition form is filled it is delivered to the ordering clerk at

which point the order is checked (by the ordering clerk and/or Head

Nurse) before being placed. Occasionally, the ordering clerk will notice

an error on the requisition form (i.e. the quantity of the item being

ordered is too high), will make appropriate changes on the form, and

will then place the order. Occasionally, the yellow copy of the

requisition form is given back to the R.N. or M.A. after the order has

been placed or even after the shipment has arrived. This is mostly

because the lead time for an order is on average very short and papers

get lost in the shuffle. Unfortunately, this results in shipment errors or

creates confusion in keeping track of the ordering process.

• Errors in requisition forms may occur when the wrong code number is

written on the form. This also results in an incorrect shipment. Thirty

to fifty orders are placed per day. The ordering clerk and the Head

Nurse can not always catch such errors among all the orders that are

placed daily by each service.

9

• The stockkeeper replenishes the main store room with general items

that are delivered daily. From there, the cores are also replenished

from the items originally stored in the main store area. This creates

double handling of the materials.

4.2 Delivery of Supplies

The method in which supplies are brought into the OR also differs

between special items and general items. They have different arrival/drop-

off points and are followed by their own independent system of checks to

ensure that each delivery is correct. Deliveries of both of these types of

inventories are received on a daily basis.

4.2.1 Special Orders

Delivery of special items arrive on a daily basis in quantities of

approximately fifty cases per day. They are checked by the ordering clerk

and double checked by the C.N. III once they are delivered to the core to

help ensure that the order received is correct. However, no system is

currently being used to check that the correct prices are charged on these

deliveries. In addition, Federal Express and rush deliveries are received

on a daily basis. The flow for the delivery of Special items is as follows

(Appendix C):

• Orders arrive on a daily basis into the OR. These orders are received by

the ordering clerk outside of their office. The white copy of the

requisition form (Appendix I) is then retrieved and the case is opened

and checked to insure proper delivery.

• If the order received matches the order placed, the white copy of the

requisition form is attached to the case and the stockkeeper will take

the order to the appropriate C.N. III in the designated core. Here, the

C.N. III or the M.A. will double check the order. If the shipment is

correct then the items are removed from the box and shelved.

Different services use different methods of storing their supplies in the

core. Some departments store the items in the cores alphabetically by

company name and some store them closely together according to the

10

cases for which they are used. If the order does not match, the C.N. III

is contacted. Upon being contacted, the C.N. III and the ordering clerk

will discuss what actions to take.

• If there is a problem with the quantifies of the items, (i.e.. excess is

received), it must be determined if the excess will be used up within

the allowable two week inventory limit. If not, the shipment is

returned and the original order is replaced. If the decision is yes, the

item will be kept and the C.N. III or stockkeeper will take the items to

the core and the binders will be updated.

• If there is a problem such that an entire shipment of supplies is

incorrect, it must be determined if the item is one that can be used

within the OR. If the answer is no, the shipment is returned but if the

answer is yes the inventory will be kept and taken to the core. In either

case it must be determined if the original item that was ordered is

needed immediately or it the surgeon can use a similar item instead. If

the supply is not needed immediately, the original order will be placed.

However, if it is absolutely necessary then the search will begm The ()search will start within the cores of the OR. If the item is not found in

the core the stockkeeper will be contacted to search within the main

storage room. If it is still not found, resources will be checked with

Kellogg and/or Mott hospitals. If the item is still not found, the

vendor can be contacted to reveal the nearest location of a hospital that

has received the item. If the neighboring hospital has the item on

hand they will ship it over. In the worst case scenario, the overnight

courier service will be used.

4.2.2 General Orders

General items are delivered every morning at approximately 5:00 AM.

These orders are received by the stockkeeper outside of the main store

room in Core A. Quantities range from ten to fifty cases per day from

Materiel Services. Orders are received the day after an order is placed from

Materiel Services and according to delivery times from outside vendors.

The flow is as follows (Appendix D):

11

• The stockkeeper will retrieve their note pad and the cases are checked

to insure proper delivery.

