- Email: [email protected]
OR waste reduction
Perioperative Care and Operating Room Management 15 (2019) 100073
Contents lists available at ScienceDirect
Perioperative Care and Operating Room Management journal homepage: www.elsevier.com/locate/pcorm
OR waste reduction☆ a,⁎
T b
c
Ross W. Simon , Elena G. Canacari , Kelly A. Gamboa , John M. Giurini
d
a
Silverman Institute for Health Care Quality and Safety, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RO-403, Boston, MA 02215, USA Perioperative Services, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA West Main Operating Room, Perioperative Services, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA d Division of Podiatric Surgery, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA b c
A R T I C LE I N FO
A B S T R A C T
Keywords: Operating Room waste procedure pack waste reduction operating room supplies implant verification hemostatics preference list have-availables
Reducing wastage in the operating room (OR) is a way to reduce the rapidly increasing cost of health care. Using structured problem solving tools, a team at Beth Israel Deaconess Medical Center (BIDMC) in Boston developed a process to reduce waste generated in the OR. In just 3 months the team identified and implemented a cost avoidance of over $68,000/year. By educating staff and surgeons, several other savings opportunities were identified and acted-upon. Methods were implemented to maintain the gains.
1. Introduction The United States spends more on healthcare than any other industrialized nation. In fact, on a per capita basis, it spends 2.5-times the average of other industrialized nations ($8,745 vs. $3,484).1 Under current law, national health spending is projected to grow at an average rate of 5.5% per year for 2017–26 and to reach $5.7 trillion by 2026. While this projected average annual growth rate is more modest than that of 7.3% observed over the longer-term history prior to the recession (1990–2007), it is more rapid than has been experienced [during] 2008-16 (4.2%). Health spending is projected to grow 1.0 percentage point faster than Gross Domestic Product (GDP) per year over the 2017–26 period; as a result, the health share of GDP is expected to rise from 17.9% in 2016 to 19.7% by 2026.2 From a microeconomic perspective (i.e., that of individuals making decisions regarding allocation of limited resources), patients have also been negatively affected by rising healthcare costs. The average cost for a family health insurance policy in 2014 was $16,834, which represents a 69% increase from 2004.3 A substantial component of the cost of surgery is disposable surgical supplies [and implants]. These include single-use instruments, implanted products (e.g., biologics, hemostatic agents) and consumable products (e.g. staple cartridges, clips, couplers). The decision to use
these items is typically left to the case's attending surgeon. However, surgeons may not effectively communicate their specific needs for a particular surgical case; this mismatch between the case's needs and opened supplies opened leads to waste. This phenomenon is estimated to account nationally for hundreds of millions of dollars of waste that cannot be captured by inventory accounting and requires special attention.4 According to Don Berwick, “The opportunity is enormous.”5 The BIDMC OR Supply Steering Committee tracks wasted supplies in the operating room through Perioperative Information Management System (PIMS) documentation. The committee recognized through yearly reports that documented waste was escalating. In Fiscal Year (FY) 2016 it was $814,900 and in FY 2017 it increased to $977,800. This created the impetus to create a team to focus on waste. 2. Methods The five phases of the project, beginning with creation of a charter by team leaders, the facilitator and sponsor, are listed below. 1 2 3 4
Charter Analysis Corrective Action Assembling the Tool Kit
☆
Declarations of interest: None. Corresponding author. E-mail addresses: [email protected] (R.W. Simon), [email protected] (E.G. Canacari), [email protected] (K.A. Gamboa), [email protected] (J.M. Giurini). ⁎
https://doi.org/10.1016/j.pcorm.2019.100073 Received 29 October 2018; Received in revised form 5 February 2019; Accepted 12 March 2019 Available online 15 March 2019 2405-6030/ © 2019 Elsevier Inc. All rights reserved.
Perioperative Care and Operating Room Management 15 (2019) 100073
R.W. Simon, et al.
Understanding that the Ortho, Neuro and Cardiac services generated the greatest percent of total waste, the team concentrated efforts on these three services. Most items wasted were orthopaedic implant such as spine cages, screws and bone grafts. While looking at the data, we realized there was a huge education component that needed to be addressed with our surgeon colleagues. This was based on an observation made by one of our surgeon colleagues who was an active team member on the waste committee. He noticed a theme of wasted implants in Orthopaedic procedures. He was not aware that implants he deemed as an improper fit for the patient were considered wasted post operatively. Based on quantity, bone screws are wasted the most. However, based on cost, the most money was spent on the following items.
5 Engaging Surgeons and Staff 6 Procedure (preference) Cards 2.1. Charter Creating a charter to describe the background, purpose, goals, suggested approach and team membership was the first step in this project. The Project Charter describes the project vision, objectives, scope, organization and implementation plan. It helps you to set the direction for the project and gain buy in from your stakeholders as to how the project will be organized and implemented. It will also help you to control the scope of your project, by defining exactly what it is that you have to achieve.6 The charter was approved by team members at our first team meeting, laying the path for subsequent problem solving steps. Since total waste in Fiscal Year (FY) 2017 was $977,821, the absolute value of the 10% cost savings goal (or more accurately, a cost avoidance) was rounded-up to $98,000.
1 Spine cages 2 Bone screws 3 Allografts The greatest reason for wastage was “Improper fit/Item explanted”. Some surgeons were unaware that if an implant is adjusted or deformed in any way in an effort to fit it to the patient, and then a decision is made to not use that implant, the implant must be wasted and not charged to the patient. The patient is charged only for final implanted items. With education, surgeons are now aware of our policy and are less likely to deform or adjust an implant if it will likely not be implanted.
2.2. Managing the work Meetings were held weekly from 0645 to 0730. The meetings were primarily used as strategy sessions to monitor progress on each active task listed on our activity scorecard. This matrix helped us manage the work necessary to complete the project by clearly listing the title, issue, next activity, priority, responsible individual, target completion date and status for each task. The scorecard drove progress – it was updated at each weekly team meeting and helped us determine next steps. Although many conversations occurred during our weekly 45-min meeting, the majority of the work transpired outside of this weekly meeting. Occasionally, the meetings were used to brainstorm solutions to problems; by doing the bulk of the work outside of the meetings we were able to parallel process several initiatives concurrently and make tremendous progress in just 3 months.
