- Email: [email protected]
Reducing undocumented supplies in hybrid ORs through multidisciplinary process improvement
Perioperative Care and Operating Room Management 18 (2020) 100087
Contents lists available at ScienceDirect
Perioperative Care and Operating Room Management journal homepage: www.elsevier.com/locate/pcorm
Reducing undocumented supplies in hybrid ORs through multidisciplinary process improvement
T
⁎
Mark T. Seelena, , Kimberly Edwardsa, Alex Bruceb, Kathy Rogersa, Chris Landriganb, Caine Dufrenec, April Calkinsc, Michael Manninga, Peter F. Dunna,d,e a
Perioperative Services, Massachusetts General Hospital, Boston, MA 02114, USA Division of Interventional Radiology, Massachusetts General Hospital, Boston, MA 02114, USA c Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA d Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA e Department of Anesthesia, Harvard Medical School, Boston, MA 02115, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Hybrid room Supply management Cost reduction Process improvement Procedural areas
Introduction: Massachusetts General Hospital (MGH) is a large academic medical center, where many proceduralists are using Hybrid Operating Rooms (OR) to perform cases, and these specialties often utilize supply inventory in the rooms and nearby spaces, but also transport supplies from other procedural areas outside of the OR. For these Hybrid ORs, we saw an increase in supply discrepancies for items used during procedures but that were not documented, and wanted to determine the root cause to minimize these events. Methods: A multidisciplinary team was assembled from across Perioperative Services, Cardiology, and Radiology to address this issue. Through a series of process improvement efforts, including relocation of Radiofrequency Identification cabinets, creation of new control processes, and education of key staff, we were able to address this problem. Results: Through the work of a multidisciplinary team, we achieved a nearly 90% decrease in the incidence of these missing supplies. This project served as one of the first initiatives of the MGH Procedural Services Committee—a group that is now working on a variety of initiatives across the procedural areas to improve patient care, increase efficiency, and reduce costs. Conclusion: As the procedural areas across hospitals continue to become more similar with respect to equipment, resources, staffing competencies, and supplies, there will need to be increased efforts to collaborate to solve shared problems. As many hospitals across the country continue to see margin pressures and declining reimbursement, it will be vitally important to standardize, share best practices, and create additional economies of scale where possible for these procedural areas.
1. Introduction
consignment variance, where the vendor would inventory the shelves, and when the items were missing, the hospital was forced to reorder, and thus must pay for the cost of the item without any associated documentation or potential charge capture. Once the data for missing items was analyzed in aggregate, there were 61 unique items worth almost $110,000 that were considered consignment variances over a six-month period. These missing items were exclusively in the Hybrid ORs, and were namely for items that were used across multiple procedural areas, including in Interventional Radiology and Cardiology. With recent advances in minimally invasive procedures and improvements to imaging technologies, Hybrid ORs have increased in quantity. This increase is also due to more multidisciplinary care, along with the ability to perform several complex procedures in one suite.1
The Massachusetts General Hospital (MGH) is a 1035-bed quaternary medical center in Boston that performs nearly 100,000 procedures annually across 91 procedural rooms. These rooms include a variety of procedural areas, namely the Operating Rooms (ORs), Endoscopy Suite, Electrophysiology Lab, Cardiac Catherization Lab, and Interventional Radiology Suite. Many proceduralists from these different disciplines are now sharing the use of the Hybrid ORs, presenting new challenges around management of staffing and supplies. For Hybrid OR cases, there was an increase in missing supplies, largely of consigned items, that were never documented, but were almost certainly used in cases. These missing items represented a ⁎
Corresponding author. E-mail address: [email protected] (M.T. Seelen).
https://doi.org/10.1016/j.pcorm.2020.100087 Received 15 May 2019; Received in revised form 31 December 2019; Accepted 3 January 2020 Available online 07 January 2020 2405-6030/ © 2020 Elsevier Inc. All rights reserved.
Perioperative Care and Operating Room Management 18 (2020) 100087
M.T. Seelen, et al.
