JULY 1998, VOL 68, NO 1 Bell

Hospital Uses Team Approach to Improve Processes, Reduce Costs

hen staff members at Phoenix Memorial Hospital took on the common health care challenge of improving patient care and Respect each person. saving money, they turned to a new Share responsibilities.

Marotti’s training, the team used the following seven rules of conduct. W group process and program to improve Criticize only ideas, not people.

the system. The new group comprised 11 members: a team leader from the quality management depart- ment, an OR staff nurse, the director of perioperative services, a clinical nurse educator, a nursing repre- sentative from ambulatory services, the nursing director of the emergency department, the infection control nurse, the director of housekeeping, the nurse educator of the obstetric and labor and deliv- ery areas, the manager of the central processing department (CPD), and a CPD employee. To help implement the change, these members were chosen for their knowledge and expertise of the current sys- tem and of their specific areas.

GElTING STARTED Before beginning, the hospital adopted the

“Seven Steps to Quality” process by Peter Marotti, a professional continuous quality improvement (CQI) trainer.’ Some team members, including the leader, attended Marotti’s three-day course at the facility shortly after the team was assembled. From

Keep an open mind. Question and participate. Attend all meetings. Listen constructively.

To this, the team added two rules. Stay focused on meeting agendas, and help the group to do so also. Come prepared to meet the objectives of each meeting.

The team members believed each individual’s time was valuable and needed to be spent on the specific agenda for each meeting. To enhance this, meeting minutes, including the agenda for the next meeting, were distributed before each meeting.

REASONS FOR IMPROVEMENT The challenge facing the group was that the

expiration dating system for sterile instrumentation was time consuming and took instruments out of the system unnecessarily. Instruments were not always available when needed for patient care, and

the system generated unneces- sary costs ‘with staffing, packag- ing materials, and sterilizer runs.

In the old system, the CPD received contaminated surgical instruments and prepared them for redistribution. The instru- ments were processed through several steps, including deconta- mination, washing, terminal ster- ilization, reassembling in trays or as single items, wrapping,

A B S T R A C T This article describes a group process and how it was used to

reduce reprocessing turnover time and increase the availability of sterilized instruments, A team of staff members used the ”Seven Steps to Quality” and an event-related sterility maintenance pro- gram, thereby improving patient care and reducing costs, With a defined process, the team members‘ expertise, and clearly defined objectives and goals, the team was able to complete its work and implement a substantial change in a short amount of time. AORN J 68 (July 1998) 68-72.

M A R L E N E B E L L , R N

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The outdated items put an

additional strain on the

stressed system and increased

some turnover times.

labeling, and resterilizing. These items then were delivered to the different departments within the facility as well as to several family health centers outside the facility.

Expiration dates. All items sterilized by the CPD were assigned expiration dates or dates when they no longer were considered sterile. The last week of each month, all areas of the hospital and clinics that store medical instruments sterilized by the CPD inventoried the items and removed the ones that had expired. The expired items then were delivered to the CPD for reprocessing. The CPD- which was not exempt from staffing cutbacks throughout the facility-had an already high vol- ume of instruments to process from daily use. The outdated items put an additional strain on the stressed system, resulting in a turnaround time of up to one week for some instruments.

Unavailable instruments. Although the CPD employees tried to prioritize the i tems they processed, it was not uncommon during the last week of the month and into the first week of the next month for OR staff members to be missing an item essential to a surgical procedure. This resulted in staff members’ having to take the elevator down one flight to the CPD, search for the item, and bring it up to flash sterilize it-a procedure not rec- ommended by AORN. The practice of finding and flash sterilizing an item also took time, potentially increasing the length of the procedures. During the night and weekend shifts, when support personnel was not available, the availability of supplies and instruments often was questionable, making it diffi- cult to meet unexpected needs and requests. These situations resulted in possible prolonged procedure and anesthesia times that are associated with com- plications such as wound infection and pneumonia.