• If the order matches, the inventory is taken into and distributed

throughout the main store room. The remaining inventory that was

ordered is then brought to the designated location within the cores.

• When the inventory within the cores is checked the carts are filled

from the main store room as mentioned in the ordering process.

These carts are then taken from core to core to replenish the cores

inventories from the main store room. This process is usually

performed three times a day by the stockkeeper (Appendix E).

4.2.3 Delivery of Supplies Findings

• When an order is received and it is correct, it is not checked if the

correct price has been charged by the supplier for the items received.

The price listings are available on computer but are not displayed on

the requisition form. The original requisition form is the only thing

that the ordering clerk checks as the orders are delivered.

• Depending of the vendor, a wrong shipment will be taken back by the

company up to 30 days from the delivery date if the items are not

opened. However, if the supplier insists that the error was made by the

OR then the hospital has to pay for the excess re-shipment costs. A

wrong order is kept if it is less expensive to keep the items on stock

than to ship them back to the vendor, assuming that the inventory will

be used in the immediate future. This results in extra money being

tied up in inventory and in extra cost for Federal Express orders to

account for the item which was needed in the first place.

12

5.0 SERVICE SCHEDULING PROCESS:

The service scheduling process does not have any influence on the

materials ordering process. Ordering is based on quotas as mentioned above,

and it is not case generated. The service cheduling process is very involved

since there are many staff members engaged in the process. The Service

Scheduling Process is subdivided into two categories: The first cases of the

day which are picked the night before (Appendix F) and the following cases

picked the same day of the surgery (Appendix G).

Computerized pick lists are generated by Surgi-Server every day at

approximately 11:30 AM. The final schedule of surgeries for the day is

set only 24 hours in advance, but the schedules can be changed up to

the day of surgery due to such factors as cancellations. Once the

schedule is finalized, the pick lists that match the cases on the schedule

are printed and distributed to the nurses or medical assistants for each

department.

Pick lists are made available for the nurses at approximately 1 p.m. of ( )the day prior to the surgery. It takes on average 10 to 30 minutes to pick

a case. Depending on the department, either the M.A.’s or the Clin II

use the pick lists to gather all the items for the specific case. The

“hunt” for items begins, as items on the pick lists are not listed in any

particular order. Only the first case for the following day is picked for

each room because there are not.enough bypods and not enough space

in the cores to store them. All succeeding cases are picked during the

course of the same day in between surgeries. As an item is picked it is

checked off on the pick list and placed into an appropriate cart or bypod.

Bypods are sometimes difficult to locate since there is no specific

storage area for bypods only.

• If an item on the pick list is not available in the cores it is marked off

on the pick list as “missing”. If the case being picked is the first one of

the following day, then the missing items are hunted the next

morning, approximately 30 minutes before the case is set up.

Otherwise, the M.A. or the C.N. III will look for it right away. Usually,

13

the items not available are general items. This might occur either

because the item has not been restocked yet in the cores or because the

item is out of stock.

• Once all the available items are stored in the bypod, the bypod is placed

outside the designated operating room with the pick list attached to it.

If an item on the pick list is missing in the cores and it is out of stock,

then Federal Express orders are placed. Depending on the service,

orders are usually placed 2 to 3 times per week

• The day of the surgery, the bypod already prepared is brought into the

operating room. As the scrub nurse and the circulating nurse(s) open

the supplies they double-check the pick list. In most of the cases, pick

lists are not complete. This is often because of surgeon preference. This

contributes to the number of products lines in the OR inventory

because different types of the same item can be used to perform the

same surgery.

• During the course of the surgery, the surgeon or the scrub nurse

request items that weren’t originally on the pick list. At this point, the

circulating nurses are in charge of gathering these items in the least

amount of time possible.

• The circulating nurse first looks for the item in the cabinets inside the

operating room. This is where the small quantities of supplies most

frequently used are also stored. If the item is not available, then the

circulating nurse will start hunting for the item in each of the three

cores, starting with the closest core first. If the item cannot be found

and the surgeon can not agree to use a substitute supply then the search

is extended, depending on the emergency, to Mott and Kellogg. Other

Hospitals will be contacted as well if necessary.