patient care, staff satisfaction, and operational efficiency. The working group's recommendations included the following:
More patients can now safely be treated with endovascular, cerebrovascular, or interventional catheter-based procedures. Hybrid ORs offer flexibility between patients of different types (open vs. interventional), but for some specialties can still can present challenges to change the case type intraoperatively due to positioning of the patient. These Hybrid rooms are different as the radiology tech in the room employs angiography to provide image-guidance to the proceduralist, but the rooms still have all the necessary equipment for a traditional open surgical case.1 Many specialties now regularly use these Hybrid ORs, including Vascular Surgery, Cardiology, Cardiac Surgery, Interventional Radiology, and Neurosurgery.2–4 More recently, Urology and Thoracic Surgery services have begun utilizing these Hybrid ORs and minimally invasive techniques.5,6 By using these rooms, some of these specialties have seen a financial advantage due to decreased operating time, while others affirm that the total economic cost of the patient encounter is also lower.7,8 Many of these services have also seen improved efficiency, quality, and safety by operating in a Hybrid OR.9–11 Neurosurgery has specifically seen increased accuracy and timeliness in spine procedures in Hybrid ORs, and these rooms have also allowed for two different treatment approaches without having to move the patient.12,13 Cardiovascular specialties also view the Hybrid OR as a key element for image-guided cardiovascular surgery.14 ORs are known to generate over 40% of hospital revenue, while supply costs are usually over 50% of the cost of running the ORs.15 Controlling costs in the OR is essential to overall hospital financial success, while managing its supply chain is vital to maintaining financial health.16,17 One way to do this is through education of frontline staff about costs and waste.18,19 Another way is through point of use supply automation to increase supply capture and accountability.20 These systems, often utilizing Radio Frequency Identification (RFID), can help with charge capture, supply tracking, supply chain expenditure, and productivity.21 Previously at MGH, Interventional Radiology was able to spearhead the introduction of such technology and demonstrate its return on investment.22 The aim of this project was to demonstrate a way to reduce the incidence of missing supply items in the Hybrid ORs and measure its effectiveness. The project would use multiple strategies to solve this complex problem, employing some aspects from previous studies, while also developing and integrating new solutions. This work is novel because of the dearth of literature looking at supply optimization specifically for consigned high-cost supplies used across multiple specialties in the Hybrid ORs.
2.1. Relocation of RFID cabinets The first intervention included the relocation of two idle RFID cabinets from another OR to store high-dollar items. These cabinets were not being used in their current location due to issues with temperature control, thus they could be moved to house high-dollar items that were previously on normal shelving. These high-dollar items would now be automatically scanned into the patient record during the procedure, versus previously needing to be scanned by a nurse or technician. This increased automation of supply capture would help reduce human error from manually scanning items into the EHR. This effort took approximately two months to coordinate the work to be performed with the vendor and during a time that would not negatively impact perioperative flow. 2.2. Creation of new control processes A new report was developed and distributed to all procedural areas each day that showed any item that was removed from any RFID enabled location across the ORs, Interventional Radiology Suite, Cardiac Catherization Lab, and Electrophysiology Lab. This increased the visibility to all the inventory managers of these areas, who could now follow up to ensure these items were documented in the patient record, or if they needed to be reconciled. There was also a formal process created for reconciliation of borrowed items for internal use and loaned items for external use at another hospital. This ensured that these removed items were properly billed, purchased, and restocked under the correct cost center. Each inventory manager now knew the steps he or she should take each day to ensure that items taken from their area were properly accounted for in the hospital's inventory system. Additionally, a formal mechanism for bi-weekly accountability between procedural areas was created to ensure that all loaned items were reconciled. This took place during a biweekly meeting of all the inventory managers, where face-to-face accountability was ensured. Finally, for vendors with a high frequency of consignment variances, inventories were moved from a quarterly to a monthly basis. This was important to utilize the vendors to do more frequent inventories of their own product, and this would leave less time between such accountability visits for items to go missing. All these new control processes were implemented in succession over a two month period.
2. Methods 2.3. Education of key staff This was a single-center retrospective analysis from January 2017 to December 2017. Inclusion criteria included all supply inventory used in Hybrid ORs on a floor at the MGH Main Campus. These rooms are used primarily for Vascular Surgery, Neurosurgery, and Interventional Radiology. Data was obtained through the hospital's electronic health record (EHR) and purchase orders for supplies. The project was undertaken as a quality improvement initiative, and as such was not formally supervised by the Institutional Review Board per their policies. After analyzing the initial data, a multidisciplinary working group was formed, including administrators, supply chain experts, and radiology technicians, which reported out regularly to senior nurses, administrators, and clinicians. This team primarily sought to identify interventions to reduce the incidence of consigned items that were used across procedural areas not being documented in the EHR and subsequently not captured in billing data. There were several weeks of discussion, problem identification, and solution generation, followed by two months of implementation efforts. This working group was part of the newly formed hospital-wide Procedural Services Committee (PSC), which sought to bring together triads of leaders from across the procedural areas at MGH to improve
Tailored education was created for different role groups throughout the procedural areas, including surgical technologists, radiology technologists, and nurses. This educational material included how to interact with RFID cabinets, namely key functions and constraints. Education occurred throughout all areas using the RFID cabinets (e.g. ORs, Cath Lab, and Interventional Radiology) over a two month period. This education was scheduled through the leadership of each procedural area, and each group received a tailored class for applicable functionality that they may be using. This was important, as many staff had been hired who never received any formal education on how to properly use the RFID technology. Common errors were discussed such as not transferring between procedural areas when items are moved, and also how to properly restock the cabinets to ensure accurate RFID chip reading. 2.4. Statistical analysis Once the interventions were in place for six months, a statistical analysis was performed in order to validate that there was a statistically 2
Perioperative Care and Operating Room Management 18 (2020) 100087
M.T. Seelen, et al.