Effects on other areas.’’ The unavailability and length of turnaround time of instruments also affect- ed other areas. At Phoenix Memorial Hospital, the CPD services all areas of acute patient care within the facility, including the cardiac catheterization laboratory, the emergency department, and the obstetric ORs. In addition, each physician clinic owned by the hospital adds its sterilization require- ments to the CPD’s workload. The hospital and its clinics are considered a networked care center; thus, the same standard of care is offered throughout all areas, whether on or off campus. To meet this requirement, the hospital CPD handles all the ethyl- ene oxide and steam sterilization for all 10 sites. The number of sites is continually increasing as the hospital continues to expand the network.

In addition to the CPD manpower required to support the previous system, manpower also was required from the areas that store the instrumentation. These department personnel had to go through all sterilized instruments at the end of each month in search of the outdated supplies. The outdated supplies then were sent to CPD for reprocessing. When the items were returned they had to be reshelved. In areas such as ORs and obstetric units, this required many manpower hours.

CHOOSING THE PROGRAM The group decided implementing an event-

related sterility maintenance (ERSM) program would improve the existing system by alleviating unnecessary reprocessing of items that had not been opened or used. The ERSM program changed the traditional system, in which sterilized items were given outdates, by placing the focus on the integrity of the package, instead of on an arbitrary date when the package is thought to be unfit for use.

The ERSM program’ emphasizes how an item is stored, how it is handled, how often it is handled, the cleanliness of the storage area, and its tempera- ture and humidity to determine whether an item is considered sterile. With the program, if these con- ditions are met, there should be no limit on the amount of time an item remains sterile. Implement- ing the program can improve internal processes by expediting workflow, enhancing productivity, and reducing costs. Many manufacturers that supply sutures, implantable items, and disposable products used during surgery have stopped using expiration dates. Their products are considered sterile as long as the package integrity is intact.

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ANALYZING OBSTACLES To implement this change, potential obstacles

were identified and analyzed. One potential problem was the environment. According to the AORN Standards, Recommended Practices, and Guide- lines,’ factors that influence the sterility of an item include

condition of the storage area (eg, cleanliness, temperature, humidity), how many times the item is handled, and the type and configuration of the packaging material.

A second potential problem was staff member education. Staff members needed a clear under- standing of how to maintain proper storage condi- tions and how to adhere to the principle of “first in, first out” when choosing an item for use. Staff members also needed to learn to carefully inspect a package to make sure it was intact before opening and using. This is a basic principle for OR person- nel; however, it cannot be assumed that individuals outside the OR setting have this knowledge.

The third potential problem the team identified was the quality of the products used to contain the sterilized items. The team wanted to find literature to support that the materials currently being used (eg, peel packages, wrappers, rigid containers with filters) could be adapted to an ERSM environment. A final problem was to ensure that the ERSM pro- gram would be supported by accrediting agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

ACTION PIAN To address the environmental problem and the

storage conditions, team members surveyed their respective areas. A monitoring tool was developed based on the recommendations of the Association for the Advancement of Medical Instrumentation and AORN so that all members surveyed for the same inf~rmation.~ A simple “yes” or “no” ques- tionnaire tool included the following questions.

Do items have adequate space? Is storage area clean and lint and dust free? Are infrequently used items dust covered (ie, do they have plastic outer wrap)? Is the area free from moisture? Are all items at least 18 inches from the ceiling? Are all items eight to 10 inches from the floor? Are items being rotated (ie, first in, first out)? Are peel packages not folded or stacked?

Staff members were taught

how to carefully examine

package integrity and use the

“fmt in, first out” principle.

Is package integrity maintained (ie, no signs of damage)?

T o solve the environmental problems, team members were expected to correct any areas of noncompliance.

Temperature and humidity readings also were done to comply with the suggested limits of the Association for Professionals in Infection Control and Epidemiology ( APIC).J To address deficien- cies, the infection control nurse and the director of housekeeping implemented changes to meet the APIC standards before the ERSM program was implemented.

To address the second potential problem of staff education, education inservice programs and posters were developed to disseminate information. With the help and expertise of the hospital clinical nurse educator, the education offerings included information on the ERSM program, how to careful- ly examine package integrity, and how to use the “first in, first out” principle.

The CPD manager also reviewed available products and placed color-coded labels on products so that the earliest dated sterilized package could be easily identified. This information was included in all education offerings, as well as on signs that were posted by sterilized items for quick reference.