• When the item is found and brought into the operating room, the

circulating nurse records the change on the pick list and the additional

cost of the item on a separate sheet of paper. At the end of the surgery

14

the C.N. III must sign the pick list to approve the changes made during

surgery. (

The clerk will not add the new items onto the pick list without a

signature, but will return the pick list to the nurse coordinator for

approval. Occasionally, the nurse coordinator will not approve for the

changes to be permanently made on the pick list, but specifies the item

as “have available” only. This is because the extra item used was only

specific to that particular procedure and to that particular patient, hence

it is not necessarily required for the case. When the final signed pick

list is delivered to the scheduling department change will then be

recorded accordingly in the computer.

5.1 Service Scheduling Process Findings:

The surgery schedule is finalized only the day prior to the date of the

surgeries. Although this is necessary because of issues such as

cancellations, it doesn’t provide enough time to ascertain that all the

supplies needed for each case are available in the OR. Usually, each

department will keep a backup of a special order item in case of an

emergency. Occasionally the item needed for the surgery is out of

stock. This is the worst case scenario in the inventory process because

the hospital results in paying higher cost because of excessive Federal

Express orders or other means of immediate delivery for missing

items. Charges for such delivery services are estimated to range

between $20,000 to $30,000 per year.

• When the cases for the following day are picked, missing items are not

looked for right away. Nurses will search for them the following day

just before the surgery. This also contributes to the additional

immediate delivery charges that the hospital faces every year.

015

6.0 ADDITIONAL FINDINGS

• Summary of department differences

Data was gathered by interviewing nursing staff members from the

three different departments, Comparisons can be made among the

departments and the results are shown in Table 1.

Table 1. Comparison of Departmental Services

Each service deals with a different number of total line items and a

different percentage of on consignment items. Because of differences

in the way each service records their on-hand inventory and their

ordering, the time engaged in the inventory process slightly differs as

well.

V

Cardiac ENT Neuro

Number of line 200 409 240

items

Percentage on 0% (heart valves 47% 70% of. only) aneurysm clios

Consignment and 70% olimplants

Day to take Friday Wednesday Tuesday

inventory

Inventory on- 1 week 1-2 weeks 1 week

handdependingonitem

Time to take 3 hours 2 hours 3 hours

Inventory

Average orders 2-10 companies 15-20 —305-30 cases

per week

Average Fed EX 2 per week 2 per month 2-3 per week

orders

Number of 3-4 boxes 5-15 boxes 2-10 boxes

arrivals per day

Average lead 3-7 days 5 days —5 days

time

Advanced 1 week in advance 1 week in advance calls to find next

schedule?weeks schedule

16

• Consignment Items

Consignment items are items which are not charged to the department

until usage. There is no specific space allocated to store consignment

items. These are shelved together with the general supplies in the

designated space for each service. Consignment items are usually high-

ticket items negotiated by the Head Nurse. Currently, an estimated

$2,000,000 worth of supplies in storage are consignment items, and

some departments have a majority of their inventory as consignment.

There is no visual indication in the cores of an item being on

consignment, because it assumed that the nurses have proper

knowledge of all the supplies available. Should a consignment item be

used, special consignment forms are filled out by the nurse. A copy of

this form is sent to the vendor for billing purposes.

• Issues regarding Inventory Management during Surgery

The tour of the operating room during surgery provided a number of

findings. The surgery withessed was a removal of a cancerous thyroid

gland. First, the set-up time for the surgery witnessed took

approximately 70 minutes. This was an extremely long time in

contrast with the expected set-up times of about twenty minutes. The

nurses preparing the room were careful to point out that particular

surgery involved several departments. Indeed, the positioning of the

patient was a key issue between the ENT, Anesthesia and General

Surgery departments. In the time it took to prepare the room, a

number of additional supplies not on the bypod were brought not all at

once, but piece-by-piece over time. The supplies were requested by

surgeons from the different departments.