Table 1 List of item types that were unaccounted for before the intervention. Item type
Quantity
Drug Eluting Stent Embolization Coil Carotid Stent Vascular Graft Vascular Stent Neurointerventional Stent Tracheal Stent Biliary Stent Total
15 14 12 11 4 2 2 1 61
Table 2 Consignment variances in dollars and unique items pre and post-intervention.
Pre-intervention Post-intervention
Days
Proportion
P-value
$108,429.23 $ 12,547.62
61 9
180 183
34% 5%
<0.05
Through the use of a multidisciplinary approach with team members from across the hospital's procedural areas, including Perioperative Services, Cardiology, and Radiology, we were able to reduce the incidence of supply items that went missing without the correct documentation by nearly 90%. The team employed a variety of generalizable process improvement efforts to address this issue, namely relocation of RFID cabinets, formation of new control processes, and education of staff. This also helped to form stronger bonds between the procedural areas and set the stage for future collaboration. Additionally, with a dearth of literature on the topic of supply optimization across procedural areas, this project demonstrated a new way to address downstream effects of an increasing trend towards Hybrid ORs. As specialties and procedural areas continue to have more crossover, there will be a growing need to be mindful of supply transfers and costs. This is particularly true with increasing financial pressures on hospitals and health systems nationwide—clinical documentation and supply capture in the ORs, and other procedural spaces, are essential to the financial well-being of a hospital to increase revenue and to decrease unnecessary supply costs.15–17 Collaboration between the different procedural areas is key for success of the hospital for not only finances, but also patient care. Developing multidisciplinary teams to address shared challenges among the procedural areas will help to advance the hospital's mission of optimal patient care. Multidisciplinary teams, similar to the one created to address this issue, have been shown to be valuable to improving patient outcomes and increasing efficiency.23–25 These previously separate and distinct procedural areas will need to further collaborate in the coming years; therefore, starting with timely and relevant initiatives like this will help to start foster the necessary teamwork. Through the MGH PSC, the hospital has tried to begin to break down siloes to build a team-based approach to procedural care, and there have been challenges with changing long-established practices and culture. However, targeted initiatives like this help with organizational change, gaining trust, and developing small wins to build on. Through this project, different stakeholders saw the tangible value of such efforts and began to more freely collaborate. This study, though, was not without limitations. Namely, this was performed at a large academic medical center with additional project management support to assist and lead such process improvement efforts. Other small hospitals may not have such resources. Additionally, RFID cabinet technology can be cost prohibitive, and may not be financially advantageous for smaller hospitals that do not have the same volume of expensive devices being used intraoperatively. However, the additional process controls and education of key staff would certainly be scalable to other hospitals facing similar challenges. The group has continued to expand the work of optimizing inventory across the multiple procedural areas, as it has found that standardization of supplies reduces variability, reduces par levels, and ensures the proceduralist has the supplies necessary for safe patient care. Specifically, the group has developed a new product process for all procedural areas, realized additional contracting synergies through collective negotiating for some service contracts, and standardized inventory transfer function for RFID-enabled cabinets across all procedural areas. This project was the initial inventory effort to work across the
3. Results Through these process improvement initiatives, there was a nearly 90% decrease in consignment variances over six months. The initiatives were all fully implemented in July 2017. In the six months leading up to the interventions, there were 61 unique items valued at $108,429 that went unaccounted for and were never captured in clinical documentation. These items were then repurchased from the vendor, representing a loss (see Table 1). The 61 items represented a variety of different interventional devices, including stents, coils, and grafts. The largest type of items were drug eluting stents, followed by embolization coils and carotid stents, respectively. These three types of devices made up 67% of the unique items that went unaccounted for before the intervention. Following the interventions, only 9 items went unaccounted for, representing approximately $12,548 of inventory. This was an 88% reduction in dollars and 85% reduction in unique items (see Fig. 1). Of those 9 items, 4 items were unaccounted for in the month immediately following the implementation of the interventions. Following the first month, no items went unaccounted for again until nearly 90 days later. Overall, the 9 items consisted of embolization coils, vascular grafts, and tracheal stents. Additionally, in the pre-intervention period, there were 61 missing items over a 180-day period. Post-intervention, there were 9 items unaccounted for over the 183-day period. From comparing these proportions, a z-test found a standard error of 0.041, z-value of 6.995, and p-value of less than 0.05, indicating that this was a statistically significant difference in items that were unaccounted for after the interventions were implemented (see Table 2).
$120,000.00 $100,000.00 $80,000.00 $60,000.00 $40,000.00 $20,000.00 Pre-Intervention
# of Items
4. Discussion
significant difference in the number of missing items before and after to validate these efforts. The test chosen was a z-test to compare the proportion of items identified as missing in the six months prior to the intervention and the six months after the intervention.