2.4. Back table audits To identify all items that were not used in a variety of case types, the team conducted back table audits. The back table audits were performed by the circulating nurse with assistance from the scrub person. They marked anything that had been opened and unused for the case as a wasted item. Reasons for items being wasted were documented and captured with the audit. Types of waste identified included unused items from procedural packs (PBDS), hemostatic agents opened prematurely, staples opened that were not listed on the preference and sutures opened prematurely. A Pareto Analysis of reasons for wastage in all cases is presented in Fig. 1.
2.3. Analysis Current State The team began work by identifying the current state through examination of documented waste (see Table 1.) We analyzed the data many ways each month:
2.5. Communication
• Waste by service line, • Waste by cost of item wasted, • Reasons for waste to better understand our problem.
Communication failures were the greatest reason for wastage. Communication failures in the OR [exhibit] a common set of problems. They [occur] in approximately 30% of team exchanges and a third of
Table 1 Waste by service FY’17. Service
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
YTD
Monthly Average
% of Total Waste
ORTHO NEURO CARDIAC PLASTIC THORACIC VASCULAR GYN GEN UROLOGY COLORECTAL TRANSPLANT PODIATRY EYE SURG\ONC DENT\ORAL ENT TOTAL
42,305 4397 17,654 4051 731 327 756 3309 297 1224 2007 3829 1558 195 836 164 83,639
41,500 8711 9259 4674 3142 661 2145 4195 2,250 532 1689 1087 1316 172 2088 151 83,572
20,887 30,485 6542 2452 721 16,252 3540 1,249 464 1340 3575 514 444 109 1193 1188 90,955
44,060 3058 11,660 3318 5928 543 2737 1470 1073 670 1703 2231 1394 1557 735 425 82,562
35,857 20,555 4611 1553 3672 183 2746 4021 303 187 568 506 1823 364 – 5 76,952
41,746 6975 12,400 1781 6650 2747 1833 854 15,201 1618 2100 246 939 264 – 576 95,929
56,616 6872 8854 2410 3,392 1,630 3,499 1,786 1,263 548 19 2 939 278 – 300 88,408
29,276 5142 6602 5339 1215 1018 1792 3600 646 1311 3151 130 206 470 241 277 60,415
26,217 8619 8403 4805 3727 3050 7130 2517 1262 262 865 2277 1215 643 453 706 72,152
30,583 6675 4604 2314 3479 5377 697 1355 3969 314 450 4190 534 1708 169 – 66,415
40,278 5499 10,141 5,010 8526 1764 1473 2642 658 15,064 2662 557 2543 725 1813 453 99,808
33,848 5085 10,106 11,649 1498 4572 1529 1763 624 1315 237 570 1007 2033 249 929 77,013
4,43,173 1,12,070 1,10,836 49,355 42,681 38,122 29,877 28,762 28,010 24,385 19,026 16,138 13,917 8518 7777 5174 9,77,821
36,931 9339 9236 4113 3557 3177 2490 2397 2334 2032 1,585 1345 1160 710 648 431 81,485
45% 11% 11% 5% 4% 4% 3% 3% 3% 2% 2% 2% 1% 1% 1% 1% 100%
2
Perioperative Care and Operating Room Management 15 (2019) 100073
R.W. Simon, et al.
Fig. 1. Pareto analysis – all back table audits.
• Some new inexperienced staff prematurely opens supplies that may not be used. • Kits opened randomly in search of an instrument. • Some surgeons not willing to wait for items to be opened onto field.
these [result] in effects which [jeopardize] patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.7 Statistical insurance claims data support these findings: in a review of closed surgery claims from 1991 to 2000 the Controlled Risk Insurance Company (CRICO) identified inadequate information sharing among team members as a primary trigger for claims and reported that 15% of claim cases included a “communication breakdown”.8 As illustrated in Fig. 1, communication was found to be our biggest hurdle when managing waste. By educating the surgeons and empowering the nurses to start an open dialogue with the surgeon about available items this can reduce waste. This tactic must be made clear by the OR staff at the start of the case; failure to communicate this will likely result in wasted supplies.
Communication
• Opening items prematurely in rooms • Premature preparation of bone cement • Surgical booking process Methods
• Inaccurate Preference Lists • Contaminated instrument kits • Incorrectly mixing Surgifoam and other clotting agents • Opening supplies too early (when can wait to determine if needed) • We do not recycle blue wrap (costs .06/lb. to discard)
2.6. Procedure packs The next most frequent cause of wastage identified in back table audits is waste from procedure packs. A “procedure pack” can be defined as an assembly of medical devices that are packed together and sold on the market with the intention of being used during procedures (e.g., surgical procedure) or medical treatment.9 The team conducted a complete review of procedure packs. Working with our pack distributor, our team compared information collected in back table audits with pack lists and materials to start drilling down on what is wasted. We enlisted the help of our staff and surgeons to review the packs to identify wasted items. And we held table top demonstrations exhibiting pack contents in order to discuss items that can be removed or changedout for better pricing from the pack company. Seventy-eight packs were reviewed, 51 in the ORs and 28 in Cardiac Cath Lab, Electro Physiology Lab, Angiography, Interventional Radiology, Endoscopy Suite, Pain Clinic, NICU and Labor and Delivery. Changes were approved in 20 packs. There were a number of deletions and additions to the packs. After accounting for the additions, 13 items were deleted.
Materials
• PBDS Packs that have supplies that are not used • Overstocked supplies • Outdated supplies • Staff open a whole separate Hemopro box if one of the accessory pieces fell or was contaminated Equipment
• Shavers on East & West – Reprocessing opportunity? ○ Prohibited by contract
2.8. Education
2.7. Types of waste
At less frequent rates, a lack of education, inaccurate surgeon preference cards and defective equipment were identified as reasons for wastage. During service line meetings, education was provided to OR staff on the following topics. Charging for all items
Throughout the project we captured all the reasons for OR waste using a cause and effect diagram. Normally used as a brainstorming tool, the cause and effect diagram served as a storehouse for opportunities to reduce waste that we identified during the life of the project. With the question, “What causes wastage in the OR?”, reasons by types of causes of wastage are presented below. People
• Accurate charging is required to identify items used/wasted. • Surgical Technologists opened items but did not communicate to nurses to charge them. • Communication with surgeon to ascertain accurate reason for waste.
• “I do it the same way all the time.” 3
Perioperative Care and Operating Room Management 15 (2019) 100073
R.W. Simon, et al.
multidisciplinary team and achieving financial health, the foundation of the BIDMC Operating Plan. The goals of this effort were as follows.
