- Email: [email protected]
Suture Cost Savings in the OR
Suture Cost Savings in the OR SUSANNA S. WALSH, BSN, RN
ABSTRACT Materials management personnel at a health care facility in Baltimore, Maryland, were stocking too much suture. They stocked suture requested by surgeons or recommended by suture company representatives, and, because the facility is a teaching institution, they stocked suture requested by residents. No master suture database was available to determine what was needed and what was not. As a result, some suture was rarely used, which cost the facility money and took up inventory space. In response, I created a list of the existing inventory and coordinated with the specialty surgical service coordinators to determine which suture was typically used and in what quantities. I used this information to create a master list, with the goal of eliminating the purchase of suture that was not on this list. I gave the staff members and surgeons two months to assess the list and determine whether the suggested suture was sufficient for their needs. I then asked the materials management personnel to order and maintain suture stock based on the master list. This process took approximately four months and shows how health care providers can take a high-volume item, such as suture, and create cost-saving processes that will serve surgeons’ and patients’ needs while reducing costs and streamlining stock. AORN J 95 (May 2012) 631-634. © AORN, Inc., 2012. doi: 10.1016/j.aorn.2012.02.005 Key words: suture, cost-saving methods, teamwork, streamlining, standardization.
A
ccording to the Organisation for Economic Co-operation and Development, the United States spends more per capita on health care than other countries and also has one of the highest health care spending growth rates.1 Health care expenditures have increased faster than inflation and represented approximately 16% of the gross domestic product of the United States in 2008.1 Suture can be a high-cost item in any OR because it is a highvolume item. If suture purchases and inventory levels are not tracked and perioperative personnel are not sure what is really being used, then the outcome can be very costly. At a 600-bed, 10-OR, level I trauma center in Baltimore, Maryland, for example, there were five carts of suture, much of which was not routinely
used; no master suture database; and no one to organize or streamline the amount of suture in stock. There were frequent requests from surgeons and residents to order new suture and complaints from these same surgeons and residents who claimed that the facility did not stock the suture they needed. Staff members complained that there was too much suture in stock to find what they needed easily, and materials management staff members were confused about which suture was used for which procedures and what needed to be ordered. This abundance of unorganized, not easily found suture represented an exorbitant expense to the facility. Perioperative staff members and materials management personnel needed to know what was
doi: 10.1016/j.aorn.2012.02.005
© AORN, Inc., 2012
May 2012
Vol 95
No 5 ●
AORN Journal
631
May 2012
Vol 95
No 5
already in stock and what was actually used. To better manage a supply budget and to accurately project supply costs, managers need to know caseload projections according to specialty.2 Another way to control cost is by standardizing the number and types of supplies purchased. By confirming what suture is used by each specialty service, eliminating unused suture, and standardizing the length and color of suture (eg, gaining consensus on whether to use 18-inch or 30-inch suture, dyed or undyed) to limit the amount on the shelf, a manager can achieve significant savings.3
WALSH
mine, and compared them so to create a master list of regularly used suture. I took all of their requested par levels and averaged them by adding the par levels given to me by all the specialty coordinators and dividing this number by the number of services that used the suture. This gave me the average number of boxes needed to sustain a week’s worth of surgery. It also gave me a starting point for the par levels; if a service needed more later on, then the par level could be adjusted accordingly to ensure that all suture needs would be met at any point during a week. After I completed the master list, I sent an BEGINNING THE e-mail to all perioperative staff members and STANDARDIZATION PROCESS To begin the process, I created a detailed list of spoke at a staff meeting and a meeting with the what was currently in stock, including needle size, evening and night shift staff to announce that all suture size, suture color, order number, and number suture not on the list would be removed from of boxes of each type stock. I explained on the shelf. Because how the list had been surgeons continued to compiled and that I asked the specialty service coordinators to perform surgeries the suture removed create a list of the suture they used on a while this cataloguing from stock would regular basis for each of their services. I compared their lists to mine to create a process was occurstill be available master list. ring, I had to have a from me if needed. way of knowing Many staff members whether I had counted were skeptical about a suture or not. To do whether this process this, I placed a yellow adhesive dot on counted would work, but I pressed forward. I combatted boxes so that if a box was moved from the suture the skepticism by communicating with staff memcart, I would still know that it had been counted. bers routinely and going into the rooms first thing I asked the staff not to throw the boxes away but in the morning and again at noon to ask whether to place them in