During the surgery, the circulating nurse took care to track all items

used. Upon interviewing this nurse, it was determined that it was the

nurse’s responsibility to look for potential areas to cut costs.

Specifically, this included considering the use of an alternate item if it

was more cost-effective and feasible.

C.17

• Responsibilities of Nursing Staff

In addition to finding potential for decreasing cost, nurses also act as

arbitrators in cases where not enough inventory is available for all

those who request it. In such a case, it is the nurses responsibility to

prioritize the use of the items based on knowledge of surgical

procedures.

Some concern was raised by members of the nursing staff that up to a

half day per week was spent in the reorder process. This is time which

should be spent in the OR assisting in the progress of surgeries.

A interesting finding about the nurses in charge of inventory was that

they knew little about the processes of other departments in the OR.

They assumed that the basic procedure of order and receiving were the

same, but expected that subtle difference existed throughout the flow.

• Responsibilities of Head Nurse

The Head Nurse is currently an integral and non-interchangeable piece

of the inventory process The Head Nurse is the major central figure

between departments because all decisions regarding adjustment of par

levels and ordering must get approval of this person Additionally, the

Head nurse is a key player in the negotiation for supplies. Price is

always the key issue, and higher costs must be justified.

• Duplicate System with Preference Cards

Although preference cards are in the process of being eliminated, they

are still referred to in some departments. Supposedly, only the pick

lists should be used to pick the cases but some M.A. or floaters still use

the preference cards as a backup since the pick lists are often not

completely accurate.

• Issues Regarding Standardization

The issue of standardizing processes is being examined. It appears as a

fundamental concept for the success of computerizing the inventory

process. The problem with the computer is that it does not perform

judgment-based decisions. Upon evaluation of the patient’s health and

18

condition, additional items may be requested, so a nurse may get a

particular supply even though it contradicts the pick list order.

Another issue which confronts standardization is the reluctance of the

surgeons. Each surgeon may have a different list of supplies for the

same surgery. These differences are based on preference or the

surgeon’s educational background. Thus, standardization will not be

easily implemented.

• Status of the Inventory Software Implementation:

The current attempt to implement the DOS-based Surgi-Server

software (SSI) is the fifth in eight years. A current goal is to remove the

DOS base of SSI. The software is primarily being used only to generate

pick lists, as that aspect only involves a simple database, but it is not

being utilized for inventory purposes. SSI is designed for a case cart

system which is not the system being used by UH. In addition there is

inadequate training for the use of SSI. Another system upgrade is due

in May, and implementation of a Pathways Healthier Scheduling.

U• Issues Regarding Implementation of Inventory Software

Implementation of the SSI Surgi-Server computer inventory software

has been a goal of UI-I for the past eight years. The ultimate goal of

computerizing the inventory process is to have a perpetual inventory

system. In such a system, the ordering process would be synchronized

with the service scheduling process as the software would decrement

inventory individually and trigger the ordering process when it

reaches a determined reorder point. This would ideally replace the

current requisition process and cut down the amount of paperwork.

Other goals for SSI include on-line receiving and shipping, which

would speed up the process even more.

To deal with the current dilemma of independent ordering and

scheduling processes, a new scheduling system called Pathways

Healthcare Scheduling is being considered. The advantage of this new

system is its direct interfacing with SSI.

19

A more intangible dilemma arising from SSI is its history of

implementation at UH. Many attempts have been made in the past for

implementation and an attitude exists in the OR that computerizing

the process does not effect the ultimate goal: the welfare of the patient.

Inadequate coordination in the past has also soured enthusiasm for thesystem. SSI is comprised of five main aspects, and previousimplementation attempts over zealously wanted to start up all five.

The current attempt has been more gradual, and the new scheduling

system forces the staff in the OR to look at the overall picture.

Concern was also raised that the success of SSI depended upon a

complete pick list. In the current early stage of implementation, many

pick list items in the computer database are not accurate. This is due to

the massive number of items which only the nurses have detailed

knowledge of.