Use of hemostatics
• High-cost items that are sometimes wasted due to not opening according to Instructions for Use (IFU). • Implant verification process. • During the project, a long hemiarthroplasty stem was opened [wasted] instead of opening the requested short stem. • There were many new employees in the OR. The verification process
• Reduce OR supplies wastage by 10%. • Create cultural awareness of the impact of OR waste. Lean tools and methodology such as use of a team charter to clearly outline goals, observations [back table audits], activity scorecards, Pareto analysis and holding the gains were employed in this project. Choreographing these select tools to healthcare improvement projects at BIDMC has been described previously.12 At BIDMC the OR Supply Steering Committee has been tracking waste for several years. This committee meets twice a month and the team is represented by finance, nursing, surgery and contracting. This waste reduction team defined waste as items brought into the OR, opened/implanted but not used and cannot be used for other patients or future cases. As an example, items may be opened onto the field and not needed or, a surgeon may request an incorrect item. Any item wasted in the OR is tracked using our intra operative charting system called the Perioperative Information Management System (PIMS). The nurse caring for the patient documents the item wasted and the reason why it was wasted. Over the past three years items wasted in the OR have increased creating a sense of urgency to curtail this costly trend – see Fig. 4. Building on that sense of urgency, leadership at BIDMC formed a process improvement team to reduce waste. Because organizations and their environments constantly change, one of the core responsibilities of leaders is initiating and managing the internal changes necessary to adapt to changing circumstances.13 Support from leadership continued throughout the project by active participation of our sponsor, the Associate Chief Nurse, and feedback from the Perioperative Operations Committee and the OR Executive Committee. Some waste is not preventable, for example, the case that cancels after set-up due to an unexpected change in the patient's status. However, by increasing awareness of this problem and taking actions to reduce waste, this team has saved over $68,000/year in just one initiative, removing unused items from procedure packs.
needed to be reviewed.
Ensuring have-availables are inside room
• By ensuring that have-availables are inside the room, OR staff can provide supplies needed without delaying the case. • Only by doing this, we were able to enlist the support of surgeons for OR staff to wait to open supplies until needed. Red bag waste vs. regular waste
• Not all sponges collected at the end of the case contain enough blood • •
to justify spending $0.22/lb. vs. the $0.06/lb. cost of regular waste to dispose of these. There was no standard for staff to refer to make this determination. To train attendants, the team created and posted a depiction of sponges that do and do not contain enough blood to warrant disposing them in red bag trash. In 1991, the Occupational Safety and Health Administration (OSHA) promulgated the Occupational Exposure to Bloodborne Pathogens Standard defining the amount of blood in regulated waste as, “items contaminated with blood or OPIM and which would release these substances in a liquid or semiliquid state if compressed’.10 General awareness of OR waste problem
• Posted graphs by scrub sinks highlighting increasing cost of waste while surgical volume was dropping. • For increasing awareness of the wastage problem the team created a
1-page training document referred to as a “Teach Back” that is posted in the OR – see Fig. 2.
4.1. Actionable causes of waste 3. Results Among the most actionable causes of waste we were able to affect are listed below in Table 2.
Work described in this paper demonstrated the many opportunities for reducing waste in the OR. Contrary to others who have undertaken similar OR waste projects and did not overhaul procedure packs,11 half of our initial savings of $68,024/year was a result of removing unused items from procedure packs. By reducing waste of other OR supplies we realized a cost avoidance from FY17 ($977,821) to FY18 ($910,221) of $67.600, so the overall saving to the Medical Center was $135,624 through September 2018. As illustrated in Fig. 3, there is a direct correlation between waste and volume in FY2017. After launching this effort in August 2017, note that while volume increased, waste remained stable during the first 3 quarters of FY 2018. Though waste/case appears to have been highest in Q1 of FY18 due to a marked decrease in the number of cases compared to the quarter before, waste did not increase with increasing case volume in FY 18.
4.2. Surgeon and staff engagement Cost transparency and awareness has become increasingly important in the current healthcare environment. In this context, it is ever more incumbent on physicians to better understand the costs of their services, supplies, and implants that they use, as a first step toward cost containment and providing cost-effective care. In a recent study, [the] majority of surgeons were unable to correctly estimate the costs of items/implants used in their OR. These results are despite the importance that most surgeons placed on costs.14 Towards the end of the project team leaders met with surgeons in service-specific meetings to present a summary of our work, the items and cost of wasted supplies in their service and to solicit their support to enact the cultural changes necessary to reduce waste. Correspondingly, we assured surgeons that no significant time will be lost during the procedure by waiting for have-availables to be opened when needed. Other requests we made in these service-specific meetings were as follows.
4. Discussion BIDMC is a 621 bed, academic, level 1 trauma center located in Boston, MA. We have 39 operating rooms located on two campuses in which 26,000 surgical procedures are performed annually. In this paper, the authors describe the methodology and results of a project to reduce waste in the OR. Identifying and creating a culture of awareness about decreasing OR waste was a viable way of engaging a
1 Review instrumentation, medications (i.e.: Surgiflow and Surgifoam) implants, supplies before start of case during the time4
Perioperative Care and Operating Room Management 15 (2019) 100073
R.W. Simon, et al.
Fig. 2. Teach Back.
hemostatic to a less expensive brand that provides the same results.
out. 2 Continuously review/update preference lists. 3 Communicate supplies needed to the OR team at the earliest opportunity.
4.3. Holding the gains Planning on how the team will maintain the savings we've achieved and to support expected additional savings from reducing waste generated by prematurely opening supplies, improper use of hemostatics, inaccurate preference lists, premature preparation of bone cement, etc., was a key step in this project. Characteristics of this “control plan” are as follows.15
The initial response from surgeons was incredulity that supplies were wasted in their service. However, the skepticism quickly changed to a constructive conversation between surgeons about actions they could take to further reduce wastage and spending. In fact, surgeons made suggestions we had not considered such as changing the type of 5
Perioperative Care and Operating Room Management 15 (2019) 100073
R.W. Simon, et al.
Fig. 3. Waste and case volume by quarter.
• Outlines key measures and documentation to be maintained to ensure project gains are sustained • Provides plan to monitor key measures • Identifies person to notify if gains slip • Creates plan to take corrective action if needed
•
``Waste by Service/Month". Includes graphic depiction of ``Totals by Fiscal Quarter" as well. If there are any concerns with an increasing trend of waste, OR West Director will address it with the chief of those services.