a “recycle bin” where I could the staff members had sufficient suture for the check them at a later time if I needed to clarify day. After a few weeks of using the system, the counted number of boxes of a certain type of everyone saw that suture was not in short supply suture. At the end of this week-long process, my and that I was readily available to help. If somelist was 10 pages long. thing was missing, I would get it back on the Next, I needed to know what suture was used shelf within the day. routinely and what was not. I spoke to the speI asked specialty service coordinators to inform cialty service coordinators and asked them to crethe surgeons they worked with about this process. ate a list of the suture that they used on a regular The surgeons were surprisingly accommodating basis for each of their services. I also asked them and helpful. They provided input on the process, to include in the list how many boxes of each and, if they had a specific request, they would suture they used per week. I took those lists and come to me directly, and we would discuss what 632
AORN Journal
SUTURE COST SAVINGS IN THE OR they needed and whether there was an acceptable alternative already in stock. After removing the unused suture, I packed it into boxes and stored it in a room where we stored orthopedic implants from vendors so to create more space in the center core area where the other carts had to reside. It was a centrally located room to which everyone had access. I was then faced with the task of organizing the remaining suture by size and type. This process took approximately two weeks and reduced the number of suture carts from five to three. I kept a fourth cart to store miscellaneous suture (eg, suture from a different vendor, venous clips, cardiac wire). After the initial sorting process, I made space on the suture room shelves for the suture we chose to keep. I kept the boxes of unused suture for an additional two months to confirm that it was not needed. At the end of this period, I returned all unopened boxes of suture to the suture companies for credit. I donated opened boxes to the facility’s collection for developing countries and took some potentially usable suture to the other hospital in our organization. Occasionally, someone would ask for a suture that had been removed from stock. I took the request to the specialty service coordinator involved to determine whether the suture would be routinely used and need replacement or whether it was a one-time request. For a one-time request, we asked the suture company representative to give us a trial box of suture, and then the surgeon put it through the value analysis process if he or she believed the suture was going to be needed routinely. TRACKING AND ORDERING Next, I needed to involve materials management personnel. These staff members order the suture, and they needed to have a process that was easy to follow and that did not require extensive suture knowledge to manage. I began the tracking and ordering process as a trial. At the start of this trial, I ordered suture twice a week, kept track of orders, and did a stock count before placing any order. This system gave me a general idea of
www.aornjournal.org
weekly usage. I used this data to predict a usage level that would allow materials management personnel to order routinely used suture without having to perform the more complicated process that I was completing twice a week. After about a month of performing the twice weekly checks, I was confident that the par levels that I created would accurately stock all services during the week. After I determined these par levels, I began ordering suture on a weekly basis. I did this for approximately one month to ensure that I was not missing anything and that the par levels were accurate. One of the materials management staff members still has to count and track suture, but the process is a much faster process now that there are fewer sutures to track. I consulted with materials management personnel on a process that would fit with the workflow, and we decided to have a technician provided by the suture company order suture for us. We streamlined the process by asking the technician to use the list we provided and have me or one of the materials management team members sign off on the order. I made sure that the technician understood what I expected and the process I needed her to follow. For a month after she started ordering suture, I checked the order sheets after she completed them to ensure that she was ordering based only on the par levels. At this point, the process was complete and materials management personnel were able to take over the ordering from the technician. We were able to handle the entire process and finally had control over what was on the shelf and how it was ordered. Requests for any new suture must now go through the specialty service coordinators who analyze the cost of the new suture and determine whether it is possible to use an already stocked suture. This is not always possible, but it is important to evaluate. COST SAVINGS During this project, OR procedure volumes increased from the previous year. Suture cost could be expected to go up as well, but we actually saw a decrease in suture cost because of the new AORN Journal
633
Vol 95
WALSH
No 5
9,000
$1,600,000.00 $1,400,000.00
Suture cost
$1,200,000.00
$1,335,898.08
8,937
8,900 8,850
$1,224,156.23
8,800
$1,000,000.00
8,750
$800,000.00 8,688
$827,995.74
$600,000.00 $400,000.00
8,950
8,700 8,650 8,600
8,620
Procedure volume
May 2012
8,550 $200,000.00
8,500
$0.00
8,450 FY08
FY09 Suture cost
FY10
Procedure volume
Figure 1. Comparison of suture spending and surgical procedure volume for fiscal years (FY) 2008, 2009, and 2010.