$0.00
Dollars
Post-Intervention
Fig. 1. Consignment variances in dollars pre and post-intervention. 3
Perioperative Care and Operating Room Management 18 (2020) 100087
M.T. Seelen, et al.
procedural areas of the hospital. Subsequently, formal working groups have also begun on regulatory and policy, sterile processing, and quality and safety initiatives. Future efforts are planned for proceduralwide initiatives around scheduling optimization, staffing, and facilities design as the procedural areas, particularly Hybrid ORs, have much in common.
Informed consent
5. Conclusion
1. Odle TG. Managing transition to a hybrid operating room. Radiol Technol. 2011;3(2):165CI–181CI. 2. Grüter BE, Strange F, Burn F, et al. Hybrid operating room settings for treatment of complex dural arteriovenous fistulas. World Neurosurg. 2018;120:e932–e939. 3. Chinnadurai P, Duran C, Al-Jabbari O, Abu Saleh WK, Lumsden A, Bismuth J. Value of C-Arm cone beam computed tomography image fusion in maximizing the versatility of endovascular robotics. Ann Vasc Surg. 2016;30:138–148. 4. Papakonstantinou NA, Baikoussis NG, Dedeilias P, Argiriou M, Charitos C. Cardiac surgery or interventional cardiology? Why not both? Let's go hybrid. J Cardiol. 2017;69(1):46–56. 5. Schroeder C, Chung JM, Mitchell AB, Dillard TA, Radaelli AG, Schampaert S. Using the hybrid operating room in thoracic surgery: a paradigm shift. Innovations (Phila). 2018;13(5):372–377. 6. Panayotopoulos P, Bouvier A, Besnier L, et al. Laparoscopic partial nephrectomy following tumor embolization in a hybrid room. Feasibility and clinical outcomes. Surg Oncol. 2017;26(4):377–381. 7. Rosenberg BL, Comstock MC, Butz DA, Taheri PA, Williams DM, Upchurch Jr GR. Endovascular abdominal aortic aneurysm repair is more profitable than open repair based on contribution margin per day. Surgery. 2005;137(3):285–292. 8. Sud M, Tam DY, Wijeysundera HC. The economics of transcatheter valve interventions. Can J Cardiol. 2017;33(9):1091–1098. 9. Varu VN, Greenberg JI, Lee JT. Improved efficiency and safety for Evar with utilization of a hybrid room. Eur J Vasc Endovasc Surg. 2013;46(6):675–679. 10. Harskamp RE, Puskas JD, Tijssen JG, et al. Comparison of hybrid coronary revascularization versus coronary artery bypass grafting in patients ≥65 years with multivessel coronary artery disease. Am J Cardiol. 2014;114(2):224–229. 11. Sikkink CJ, Reijnen MM, Zeebregts CJ. The creation of the optimal dedicated endovascular suite. Eur J Vasc Endovasc Surg. 2008;35(2):198–204. 12. Kageyama H, Yoshimura S, Uchida K, Iida T. Advantages and disadvantages of multiaxis intraoperative angiography unit for percutaneous pedicle screw placement in the lumbar spine. Neurol Med Chir (Tokyo). 2017;57(9):481–488. 13. Mori R, Yuki I, Kajiwara I, et al. Hybrid operating room for combined neuroendovascular and endoscopic treatment of ruptured cerebral aneurysms with intraventricular hemorrhage. World Neurosurg. 2016 May;89:727 e9-727.e12. 14. Kpodonu J. Hybrid cardiovascular suite: the operating room of the future. J Card Surg. 2010;25(6):704–709. 15. Babu MA, Dalenberg AK, Goodsell G, Holloway AB, Belau MM, Link MJ. Greening the operating room: results of a scalable initiative to reduce waste and recover supply costs. Neurosurgery. 2018. 16. Buchler R. Achieving strategic cost reduction in the or. Healthc Financ Manag. 2014;68(10):42–44 46. 17. Bilyk C. Don't break the chain: importance of supply chain management in the operating room setting. Can Oper Room Nurs J. 2008;26(3):21–22 30-4. 18. Rigante L, Moudrous W, de Vries J, Grotenhuis AJ, Boogaarts HD. Operating room waste: disposable supply utilization in neurointerventional procedures. Acta Neurochir. 2017;159(12):2337–2340. 19. Zygourakis CC, Yoon S, Valencia V, et al. Operating room waste: disposable supply utilization in neurosurgical procedures. J Neurosurg. 2017;126(2):620–625. 20. Work M. Automating the or supply chain at memorial hermann healthcare system. Healthc Financ Manag. 2010;64(10):100–104. 21. Coustasse A, Tomblin S, Slack C. Impact of radio-frequency identification (RFID) technologies on the hospital supply chain: a literature review. Perspect Health Inf Manag. 2013;10:1d eCollection 2013. 22. Byers E, Gomez MA, Sheridan RM, Orr NW, Hirsch JA. Radio frequency identification for inventory in neuro-interventional practice. J Am College Radiol. 2011;8(3):191–198. 23. Epstein NE. Multidisciplinary in-hospital teams improve patient outcomes: a review. Surg Neurol Int. 2014;5(S7):S295–S303. 24. Seger RF, Dunn PF, Prestipino AL, McDougal WS. Multidisciplinary team streamlines hospital schedules, patient care. MGMA Connex. 2010;10(7):46–49. 25. Morley L, Cashell A. Collaboration in health care. J Med Imagining Radiat Sci. 2017;48(2):207–216.