4.4. Spreading the learning
Accordingly, the Sr. Financial Analyst who served on this team provides the following.
One important step that is often neglected is the communication of successes throughout the organization—to organizational leaders as well as clinical and administrative staff. By discussing successful
• On a monthly basis provides to team members graphic depiction of
Fig. 4. Waste increasing while case volume decreasing. 6
Perioperative Care and Operating Room Management 15 (2019) 100073
R.W. Simon, et al.
Table 2 Actionable causes of waste. Category
Problem
Action
People
Surgeon not willing to wait for items to be opened onto field Some new, inexperienced staff prematurely opens supplies that may not be used Procedural Packs that have supplies that are not used
Discussion prior to case start to make clear that have-availables are in the room and will be provided without delay Staff education
Materials
Staff open a whole separate Hemopro box if one of the accessory pieces fell or was contaminated Methods
Inaccurate preference lists
Communication
Incorrectly mixing Surgifoam and other hemostatics Premature preparation of bone cement
Based on data collected from back table audits after cases, working with our vendor we reduced the content of procedural packs that resulted in a cost avoidance of over $68,000/year Added Hemopro Accessory Pack to inventory in order to reduce waste in cardiac so staff doesn't have to open up a whole separate Hemopro box if one of the accessory pieces fell or was contaminated Updated preference lists such that they are accurate and set in-place a system to maintain accuracy Staff education Staff education
projects, the team helps to reinforce the culture of quality improvement, build credibility for the intervention, reward those involved, and foster the spread of effective innovations.16 We spread the learning to other parts of the organization that can benefit from the work we accomplished; a presentation describing the project was delivered to the Medical Executive Committee. Accordingly, education has been provided to leadership and staff on our East Campus so the work to reduce waste can be spread to the remaining operating rooms at BIDMC.
4.
5.
6.
7.
5. Conclusion Using structured problem-solving techniques, a team at BIDMC developed a methodology for reducing OR waste. In just 3 months, the team identified and implemented changes in procedure packs that yielded a cost avoidance of 68,024/year. Savings from a reduction of waste of other OR supplies was $67.600 so the overall saving to the Medical Center was $135,624 through September 2018. By monitoring spending and waste over the next year, the team will document additional savings achieved as a result of the education provided and systems implemented to monitor and prevent waste. We achieved a successful outcome in this project through leadership and by engaging the stakeholders. Having completed the first quarter of FY19 without any additional interventions we are projecting documented waste at $903,600, which is $6,500 less than FY18. In an effort to sustain awareness and the gains, a summary of surgical waste was presented to the OR Executive Committee in February 2019. There must be cost effective care and judicious use of resources.17
8. 9. 10.
11.
12.
13.
14. 15.
References 1. Lorenzoni L, Belloni A, Sassi F. Health-care expenditure and health policy in the USA versus other high-spending OECD countries. Lancet. 2014;384(July (9937)):83–92 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821743/ Accessed May 23 2018. 2. National Health Expenditure Projections 2017-2026, Centers for medicare and medicade services, NHE Projections projections 2017-–2026 - forecast summary, accessed Accessed 5/21/18 21 May 2018. 3. Christopher C. R. Jackson, MD, Roland R. D. Eavey, MD SM, and David D. O. Francis, MD MS, Surgeon awareness of operating room supply costs, Volume: 125 issue: 5, pages: 369–377, Article first published online: November 1, 2015; Issue published:
16.
17.
7
May 1, 2016, https://doi.org/10.1177/0003489415614864, accessed Accessed 5/ 29/1829 May 2018. Operating Room Inefficiencies & Costs, Explorer Surgicalsurgical, http:// explorersurgical.com/wp-content/uploads/2016/10/White-Paper_June-2016.pdf, accessed Accessed 4/30/1830 April 2018. Berwick Donald DM, Hackbarth Andrew D. Eliminating waste in US health care. JAMA. 2012 Apr 11;307(April (14)):1513–1516. https://doi.org/10.1001/jama. 2012.362 Epub 2012 Mar 14 https://www.ncbi.nlm.nih.gov/pubmed/22419800 Accessed February 4 2019. How to Create your Project Charter, Method123 Inc., June 3, 2009, http://blog. method123.com/2009/06/03/create-your-project-charter/#!prettyPhoto, accessed Accessed 5/9/189 May 2018. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. BMJ Qual Saf. 2004;13. https://doi.org/10.1136/qhc.13.5.321 321-321 Published Online First: 01 Oct 2004pg 2 of 14 http://qualitysafety.bmj.com/content/13/5/330.full Accessed May 23 2018. Ibid, pg. 3 of 14. http://obelismedical.net/medical-device-directive-systems-procedure-packs/ accessed Accessed 4/25/1825 April 2018. OSHA Standards for Bloodborne Pathogens, Healthcare Environmental environmental resource Centercenter, 2015, http://www.hercenter.org/rmw/osha-bps.cfm, accessed Accessed 5/31/1831 May 2018. Corinna C. Zygourakis, Seungwon Yoon, Victoria Valencia, et al, Operating room waste: disposable supply utilization in neurosurgical procedures, J Neurosurgery, Published online May 6, 2016; DOI: 10.3171/2016.2.JNS152442, http://thejns.org/ doi/pdf/10.3171/2016.2.JNS152442, accessed Accessed 5/29/1829 May 2018. Simon RW, Canacari EG. A practical guide to applying lean tools and management principles to healthcare improvement projects. AORN J. February 2012https://www. researchgate.net/publication/51925744_A_Practical_Guide_to_Applying_Lean_Tools_ and_Management_Principles_to_Health_Care_Improvement_Projects, Accessed date: 15 October 2018. Rihal Charanjit S. The Importance of Leadership to Organizational Success. NEJM Catalyst; December 2017 https://catalyst.nejm.org/importance-leadership-skillsorganizational-success/ Accessed August 6 2018. Ibid Citation #3. Ruth S. Gubernick, MPH and Michael M. L. Rinke, MD PhD, Holding your gains: strategies for sustaining improvements, learning session 2, slide 25, November 9, 2013, https://www.aap.org/en-us/professional-resources/quality-improvement/ Quality-Improvement-Innovation-Networks/Documents/Strategies_for_Sustaining_ Improvements.pdf, accessed Accessed 5/9/189 May 2018. Ways To Approach the Quality Improvement Process. Content last reviewed. Rockville, MD: Agency for Healthcare Research and Quality; July 2017http://www.ahrq.gov/ cahps/quality-improvement/improvement-guide/4-approach-qi-process/index.html, Accessed date: 30 May 2018. Martin, EllenE., Eliminating waste in healthcare, ASQ healthcare update, July 2014, http://asq.org/health/2014/06/basic-quality/eliminating-waste-in-healthcare.pdf, accessed Accessed 2/4/194 February 2019.