• Potential for Bar-Coding to the Inventory Process

Currently being tested at the Kellogg Eye Center is a bar-code scanner to

increment and decrement items. A mandate is being considered to

standardize the bar coding for all medical products which is slowing

I down the process. The SSI program does not function with bar codes,

but use of the bar code for the tracking of inventory held in the system

is certainly under consideration.

20

7.0 RECOMMENDATIONS

• Standardize inventory count process

An exact physical count should be taken for each department on a

weekly basis. The problem with the current process of estimating the

inventory level is that it provides only an approximation of on-hand

inventory. By keeping an exact count, the system will be more accurate

and inventory levels will be kept closer to the par levels.

• Further training of Medical Assistant

The medical assistants should be comfortable with handling all aspects

of inventory control. The M.A. should have a broad and extensive

knowledge of all items. With this knowledge, they should be given the

responsibility of taking inventory and filling out requisitions for items

in order to allow nurses more time in the OR. Proper and quicker

training is possible by reorganizing the storage areas, and having

sufficient identification of items. One area of improvement could be to

label all consignment items, and to store items onto a shelf based on (surgical procedure.

• Encourage all C.N. III’s/M.A.’s to look at advanced surgery schedule

All departments should have the advanced schedule (for either one or

two weeks) available on the day they take inventory which is also the

day on which they place most of the orders. It should not be the

responsibility of the C.N. III to provide this advanced schedule for the

respective department. By doing this, the C.N. ifi or the MS. can have

a general idea of what it is expected to be used for the tentative

schedu1ed cases. The number of Federal Express or rush orders can be

reduced by having the item(s) on-hand in advance.

• Increase inter-departmental communication

If an order is sent to the wrong department, it should immediately be

sent to the correct department. This could be done by contacting the

stockkeeper to note that an incorrect order was received. The

stockkeeper should then deliver the inventory to the appropriate

21

department. This will reduce the amount of time spent searching for

an order.

• Encourage return of yellow requisition form immediately after order

The yellow copy of the requisition form indicates to the C.N. III or M.A.

in charge of inventory that the order has been placed. This yellow

form should be returned to the department before the order arrives, so

that the C.N. Ill or M.A. has the opportunity to confirm exactly what

items are in the order.

• Support mandate for standardized bar-coding of medical products

Standardization in any form aids in the implementation of software to

support computer-generated decisions. B ar-coding technology allows

for a highly efficient manner of tracking inventory quantities.

Through bar-coding, the process of filling inventory count forms can be

eliminated. This will reduce the time spent keeping track of the on

hand count to a minimum. Also, bar-coding helps reduce the effect of

human errors, where an item is ordered, but an incorrect product

number is entered.

22

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Appendix I

UNiVERSiTY OF MICHIGAN HOSPITALS

OPERATING ROOMSEQUIPMENT! SUPPLY REQUISITION

DATE: / / REQUESTED BY:____________________________________ ROOM:

_____________

NAME OF COMPANY (ONE COMPANY ONLY!)

Y N

V N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

Y N

V N

Y N

V N

Y N

Y N

Y N

Y N

V N

________________

BE SURE AND CHECK IJNE IF ITEM IS PATIENTCHARGE IFOR OFFICE USE ONLY

SHIPPING: 1st DAY

po# 2ndDAY

RELEASE # NORMAL

CONFIRMING TO: DELIVERY ADDRESS VERIFIED? Y 0 N 0- fl1 ‘7ñ 4/01

()

Tye: STND Rn Time: 10:46am - 02/16/96 AppendixJSUPPLY REQUISITIONUniversity Michigan Medical Page