This article does not contain any studies with human participants or animals performed by any of the authors. References
This work is novel because it focuses on cost containment in Hybrid ORs, where many departments are using the same rooms for high-cost procedures. Moreover, it leverages strategies from previous work, while also developing new solutions to solve a complex, costly problem. Through a multi-effort strategy and a strong multidisciplinary team, the group was able to reduce waste and increase supply capture. It also laid the groundwork for future formalized governance across the procedural areas of the hospital. As the equipment, resources, staffing competencies, and supplies continue to become more similar across all the procedural areas in the hospital, more efforts will be needed to share best practices, standardize, and create collaborations through economies of scale. As margin pressures increase, work such as this will become even more relevant as part of system-wide efforts to reduce costs and increase revenues, all the while maintaining the highest standards of patient care. Multidisciplinary initiatives like this will help to drive collaboration and demonstrate the value of working together across the procedural areas. CRediT authorship contribution statement Mark T. Seelen: Project administration, Writing - original draft, Visualization. Kimberly Edwards: Project administration, Methodology, Writing - review & editing. Alex Bruce: Conceptualization, Methodology. Kathy Rogers: Conceptualization, Methodology, Writing - review & editing. Chris Landrigan: Conceptualization, Methodology. Caine Dufrene: Conceptualization, Methodology. April Calkins: Conceptualization, Methodology. Michael Manning: Conceptualization, Investigation. Peter F. Dunn: Supervision, Writing - review & editing. Declaration of Competing Interest The authors have no conflicts of interest to declare. Acknowledgments The authors would like to thank Bethany Daily and Dr. Kyan Safavi for their assistance throughout this project. Funding source This work was supported by department funds of Massachusetts General Hospital. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
4
Contents lists available at ScienceDirect
Perioperative Care and Operating Room Management journal homepage: www.elsevier.com/locate/pcorm
Reducing undocumented supplies in hybrid ORs through multidisciplinary process improvement
T
⁎
Mark T. Seelena, , Kimberly Edwardsa, Alex Bruceb, Kathy Rogersa, Chris Landriganb, Caine Dufrenec, April Calkinsc, Michael Manninga, Peter F. Dunna,d,e a
Perioperative Services, Massachusetts General Hospital, Boston, MA 02114, USA Division of Interventional Radiology, Massachusetts General Hospital, Boston, MA 02114, USA c Division of Cardiology, Massachusetts General Hospital, Boston, MA 02114, USA d Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA e Department of Anesthesia, Harvard Medical School, Boston, MA 02115, USA b
A R T I C LE I N FO
A B S T R A C T
Keywords: Hybrid room Supply management Cost reduction Process improvement Procedural areas
Introduction: Massachusetts General Hospital (MGH) is a large academic medical center, where many proceduralists are using Hybrid Operating Rooms (OR) to perform cases, and these specialties often utilize supply inventory in the rooms and nearby spaces, but also transport supplies from other procedural areas outside of the OR. For these Hybrid ORs, we saw an increase in supply discrepancies for items used during procedures but that were not documented, and wanted to determine the root cause to minimize these events. Methods: A multidisciplinary team was assembled from across Perioperative Services, Cardiology, and Radiology to address this issue. Through a series of process improvement efforts, including relocation of Radiofrequency Identification cabinets, creation of new control processes, and education of key staff, we were able to address this problem. Results: Through the work of a multidisciplinary team, we achieved a nearly 90% decrease in the incidence of these missing supplies. This project served as one of the first initiatives of the MGH Procedural Services Committee—a group that is now working on a variety of initiatives across the procedural areas to improve patient care, increase efficiency, and reduce costs. Conclusion: As the procedural areas across hospitals continue to become more similar with respect to equipment, resources, staffing competencies, and supplies, there will need to be increased efforts to collaborate to solve shared problems. As many hospitals across the country continue to see margin pressures and declining reimbursement, it will be vitally important to standardize, share best practices, and create additional economies of scale where possible for these procedural areas.