Contents lists available at ScienceDirect
Perioperative Care and Operating Room Management journal homepage: www.elsevier.com/locate/pcorm
OR waste reduction☆ a,⁎
T b
c
Ross W. Simon , Elena G. Canacari , Kelly A. Gamboa , John M. Giurini
d
a
Silverman Institute for Health Care Quality and Safety, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, RO-403, Boston, MA 02215, USA Perioperative Services, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA West Main Operating Room, Perioperative Services, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA d Division of Podiatric Surgery, Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215, USA b c
A R T I C LE I N FO
A B S T R A C T
Keywords: Operating Room waste procedure pack waste reduction operating room supplies implant verification hemostatics preference list have-availables
Reducing wastage in the operating room (OR) is a way to reduce the rapidly increasing cost of health care. Using structured problem solving tools, a team at Beth Israel Deaconess Medical Center (BIDMC) in Boston developed a process to reduce waste generated in the OR. In just 3 months the team identified and implemented a cost avoidance of over $68,000/year. By educating staff and surgeons, several other savings opportunities were identified and acted-upon. Methods were implemented to maintain the gains.
1. Introduction The United States spends more on healthcare than any other industrialized nation. In fact, on a per capita basis, it spends 2.5-times the average of other industrialized nations ($8,745 vs. $3,484).1 Under current law, national health spending is projected to grow at an average rate of 5.5% per year for 2017–26 and to reach $5.7 trillion by 2026. While this projected average annual growth rate is more modest than that of 7.3% observed over the longer-term history prior to the recession (1990–2007), it is more rapid than has been experienced [during] 2008-16 (4.2%). Health spending is projected to grow 1.0 percentage point faster than Gross Domestic Product (GDP) per year over the 2017–26 period; as a result, the health share of GDP is expected to rise from 17.9% in 2016 to 19.7% by 2026.2 From a microeconomic perspective (i.e., that of individuals making decisions regarding allocation of limited resources), patients have also been negatively affected by rising healthcare costs. The average cost for a family health insurance policy in 2014 was $16,834, which represents a 69% increase from 2004.3 A substantial component of the cost of surgery is disposable surgical supplies [and implants]. These include single-use instruments, implanted products (e.g., biologics, hemostatic agents) and consumable products (e.g. staple cartridges, clips, couplers). The decision to use
these items is typically left to the case's attending surgeon. However, surgeons may not effectively communicate their specific needs for a particular surgical case; this mismatch between the case's needs and opened supplies opened leads to waste. This phenomenon is estimated to account nationally for hundreds of millions of dollars of waste that cannot be captured by inventory accounting and requires special attention.4 According to Don Berwick, “The opportunity is enormous.”5 The BIDMC OR Supply Steering Committee tracks wasted supplies in the operating room through Perioperative Information Management System (PIMS) documentation. The committee recognized through yearly reports that documented waste was escalating. In Fiscal Year (FY) 2016 it was $814,900 and in FY 2017 it increased to $977,800. This created the impetus to create a team to focus on waste. 2. Methods The five phases of the project, beginning with creation of a charter by team leaders, the facilitator and sponsor, are listed below. 1 2 3 4
Charter Analysis Corrective Action Assembling the Tool Kit
☆
Declarations of interest: None. Corresponding author. E-mail addresses: [email protected] (R.W. Simon), [email protected] (E.G. Canacari), [email protected] (K.A. Gamboa), [email protected] (J.M. Giurini). ⁎
https://doi.org/10.1016/j.pcorm.2019.100073 Received 29 October 2018; Received in revised form 5 February 2019; Accepted 12 March 2019 Available online 15 March 2019 2405-6030/ © 2019 Elsevier Inc. All rights reserved.
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Understanding that the Ortho, Neuro and Cardiac services generated the greatest percent of total waste, the team concentrated efforts on these three services. Most items wasted were orthopaedic implant such as spine cages, screws and bone grafts. While looking at the data, we realized there was a huge education component that needed to be addressed with our surgeon colleagues. This was based on an observation made by one of our surgeon colleagues who was an active team member on the waste committee. He noticed a theme of wasted implants in Orthopaedic procedures. He was not aware that implants he deemed as an improper fit for the patient were considered wasted post operatively. Based on quantity, bone screws are wasted the most. However, based on cost, the most money was spent on the following items.
5 Engaging Surgeons and Staff 6 Procedure (preference) Cards 2.1. Charter Creating a charter to describe the background, purpose, goals, suggested approach and team membership was the first step in this project. The Project Charter describes the project vision, objectives, scope, organization and implementation plan. It helps you to set the direction for the project and gain buy in from your stakeholders as to how the project will be organized and implemented. It will also help you to control the scope of your project, by defining exactly what it is that you have to achieve.6 The charter was approved by team members at our first team meeting, laying the path for subsequent problem solving steps. Since total waste in Fiscal Year (FY) 2017 was $977,821, the absolute value of the 10% cost savings goal (or more accurately, a cost avoidance) was rounded-up to $98,000.
1 Spine cages 2 Bone screws 3 Allografts The greatest reason for wastage was “Improper fit/Item explanted”. Some surgeons were unaware that if an implant is adjusted or deformed in any way in an effort to fit it to the patient, and then a decision is made to not use that implant, the implant must be wasted and not charged to the patient. The patient is charged only for final implanted items. With education, surgeons are now aware of our policy and are less likely to deform or adjust an implant if it will likely not be implanted.
2.2. Managing the work Meetings were held weekly from 0645 to 0730. The meetings were primarily used as strategy sessions to monitor progress on each active task listed on our activity scorecard. This matrix helped us manage the work necessary to complete the project by clearly listing the title, issue, next activity, priority, responsible individual, target completion date and status for each task. The scorecard drove progress – it was updated at each weekly team meeting and helped us determine next steps. Although many conversations occurred during our weekly 45-min meeting, the majority of the work transpired outside of this weekly meeting. Occasionally, the meetings were used to brainstorm solutions to problems; by doing the bulk of the work outside of the meetings we were able to parallel process several initiatives concurrently and make tremendous progress in just 3 months.