-Surgeon/Procedure

Suraecn: Deeb,G. Michael*

Procedure: CABG-IMA *CABG w/IMA

Prep:Gloves:Position:Drape:Sutures:Hints:Last Supply List Update: 02/13/96

Number ItemReq las Code H Description

U. HOSP. MEDICATIONS\SOLUTIONS2 5269 WATER FOR IRRIG BOTTLE 1000ML

q 6 5722 NACL 0.9% IRRIG BOTTLE 1000MLINSTRUMENT TRAYS

7GREYSEE EXTENDED PREFERENCE CARD

Location Charge Total

1 5000171 5000181 5000201 5000221 5000401 5006001 — 5006021 500654

I i 5006551 500656

U. HOSP. CORE A1 1005081 1005101 1001683 100654

I i 12351 2000411 300013

I1252

1 28501 4462

1 1001843 100187i 1001971 135400‘ 1 1502011 1850001 200182

1 1 200183

1 1 200185HOSP. CAUTERY

1 1231

1 2 1232U. HOSP. CORE A

PUMP IPUMP IIRETRACTOR MORRIS W/O SPRINGDR. DEEB CORONARY TRAYDR. DEEB SAPHENOUS VEIN TRAYIMA RETRACTORIMA BARICE PADDLE

DIUM INTERNAL PADDLESSTERNAL SAW

CARDIAC CART

TUBE CHEST 32FRTUBE CHEST 32FR CVDPUNCH VASCULAR PRECISION 4CLIP ATRAtJNAX SPRING 6TUBING ARTERIAL PRESSURE 72”RETRACT 0 TAPEBLADE BEAVER MINI #6500PLEURAVAC AUTOTRANSFUSION SYSTEM W/BAGCATHETER FOLEY TEMP SENSING 1SFRPLEUR-EVAC ADULTADAPTER MULTIPLE PERFUSION E1889CANNULA VESSEL DUCK BILL #30001TOURNIQUET ADULT COMPLETE SET 79006SYRINGE PRESSURE SENSING W/3000iVENT ADULT DLP #12002CANNULA CORONARY SINUS #94115 15FRCANNULA VENOUS 2 STAGE 36-46FR #164525SUCTION CARDIAC MINI SARNS 14991CANNULA AORTIC 8.0t #165264

SUPPLIESBOVIE PENCIL HANDSWITCHING DISPOSABLEBOVIE PAD ADULT

DRUG-U

DRUG - U

INSTU

INSTU

INSTU

INSTU

INSTU

INSTU

INSTU

INSTU

INSTU

INSTU

UCAC1O2

UCAC1O2

UCAC1O3

UCAC1O3

UCAC1O3

UCAC1O3

UCAC1O3

UCAC1O4

UCAC1O4

UCAC1O4

UCAC1O9

UCAC1O9

UCAC1O9

UCAC1O9

UCAC1O9

UCAC1O9

UCAC1O9

UCAC1O9

UCAC1O9

UCAUTERY

UCAUTERY

2.003.00

0.000.000.00

13.0016.00

23.0014.003.00

16.003.00

57.00

40.0043.00

31.00

6.00

6.0032.00

24.00

103.0023.00

21.00

32.00

5.005.00

4.00

18.00

0.000.000.00

0.000.000.000.000.000.000.00

13.0016.0023.00

42.003.00

16.003.00

0.0040.00

43.00

31.0018.00

5.00

32.00

24.00

103.0023.0021.0032.00

5.0010.00

SUPPLIES

Type: STND R,jn Time: 10:46am - 02/16/96

SUPPLY REQUISITIONUniversity of Michigan MedicalSurgeon/procedure

Location Charge

UCOA 37.00

Number ItemI Req Iss Code H Description

1 — 220234 BLADE SAW STERNAL

U. HQSP. CORE SUPPLIES

1 — 103486 MATTRESS HYPOTHERMIA LONG

1 138540 POUCH PACEMAKER #5409

2 — 150096 GEL POVIDONE IODINE TOPICAL PHARMASEAL

2 — 185331 BANDAGE ACE 6’