1. Introduction
consignment variance, where the vendor would inventory the shelves, and when the items were missing, the hospital was forced to reorder, and thus must pay for the cost of the item without any associated documentation or potential charge capture. Once the data for missing items was analyzed in aggregate, there were 61 unique items worth almost $110,000 that were considered consignment variances over a six-month period. These missing items were exclusively in the Hybrid ORs, and were namely for items that were used across multiple procedural areas, including in Interventional Radiology and Cardiology. With recent advances in minimally invasive procedures and improvements to imaging technologies, Hybrid ORs have increased in quantity. This increase is also due to more multidisciplinary care, along with the ability to perform several complex procedures in one suite.1
The Massachusetts General Hospital (MGH) is a 1035-bed quaternary medical center in Boston that performs nearly 100,000 procedures annually across 91 procedural rooms. These rooms include a variety of procedural areas, namely the Operating Rooms (ORs), Endoscopy Suite, Electrophysiology Lab, Cardiac Catherization Lab, and Interventional Radiology Suite. Many proceduralists from these different disciplines are now sharing the use of the Hybrid ORs, presenting new challenges around management of staffing and supplies. For Hybrid OR cases, there was an increase in missing supplies, largely of consigned items, that were never documented, but were almost certainly used in cases. These missing items represented a ⁎
Corresponding author. E-mail address: [email protected] (M.T. Seelen).
https://doi.org/10.1016/j.pcorm.2020.100087 Received 15 May 2019; Received in revised form 31 December 2019; Accepted 3 January 2020 Available online 07 January 2020 2405-6030/ © 2020 Elsevier Inc. All rights reserved.
Perioperative Care and Operating Room Management 18 (2020) 100087
M.T. Seelen, et al.
patient care, staff satisfaction, and operational efficiency. The working group's recommendations included the following:
More patients can now safely be treated with endovascular, cerebrovascular, or interventional catheter-based procedures. Hybrid ORs offer flexibility between patients of different types (open vs. interventional), but for some specialties can still can present challenges to change the case type intraoperatively due to positioning of the patient. These Hybrid rooms are different as the radiology tech in the room employs angiography to provide image-guidance to the proceduralist, but the rooms still have all the necessary equipment for a traditional open surgical case.1 Many specialties now regularly use these Hybrid ORs, including Vascular Surgery, Cardiology, Cardiac Surgery, Interventional Radiology, and Neurosurgery.2–4 More recently, Urology and Thoracic Surgery services have begun utilizing these Hybrid ORs and minimally invasive techniques.5,6 By using these rooms, some of these specialties have seen a financial advantage due to decreased operating time, while others affirm that the total economic cost of the patient encounter is also lower.7,8 Many of these services have also seen improved efficiency, quality, and safety by operating in a Hybrid OR.9–11 Neurosurgery has specifically seen increased accuracy and timeliness in spine procedures in Hybrid ORs, and these rooms have also allowed for two different treatment approaches without having to move the patient.12,13 Cardiovascular specialties also view the Hybrid OR as a key element for image-guided cardiovascular surgery.14 ORs are known to generate over 40% of hospital revenue, while supply costs are usually over 50% of the cost of running the ORs.15 Controlling costs in the OR is essential to overall hospital financial success, while managing its supply chain is vital to maintaining financial health.16,17 One way to do this is through education of frontline staff about costs and waste.18,19 Another way is through point of use supply automation to increase supply capture and accountability.20 These systems, often utilizing Radio Frequency Identification (RFID), can help with charge capture, supply tracking, supply chain expenditure, and productivity.21 Previously at MGH, Interventional Radiology was able to spearhead the introduction of such technology and demonstrate its return on investment.22 The aim of this project was to demonstrate a way to reduce the incidence of missing supply items in the Hybrid ORs and measure its effectiveness. The project would use multiple strategies to solve this complex problem, employing some aspects from previous studies, while also developing and integrating new solutions. This work is novel because of the dearth of literature looking at supply optimization specifically for consigned high-cost supplies used across multiple specialties in the Hybrid ORs.
2.1. Relocation of RFID cabinets The first intervention included the relocation of two idle RFID cabinets from another OR to store high-dollar items. These cabinets were not being used in their current location due to issues with temperature control, thus they could be moved to house high-dollar items that were previously on normal shelving. These high-dollar items would now be automatically scanned into the patient record during the procedure, versus previously needing to be scanned by a nurse or technician. This increased automation of supply capture would help reduce human error from manually scanning items into the EHR. This effort took approximately two months to coordinate the work to be performed with the vendor and during a time that would not negatively impact perioperative flow. 2.2. Creation of new control processes A new report was developed and distributed to all procedural areas each day that showed any item that was removed from any RFID enabled location across the ORs, Interventional Radiology Suite, Cardiac Catherization Lab, and Electrophysiology Lab. This increased the visibility to all the inventory managers of these areas, who could now follow up to ensure these items were documented in the patient record, or if they needed to be reconciled. There was also a formal process created for reconciliation of borrowed items for internal use and loaned items for external use at another hospital. This ensured that these removed items were properly billed, purchased, and restocked under the correct cost center. Each inventory manager now knew the steps he or she should take each day to ensure that items taken from their area were properly accounted for in the hospital's inventory system. Additionally, a formal mechanism for bi-weekly accountability between procedural areas was created to ensure that all loaned items were reconciled. This took place during a biweekly meeting of all the inventory managers, where face-to-face accountability was ensured. Finally, for vendors with a high frequency of consignment variances, inventories were moved from a quarterly to a monthly basis. This was important to utilize the vendors to do more frequent inventories of their own product, and this would leave less time between such accountability visits for items to go missing. All these new control processes were implemented in succession over a two month period.