2.4. Back table audits To identify all items that were not used in a variety of case types, the team conducted back table audits. The back table audits were performed by the circulating nurse with assistance from the scrub person. They marked anything that had been opened and unused for the case as a wasted item. Reasons for items being wasted were documented and captured with the audit. Types of waste identified included unused items from procedural packs (PBDS), hemostatic agents opened prematurely, staples opened that were not listed on the preference and sutures opened prematurely. A Pareto Analysis of reasons for wastage in all cases is presented in Fig. 1.
2.3. Analysis Current State The team began work by identifying the current state through examination of documented waste (see Table 1.) We analyzed the data many ways each month:
2.5. Communication
• Waste by service line, • Waste by cost of item wasted, • Reasons for waste to better understand our problem.
Communication failures were the greatest reason for wastage. Communication failures in the OR [exhibit] a common set of problems. They [occur] in approximately 30% of team exchanges and a third of
Table 1 Waste by service FY’17. Service
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
YTD
Monthly Average
% of Total Waste
ORTHO NEURO CARDIAC PLASTIC THORACIC VASCULAR GYN GEN UROLOGY COLORECTAL TRANSPLANT PODIATRY EYE SURG\ONC DENT\ORAL ENT TOTAL
42,305 4397 17,654 4051 731 327 756 3309 297 1224 2007 3829 1558 195 836 164 83,639
41,500 8711 9259 4674 3142 661 2145 4195 2,250 532 1689 1087 1316 172 2088 151 83,572
20,887 30,485 6542 2452 721 16,252 3540 1,249 464 1340 3575 514 444 109 1193 1188 90,955
44,060 3058 11,660 3318 5928 543 2737 1470 1073 670 1703 2231 1394 1557 735 425 82,562
35,857 20,555 4611 1553 3672 183 2746 4021 303 187 568 506 1823 364 – 5 76,952
41,746 6975 12,400 1781 6650 2747 1833 854 15,201 1618 2100 246 939 264 – 576 95,929
56,616 6872 8854 2410 3,392 1,630 3,499 1,786 1,263 548 19 2 939 278 – 300 88,408
29,276 5142 6602 5339 1215 1018 1792 3600 646 1311 3151 130 206 470 241 277 60,415
26,217 8619 8403 4805 3727 3050 7130 2517 1262 262 865 2277 1215 643 453 706 72,152
30,583 6675 4604 2314 3479 5377 697 1355 3969 314 450 4190 534 1708 169 – 66,415
40,278 5499 10,141 5,010 8526 1764 1473 2642 658 15,064 2662 557 2543 725 1813 453 99,808
33,848 5085 10,106 11,649 1498 4572 1529 1763 624 1315 237 570 1007 2033 249 929 77,013
4,43,173 1,12,070 1,10,836 49,355 42,681 38,122 29,877 28,762 28,010 24,385 19,026 16,138 13,917 8518 7777 5174 9,77,821
36,931 9339 9236 4113 3557 3177 2490 2397 2334 2032 1,585 1345 1160 710 648 431 81,485
45% 11% 11% 5% 4% 4% 3% 3% 3% 2% 2% 2% 1% 1% 1% 1% 100%
2
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Fig. 1. Pareto analysis – all back table audits.
• Some new inexperienced staff prematurely opens supplies that may not be used. • Kits opened randomly in search of an instrument. • Some surgeons not willing to wait for items to be opened onto field.
these [result] in effects which [jeopardize] patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.7 Statistical insurance claims data support these findings: in a review of closed surgery claims from 1991 to 2000 the Controlled Risk Insurance Company (CRICO) identified inadequate information sharing among team members as a primary trigger for claims and reported that 15% of claim cases included a “communication breakdown”.8 As illustrated in Fig. 1, communication was found to be our biggest hurdle when managing waste. By educating the surgeons and empowering the nurses to start an open dialogue with the surgeon about available items this can reduce waste. This tactic must be made clear by the OR staff at the start of the case; failure to communicate this will likely result in wasted supplies.
Communication
• Opening items prematurely in rooms • Premature preparation of bone cement • Surgical booking process Methods
• Inaccurate Preference Lists • Contaminated instrument kits • Incorrectly mixing Surgifoam and other clotting agents • Opening supplies too early (when can wait to determine if needed) • We do not recycle blue wrap (costs .06/lb. to discard)
2.6. Procedure packs The next most frequent cause of wastage identified in back table audits is waste from procedure packs. A “procedure pack” can be defined as an assembly of medical devices that are packed together and sold on the market with the intention of being used during procedures (e.g., surgical procedure) or medical treatment.9 The team conducted a complete review of procedure packs. Working with our pack distributor, our team compared information collected in back table audits with pack lists and materials to start drilling down on what is wasted. We enlisted the help of our staff and surgeons to review the packs to identify wasted items. And we held table top demonstrations exhibiting pack contents in order to discuss items that can be removed or changedout for better pricing from the pack company. Seventy-eight packs were reviewed, 51 in the ORs and 28 in Cardiac Cath Lab, Electro Physiology Lab, Angiography, Interventional Radiology, Endoscopy Suite, Pain Clinic, NICU and Labor and Delivery. Changes were approved in 20 packs. There were a number of deletions and additions to the packs. After accounting for the additions, 13 items were deleted.
Materials
• PBDS Packs that have supplies that are not used • Overstocked supplies • Outdated supplies • Staff open a whole separate Hemopro box if one of the accessory pieces fell or was contaminated Equipment
• Shavers on East & West – Reprocessing opportunity? ○ Prohibited by contract
2.8. Education
2.7. Types of waste
At less frequent rates, a lack of education, inaccurate surgeon preference cards and defective equipment were identified as reasons for wastage. During service line meetings, education was provided to OR staff on the following topics. Charging for all items
Throughout the project we captured all the reasons for OR waste using a cause and effect diagram. Normally used as a brainstorming tool, the cause and effect diagram served as a storehouse for opportunities to reduce waste that we identified during the life of the project. With the question, “What causes wastage in the OR?”, reasons by types of causes of wastage are presented below. People
• Accurate charging is required to identify items used/wasted. • Surgical Technologists opened items but did not communicate to nurses to charge them. • Communication with surgeon to ascertain accurate reason for waste.
• “I do it the same way all the time.” 3
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multidisciplinary team and achieving financial health, the foundation of the BIDMC Operating Plan. The goals of this effort were as follows.