The third issue addressed the quality of the products that were used to contain sterile instru- mentation. Manufacturers were contacted and asked to submit product research ensuring that the quality of their products supported an ERSM pro- gram. No implementation was begun until this doc- umentation was on file.

The final potential problem was alleviated by reviewing the JCAHO standards. The JCAHO manu- al states that either the expiration dating system or the

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ERSM program can be used as long as it is consistently employed throughout the facility or net- work.5 Team members wrote a new sterilization poli- cy that was reflected in the revisions of the unit policies.

WAS THE CHANGE FOR THE B€ITER? The team decided to monitor several aspects of

the program. The most important consideration was that the program did not compromise patient care. To evaluate effectiveness, Centers for Disease Control- defined class one surgical site infections were moni- tored for surgical site infections (SSI). The infection control nurse monitored not only emergency depart- ment visits for signs and symptoms of SSI, but also follow-up site cultures sent from physicians’ offices and reports from home health nurses. After quarterly monitoring the first I2 months of implementation, no increase in the SSI rate was detected.

The storage condition monitoring tool previ- ously described also was used, and team members from all areas storing sterilized instruments were asked to submit this form to the team leader on a quarterly basis. Results were compiled and distrib- uted to the team members, and the team leader referred any problems to the appropriate people.

The team leader did a cost savings analysis of both supplies and manpower hours. The analysis determined

23 manpower hours were saved monthly in the hospital alone; seven of those hours were saved in the OR by the elimination of pulling and restocking outdated items; and 16 of the hours were saved in the CPD by the elimination of washing, assembling, wrapping, sterilizing, and delivering items back to their respective areas.

The annual materials cost savings was estimated to be between $3,520 and $3,780. This included the reduction of peel packages and wrappers, but did not include the reduction in the number of sterilizer runs, the maintenance of sterilizers, and the wear and tear

NOTES

ity,” in Team Leader Training semi- nar presented at Phoenix Memorial Hospital, 13, 14, 15 January 1997.

maintaining a sterile field,” in AORN Standards, Recommended Practices, and Guidelines (Denver: Association of Operating Room Nurses, Inc,

1. P Marotti, “Seven steps to qual-

2. “Recommended practices for

1998) 289-294.

on the instruments themselves.

MAKING CHANGES CONSISTENT After one year of monitoring and reporting to

the team leader, staff members decided the ERSM program was beneficial to the facility and that it maintained the standard of care the facility wanted to offer its customers. Today, instead of monitoring and reporting to a central team, each area incorpo- rates continued monitoring into its own unit or area CQI. The team leader and members are available for consultation if their expertise is required.

SUMMARY By having a clear expectation of what is

required and being educated on the overall process itself, team members can reduce costs and improve health care quality. At Phoenix Memorial Hospital, a group process was able to solve problems related to instrument storage conditions, staff member edu- cation, product quality, and JCAHO accreditation.

In conclusion, a good CQI team starts with the inclusion of members with specific expertise to ana- lyze problems and implement changes. Team mem- bers need to receive agendas for each meeting so that they can come prepared to meet the objectives. At the close of each meeting, assignments for the next meeting need to be reviewed so that each mem- ber has a clear understanding of the expectations. This enables the team members to make decisions, move forward, and meet goals. Evaluation of the change and ongoing monitoring also is essential to ensure the process is effective. A successful work group is one with well chosen members, a defined

process to follow, and empower- ment to suggest and implement changes. A

3. Association for the Advance- ment of Medical Instrumentation, Good Hospital Practice: Steam Steril- ization & Sterili& Assur-ance (Arling- ton, Va: Association for the Advance- ment of Medical Instrumentation, 1988); “Recommended practices for maintaining a sterile field,” 289-294.

4. Association for Professionals in Infection Control & Epidemiolo- gy, Infection Control & Applied Epi-

Marlene A. Bell, RN, M N , RNC, CNOR. is the peer review coordina- tor and acting director of quality management at Phoenix Memorial Hospital.

demiology: Principles & Practice (St Louis: Mosby, 1996).

5. Joint Commission on Accredi- tation of Healthcare Organizations, “Surveillance prevention and control of infection,” in Comprehensive Accreditation Manual for Hospitals: The Oficial Handbook (Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organi- zations, 1996).

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