2. Methods 2.3. Education of key staff This was a single-center retrospective analysis from January 2017 to December 2017. Inclusion criteria included all supply inventory used in Hybrid ORs on a floor at the MGH Main Campus. These rooms are used primarily for Vascular Surgery, Neurosurgery, and Interventional Radiology. Data was obtained through the hospital's electronic health record (EHR) and purchase orders for supplies. The project was undertaken as a quality improvement initiative, and as such was not formally supervised by the Institutional Review Board per their policies. After analyzing the initial data, a multidisciplinary working group was formed, including administrators, supply chain experts, and radiology technicians, which reported out regularly to senior nurses, administrators, and clinicians. This team primarily sought to identify interventions to reduce the incidence of consigned items that were used across procedural areas not being documented in the EHR and subsequently not captured in billing data. There were several weeks of discussion, problem identification, and solution generation, followed by two months of implementation efforts. This working group was part of the newly formed hospital-wide Procedural Services Committee (PSC), which sought to bring together triads of leaders from across the procedural areas at MGH to improve
Tailored education was created for different role groups throughout the procedural areas, including surgical technologists, radiology technologists, and nurses. This educational material included how to interact with RFID cabinets, namely key functions and constraints. Education occurred throughout all areas using the RFID cabinets (e.g. ORs, Cath Lab, and Interventional Radiology) over a two month period. This education was scheduled through the leadership of each procedural area, and each group received a tailored class for applicable functionality that they may be using. This was important, as many staff had been hired who never received any formal education on how to properly use the RFID technology. Common errors were discussed such as not transferring between procedural areas when items are moved, and also how to properly restock the cabinets to ensure accurate RFID chip reading. 2.4. Statistical analysis Once the interventions were in place for six months, a statistical analysis was performed in order to validate that there was a statistically 2
Perioperative Care and Operating Room Management 18 (2020) 100087
M.T. Seelen, et al.
Table 1 List of item types that were unaccounted for before the intervention. Item type
Quantity
Drug Eluting Stent Embolization Coil Carotid Stent Vascular Graft Vascular Stent Neurointerventional Stent Tracheal Stent Biliary Stent Total
15 14 12 11 4 2 2 1 61
Table 2 Consignment variances in dollars and unique items pre and post-intervention.
Pre-intervention Post-intervention
Days
Proportion
P-value
$108,429.23 $ 12,547.62
61 9
180 183
34% 5%
<0.05
Through the use of a multidisciplinary approach with team members from across the hospital's procedural areas, including Perioperative Services, Cardiology, and Radiology, we were able to reduce the incidence of supply items that went missing without the correct documentation by nearly 90%. The team employed a variety of generalizable process improvement efforts to address this issue, namely relocation of RFID cabinets, formation of new control processes, and education of staff. This also helped to form stronger bonds between the procedural areas and set the stage for future collaboration. Additionally, with a dearth of literature on the topic of supply optimization across procedural areas, this project demonstrated a new way to address downstream effects of an increasing trend towards Hybrid ORs. As specialties and procedural areas continue to have more crossover, there will be a growing need to be mindful of supply transfers and costs. This is particularly true with increasing financial pressures on hospitals and health systems nationwide—clinical documentation and supply capture in the ORs, and other procedural spaces, are essential to the financial well-being of a hospital to increase revenue and to decrease unnecessary supply costs.15–17 Collaboration between the different procedural areas is key for success of the hospital for not only finances, but also patient care. Developing multidisciplinary teams to address shared challenges among the procedural areas will help to advance the hospital's mission of optimal patient care. Multidisciplinary teams, similar to the one created to address this issue, have been shown to be valuable to improving patient outcomes and increasing efficiency.23–25 These previously separate and distinct procedural areas will need to further collaborate in the coming years; therefore, starting with timely and relevant initiatives like this will help to start foster the necessary teamwork. Through the MGH PSC, the hospital has tried to begin to break down siloes to build a team-based approach to procedural care, and there have been challenges with changing long-established practices and culture. However, targeted initiatives like this help with organizational change, gaining trust, and developing small wins to build on. Through this project, different stakeholders saw the tangible value of such efforts and began to more freely collaborate. This study, though, was not without limitations. Namely, this was performed at a large academic medical center with additional project management support to assist and lead such process improvement efforts. Other small hospitals may not have such resources. Additionally, RFID cabinet technology can be cost prohibitive, and may not be financially advantageous for smaller hospitals that do not have the same volume of expensive devices being used intraoperatively. However, the additional process controls and education of key staff would certainly be scalable to other hospitals facing similar challenges. The group has continued to expand the work of optimizing inventory across the multiple procedural areas, as it has found that standardization of supplies reduces variability, reduces par levels, and ensures the proceduralist has the supplies necessary for safe patient care. Specifically, the group has developed a new product process for all procedural areas, realized additional contracting synergies through collective negotiating for some service contracts, and standardized inventory transfer function for RFID-enabled cabinets across all procedural areas. This project was the initial inventory effort to work across the