Use of hemostatics
• High-cost items that are sometimes wasted due to not opening according to Instructions for Use (IFU). • Implant verification process. • During the project, a long hemiarthroplasty stem was opened [wasted] instead of opening the requested short stem. • There were many new employees in the OR. The verification process
• Reduce OR supplies wastage by 10%. • Create cultural awareness of the impact of OR waste. Lean tools and methodology such as use of a team charter to clearly outline goals, observations [back table audits], activity scorecards, Pareto analysis and holding the gains were employed in this project. Choreographing these select tools to healthcare improvement projects at BIDMC has been described previously.12 At BIDMC the OR Supply Steering Committee has been tracking waste for several years. This committee meets twice a month and the team is represented by finance, nursing, surgery and contracting. This waste reduction team defined waste as items brought into the OR, opened/implanted but not used and cannot be used for other patients or future cases. As an example, items may be opened onto the field and not needed or, a surgeon may request an incorrect item. Any item wasted in the OR is tracked using our intra operative charting system called the Perioperative Information Management System (PIMS). The nurse caring for the patient documents the item wasted and the reason why it was wasted. Over the past three years items wasted in the OR have increased creating a sense of urgency to curtail this costly trend – see Fig. 4. Building on that sense of urgency, leadership at BIDMC formed a process improvement team to reduce waste. Because organizations and their environments constantly change, one of the core responsibilities of leaders is initiating and managing the internal changes necessary to adapt to changing circumstances.13 Support from leadership continued throughout the project by active participation of our sponsor, the Associate Chief Nurse, and feedback from the Perioperative Operations Committee and the OR Executive Committee. Some waste is not preventable, for example, the case that cancels after set-up due to an unexpected change in the patient's status. However, by increasing awareness of this problem and taking actions to reduce waste, this team has saved over $68,000/year in just one initiative, removing unused items from procedure packs.
needed to be reviewed.
Ensuring have-availables are inside room
• By ensuring that have-availables are inside the room, OR staff can provide supplies needed without delaying the case. • Only by doing this, we were able to enlist the support of surgeons for OR staff to wait to open supplies until needed. Red bag waste vs. regular waste
• Not all sponges collected at the end of the case contain enough blood • •
to justify spending $0.22/lb. vs. the $0.06/lb. cost of regular waste to dispose of these. There was no standard for staff to refer to make this determination. To train attendants, the team created and posted a depiction of sponges that do and do not contain enough blood to warrant disposing them in red bag trash. In 1991, the Occupational Safety and Health Administration (OSHA) promulgated the Occupational Exposure to Bloodborne Pathogens Standard defining the amount of blood in regulated waste as, “items contaminated with blood or OPIM and which would release these substances in a liquid or semiliquid state if compressed’.10 General awareness of OR waste problem
• Posted graphs by scrub sinks highlighting increasing cost of waste while surgical volume was dropping. • For increasing awareness of the wastage problem the team created a
1-page training document referred to as a “Teach Back” that is posted in the OR – see Fig. 2.
4.1. Actionable causes of waste 3. Results Among the most actionable causes of waste we were able to affect are listed below in Table 2.
Work described in this paper demonstrated the many opportunities for reducing waste in the OR. Contrary to others who have undertaken similar OR waste projects and did not overhaul procedure packs,11 half of our initial savings of $68,024/year was a result of removing unused items from procedure packs. By reducing waste of other OR supplies we realized a cost avoidance from FY17 ($977,821) to FY18 ($910,221) of $67.600, so the overall saving to the Medical Center was $135,624 through September 2018. As illustrated in Fig. 3, there is a direct correlation between waste and volume in FY2017. After launching this effort in August 2017, note that while volume increased, waste remained stable during the first 3 quarters of FY 2018. Though waste/case appears to have been highest in Q1 of FY18 due to a marked decrease in the number of cases compared to the quarter before, waste did not increase with increasing case volume in FY 18.
4.2. Surgeon and staff engagement Cost transparency and awareness has become increasingly important in the current healthcare environment. In this context, it is ever more incumbent on physicians to better understand the costs of their services, supplies, and implants that they use, as a first step toward cost containment and providing cost-effective care. In a recent study, [the] majority of surgeons were unable to correctly estimate the costs of items/implants used in their OR. These results are despite the importance that most surgeons placed on costs.14 Towards the end of the project team leaders met with surgeons in service-specific meetings to present a summary of our work, the items and cost of wasted supplies in their service and to solicit their support to enact the cultural changes necessary to reduce waste. Correspondingly, we assured surgeons that no significant time will be lost during the procedure by waiting for have-availables to be opened when needed. Other requests we made in these service-specific meetings were as follows.
4. Discussion BIDMC is a 621 bed, academic, level 1 trauma center located in Boston, MA. We have 39 operating rooms located on two campuses in which 26,000 surgical procedures are performed annually. In this paper, the authors describe the methodology and results of a project to reduce waste in the OR. Identifying and creating a culture of awareness about decreasing OR waste was a viable way of engaging a
1 Review instrumentation, medications (i.e.: Surgiflow and Surgifoam) implants, supplies before start of case during the time4
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Fig. 2. Teach Back.
hemostatic to a less expensive brand that provides the same results.
out. 2 Continuously review/update preference lists. 3 Communicate supplies needed to the OR team at the earliest opportunity.
4.3. Holding the gains Planning on how the team will maintain the savings we've achieved and to support expected additional savings from reducing waste generated by prematurely opening supplies, improper use of hemostatics, inaccurate preference lists, premature preparation of bone cement, etc., was a key step in this project. Characteristics of this “control plan” are as follows.15
The initial response from surgeons was incredulity that supplies were wasted in their service. However, the skepticism quickly changed to a constructive conversation between surgeons about actions they could take to further reduce wastage and spending. In fact, surgeons made suggestions we had not considered such as changing the type of 5
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Fig. 3. Waste and case volume by quarter.
• Outlines key measures and documentation to be maintained to ensure project gains are sustained • Provides plan to monitor key measures • Identifies person to notify if gains slip • Creates plan to take corrective action if needed
•
``Waste by Service/Month". Includes graphic depiction of ``Totals by Fiscal Quarter" as well. If there are any concerns with an increasing trend of waste, OR West Director will address it with the chief of those services.
4.4. Spreading the learning
Accordingly, the Sr. Financial Analyst who served on this team provides the following.