2 — 2560 STOCKINETTE 6” TUBULAR UNBLEACHED NS

1 300012 BLADE BEAVER MINI #6400

1 — 4441 CONTAINER SUCTION 1500CC

U. HOSP. BASIN SETS

2681 BASIN SET MAJOR CUSTOM

U. HOSP. DRAPES/LINEN

1 2147 GOWN SURGICAL XX LARGE-EXTRA PROTECTION

1 — 6132 GOWN PACK 4/PACK LARGE

6 T-841 TOWEL 4/PACK REPACK

1 1675 PACK DRAPE PUMP BASICU. HOSP. POSITIONING SUPPLIES

1 1239 FOAM KEYHOLE HEAD REST1 1600 FOAM PAD ELBOW/HEEL

U. CORE. SUTURE CART

UCOR

UCOR

tJCOR

UCOR

tJCOR

UCOR

UCOR

UCRBS

UCRDR

UCRDR

UCRDR

UCRDR117

UCRPT

UCRPT

UCSUT

UCSUT

UC SUT

UCSUT

UCSUT

UCSUT

UCSUT

UCSUT

UCSUT

UCSUT

(IC SUT

UCSUT

UCSUT

USRAAL

USRAAA4

USRABB2

USRAV1

USRAW1

USRAX3

USRAY2

USRAY3

USRAY4

USRAZ3

Page 2

Total

37.00

21.00

6.00

14.00

8.00

36.00

3.00

4.00

20.00

9.00

15.00

18.00

368.00

4 00

3.00

5.000.00

6.00

5.00

6 00

8.00

38.00

62.00

4.00

0.00

22.00

187.00

0.00

3.00

0.00

1.00

0.00

0.00

1.00

0.00

12.00

2.00

7.00

1,461.00 ()

21.00

6.00

7.00

4.00

18.00

3.00

4.00

20.00

9.00

15.00

3.00368.00

4.00

3.00

5.00

5.00

6.00

5.006.008.00

38.00

62.00

4.00

3.00

11.00

187.00

16.00

3.00

3.00

1.00

3.00

2.00

1.00

9.00

2.00

2.00

7.00

1 104234104234

1 125056

1 125112

1 125113

1 125114

1 125164

1 125174

1 125231

125394

2 125421

1 125548

125562

U. HOSP. STORE

1 150097

2781

1 1267

1737

1736

1 1063

2534

6 1744

1 1073

1 1753

LIGACLIP LT1O2 SMALL TITANIUMLIGACLIP LT1O2 SMALL TITANIUMSUTURE ETHIBOND 2-0 SH X523HLIGACLIP LT100 SMALL

LIGACLIP LT200 MEDIUM

LIGACLIP LT300 MED LARGESUTURE PROLENE 6-0 VBC M8307SUTURE PROLENE 7-0 VBBV M8304SUTURE PLEDGET PCP3O

SUTURE PDS 2-0 CT-i Z259HSUTURE STEEL MONO 5 CCS-1 M436GSUTURE E-PACK CARDIAC 3340ESUTURE PROLENE 7-0 VBBV 8304H

ROOM SUPPLIES

PAD INSTRUMENT* NEEDLE GUARD POP N COUNT

YANKAUER SUCTION W/O CONTROL VENT

SPONGE LAP 18Xl8 STER

SPONGE LAP 18X4 THORACIC

ALCOHOL ISOPROPYL

STAPLER SKIN DISPOSABLE 35W

SPONGE GAUZE DRESSING 4X8”

PREP SOLUTION POVIDONE IODINE 4 OZ

TAPE MICROFOAM 4”

Type: STND Run Time: 10:46am - 02/16/96SUPPLY REQUISITIONUniversity of Michigan Medical Page 3Surgeon/Procedure

Surgeon name: Deeb,G. Michael*Procedure: *CAB_G w/IMA

4edications: Vancomycin 500mgAlbumin 5% 50 ml x 2Papaverine 300mg = 10cc (2 amps if IMA)

dditional Supplies:

MA supplies: Small ligaclips x 3IMA RetractorIMA BarBovie at 30 for IMAStirrup attachment for IMA Bar

;uture: Cardiac E-Pack#5 Wire Ethicon 2/pkg x 22-0 Ethibond SI-i x 26-0 Prolene Multi C-i7-0 Prolerie Multi By-i2-0 Monocryl x 2

Large Pledgets x 1

ositioning: Supine, key hole foam, temp sensin foleyelbow pads.

rep: ETCH pre-wash, Gel prep x 2

ints: Bovie at 50Ether screen alwaysPicket fence to hold extremity for prepPillow x 2 under legs

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