3. Results Through these process improvement initiatives, there was a nearly 90% decrease in consignment variances over six months. The initiatives were all fully implemented in July 2017. In the six months leading up to the interventions, there were 61 unique items valued at $108,429 that went unaccounted for and were never captured in clinical documentation. These items were then repurchased from the vendor, representing a loss (see Table 1). The 61 items represented a variety of different interventional devices, including stents, coils, and grafts. The largest type of items were drug eluting stents, followed by embolization coils and carotid stents, respectively. These three types of devices made up 67% of the unique items that went unaccounted for before the intervention. Following the interventions, only 9 items went unaccounted for, representing approximately $12,548 of inventory. This was an 88% reduction in dollars and 85% reduction in unique items (see Fig. 1). Of those 9 items, 4 items were unaccounted for in the month immediately following the implementation of the interventions. Following the first month, no items went unaccounted for again until nearly 90 days later. Overall, the 9 items consisted of embolization coils, vascular grafts, and tracheal stents. Additionally, in the pre-intervention period, there were 61 missing items over a 180-day period. Post-intervention, there were 9 items unaccounted for over the 183-day period. From comparing these proportions, a z-test found a standard error of 0.041, z-value of 6.995, and p-value of less than 0.05, indicating that this was a statistically significant difference in items that were unaccounted for after the interventions were implemented (see Table 2).
$120,000.00 $100,000.00 $80,000.00 $60,000.00 $40,000.00 $20,000.00 Pre-Intervention
# of Items
4. Discussion
significant difference in the number of missing items before and after to validate these efforts. The test chosen was a z-test to compare the proportion of items identified as missing in the six months prior to the intervention and the six months after the intervention.
$0.00
Dollars
Post-Intervention
Fig. 1. Consignment variances in dollars pre and post-intervention. 3
Perioperative Care and Operating Room Management 18 (2020) 100087
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procedural areas of the hospital. Subsequently, formal working groups have also begun on regulatory and policy, sterile processing, and quality and safety initiatives. Future efforts are planned for proceduralwide initiatives around scheduling optimization, staffing, and facilities design as the procedural areas, particularly Hybrid ORs, have much in common.
Informed consent
5. Conclusion
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This article does not contain any studies with human participants or animals performed by any of the authors. References
This work is novel because it focuses on cost containment in Hybrid ORs, where many departments are using the same rooms for high-cost procedures. Moreover, it leverages strategies from previous work, while also developing new solutions to solve a complex, costly problem. Through a multi-effort strategy and a strong multidisciplinary team, the group was able to reduce waste and increase supply capture. It also laid the groundwork for future formalized governance across the procedural areas of the hospital. As the equipment, resources, staffing competencies, and supplies continue to become more similar across all the procedural areas in the hospital, more efforts will be needed to share best practices, standardize, and create collaborations through economies of scale. As margin pressures increase, work such as this will become even more relevant as part of system-wide efforts to reduce costs and increase revenues, all the while maintaining the highest standards of patient care. Multidisciplinary initiatives like this will help to drive collaboration and demonstrate the value of working together across the procedural areas. CRediT authorship contribution statement Mark T. Seelen: Project administration, Writing - original draft, Visualization. Kimberly Edwards: Project administration, Methodology, Writing - review & editing. Alex Bruce: Conceptualization, Methodology. Kathy Rogers: Conceptualization, Methodology, Writing - review & editing. Chris Landrigan: Conceptualization, Methodology. Caine Dufrene: Conceptualization, Methodology. April Calkins: Conceptualization, Methodology. Michael Manning: Conceptualization, Investigation. Peter F. Dunn: Supervision, Writing - review & editing. Declaration of Competing Interest The authors have no conflicts of interest to declare. Acknowledgments The authors would like to thank Bethany Daily and Dr. Kyan Safavi for their assistance throughout this project. Funding source This work was supported by department funds of Massachusetts General Hospital. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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