One important step that is often neglected is the communication of successes throughout the organization—to organizational leaders as well as clinical and administrative staff. By discussing successful
• On a monthly basis provides to team members graphic depiction of
Fig. 4. Waste increasing while case volume decreasing. 6
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Table 2 Actionable causes of waste. Category
Problem
Action
People
Surgeon not willing to wait for items to be opened onto field Some new, inexperienced staff prematurely opens supplies that may not be used Procedural Packs that have supplies that are not used
Discussion prior to case start to make clear that have-availables are in the room and will be provided without delay Staff education
Materials
Staff open a whole separate Hemopro box if one of the accessory pieces fell or was contaminated Methods
Inaccurate preference lists
Communication
Incorrectly mixing Surgifoam and other hemostatics Premature preparation of bone cement
Based on data collected from back table audits after cases, working with our vendor we reduced the content of procedural packs that resulted in a cost avoidance of over $68,000/year Added Hemopro Accessory Pack to inventory in order to reduce waste in cardiac so staff doesn't have to open up a whole separate Hemopro box if one of the accessory pieces fell or was contaminated Updated preference lists such that they are accurate and set in-place a system to maintain accuracy Staff education Staff education
projects, the team helps to reinforce the culture of quality improvement, build credibility for the intervention, reward those involved, and foster the spread of effective innovations.16 We spread the learning to other parts of the organization that can benefit from the work we accomplished; a presentation describing the project was delivered to the Medical Executive Committee. Accordingly, education has been provided to leadership and staff on our East Campus so the work to reduce waste can be spread to the remaining operating rooms at BIDMC.
4.
5.
6.
7.
5. Conclusion Using structured problem-solving techniques, a team at BIDMC developed a methodology for reducing OR waste. In just 3 months, the team identified and implemented changes in procedure packs that yielded a cost avoidance of 68,024/year. Savings from a reduction of waste of other OR supplies was $67.600 so the overall saving to the Medical Center was $135,624 through September 2018. By monitoring spending and waste over the next year, the team will document additional savings achieved as a result of the education provided and systems implemented to monitor and prevent waste. We achieved a successful outcome in this project through leadership and by engaging the stakeholders. Having completed the first quarter of FY19 without any additional interventions we are projecting documented waste at $903,600, which is $6,500 less than FY18. In an effort to sustain awareness and the gains, a summary of surgical waste was presented to the OR Executive Committee in February 2019. There must be cost effective care and judicious use of resources.17
8. 9. 10.
11.
12.
13.
14. 15.
References 1. Lorenzoni L, Belloni A, Sassi F. Health-care expenditure and health policy in the USA versus other high-spending OECD countries. Lancet. 2014;384(July (9937)):83–92 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821743/ Accessed May 23 2018. 2. National Health Expenditure Projections 2017-2026, Centers for medicare and medicade services, NHE Projections projections 2017-–2026 - forecast summary, accessed Accessed 5/21/18 21 May 2018. 3. Christopher C. R. Jackson, MD, Roland R. D. Eavey, MD SM, and David D. O. Francis, MD MS, Surgeon awareness of operating room supply costs, Volume: 125 issue: 5, pages: 369–377, Article first published online: November 1, 2015; Issue published:
16.
17.
7
May 1, 2016, https://doi.org/10.1177/0003489415614864, accessed Accessed 5/ 29/1829 May 2018. Operating Room Inefficiencies & Costs, Explorer Surgicalsurgical, http:// explorersurgical.com/wp-content/uploads/2016/10/White-Paper_June-2016.pdf, accessed Accessed 4/30/1830 April 2018. Berwick Donald DM, Hackbarth Andrew D. Eliminating waste in US health care. JAMA. 2012 Apr 11;307(April (14)):1513–1516. https://doi.org/10.1001/jama. 2012.362 Epub 2012 Mar 14 https://www.ncbi.nlm.nih.gov/pubmed/22419800 Accessed February 4 2019. How to Create your Project Charter, Method123 Inc., June 3, 2009, http://blog. method123.com/2009/06/03/create-your-project-charter/#!prettyPhoto, accessed Accessed 5/9/189 May 2018. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. BMJ Qual Saf. 2004;13. https://doi.org/10.1136/qhc.13.5.321 321-321 Published Online First: 01 Oct 2004pg 2 of 14 http://qualitysafety.bmj.com/content/13/5/330.full Accessed May 23 2018. Ibid, pg. 3 of 14. http://obelismedical.net/medical-device-directive-systems-procedure-packs/ accessed Accessed 4/25/1825 April 2018. OSHA Standards for Bloodborne Pathogens, Healthcare Environmental environmental resource Centercenter, 2015, http://www.hercenter.org/rmw/osha-bps.cfm, accessed Accessed 5/31/1831 May 2018. Corinna C. Zygourakis, Seungwon Yoon, Victoria Valencia, et al, Operating room waste: disposable supply utilization in neurosurgical procedures, J Neurosurgery, Published online May 6, 2016; DOI: 10.3171/2016.2.JNS152442, http://thejns.org/ doi/pdf/10.3171/2016.2.JNS152442, accessed Accessed 5/29/1829 May 2018. Simon RW, Canacari EG. A practical guide to applying lean tools and management principles to healthcare improvement projects. AORN J. February 2012https://www. researchgate.net/publication/51925744_A_Practical_Guide_to_Applying_Lean_Tools_ and_Management_Principles_to_Health_Care_Improvement_Projects, Accessed date: 15 October 2018. Rihal Charanjit S. The Importance of Leadership to Organizational Success. NEJM Catalyst; December 2017 https://catalyst.nejm.org/importance-leadership-skillsorganizational-success/ Accessed August 6 2018. Ibid Citation #3. Ruth S. Gubernick, MPH and Michael M. L. Rinke, MD PhD, Holding your gains: strategies for sustaining improvements, learning session 2, slide 25, November 9, 2013, https://www.aap.org/en-us/professional-resources/quality-improvement/ Quality-Improvement-Innovation-Networks/Documents/Strategies_for_Sustaining_ Improvements.pdf, accessed Accessed 5/9/189 May 2018. Ways To Approach the Quality Improvement Process. Content last reviewed. Rockville, MD: Agency for Healthcare Research and Quality; July 2017http://www.ahrq.gov/ cahps/quality-improvement/improvement-guide/4-approach-qi-process/index.html, Accessed date: 30 May 2018. Martin, EllenE., Eliminating waste in healthcare, ASQ healthcare update, July 2014, http://asq.org/health/2014/06/basic-quality/eliminating-waste-in-healthcare.pdf, accessed Accessed 2/4/194 February 2019.