tracking and ordering process. In 2009, the facility spent in excess of $1.3 million for suture. After this change in 2010, the expenditures for suture were just over $800,000 (Figure 1). This was a 38% decrease in suture costs, or $500,000 in savings during the course of one year. This savings could translate into money being available to spend on patient transfer devices, new OR beds or headlights, or new trays of instruments.
project more easily achievable by breaking it into small steps and having short-term goals. Eventually, we reached our long-term goals by creating a process in which everyone is involved and shares the responsibility.
CONCLUSION The results of this process change provided not only significant savings for the OR but also encouraged teamwork between clinical staff members and materials management and purchasing personnel. This contributes to the sense of shared responsibility among the specialties in the OR to aim for the best result for all the customers (ie, patients, surgeons). The knowledge that even the smallest change can have a big effect when it comes to budgetary issues was important for us to realize. Clinical staff members now have a better understanding of how individual or departmental actions can result in cost savings in everyday tasks. I made the
2.
634
AORN Journal
References 1.
3.
Snapshots: health care costs. Health care spending in the United States and selected OECD countries. April 2011. The Henry J. Kaiser Family Foundation. http://www .kff.org/insurance/snapshot/OECD042111.cfm. Accessed February 10, 2012. Perioperative Management Resources: Budgeting. Denver, CO: AORN, Inc; 2004. Sharpen your supply budget. AORN J. 2006;84(Suppl 2):S45.
Susanna S. Walsh, BSN, RN, is the robotics program manager at Mercy Medical Center in Baltimore, MD. She was a service line coordinator for gynecology, genitourinary, and robotic surgery at Bayview Medical Center, Baltimore, MD, at the time this article was written. Ms Walsh has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
ABSTRACT Materials management personnel at a health care facility in Baltimore, Maryland, were stocking too much suture. They stocked suture requested by surgeons or recommended by suture company representatives, and, because the facility is a teaching institution, they stocked suture requested by residents. No master suture database was available to determine what was needed and what was not. As a result, some suture was rarely used, which cost the facility money and took up inventory space. In response, I created a list of the existing inventory and coordinated with the specialty surgical service coordinators to determine which suture was typically used and in what quantities. I used this information to create a master list, with the goal of eliminating the purchase of suture that was not on this list. I gave the staff members and surgeons two months to assess the list and determine whether the suggested suture was sufficient for their needs. I then asked the materials management personnel to order and maintain suture stock based on the master list. This process took approximately four months and shows how health care providers can take a high-volume item, such as suture, and create cost-saving processes that will serve surgeons’ and patients’ needs while reducing costs and streamlining stock. AORN J 95 (May 2012) 631-634. © AORN, Inc., 2012. doi: 10.1016/j.aorn.2012.02.005 Key words: suture, cost-saving methods, teamwork, streamlining, standardization.
A
ccording to the Organisation for Economic Co-operation and Development, the United States spends more per capita on health care than other countries and also has one of the highest health care spending growth rates.1 Health care expenditures have increased faster than inflation and represented approximately 16% of the gross domestic product of the United States in 2008.1 Suture can be a high-cost item in any OR because it is a highvolume item. If suture purchases and inventory levels are not tracked and perioperative personnel are not sure what is really being used, then the outcome can be very costly. At a 600-bed, 10-OR, level I trauma center in Baltimore, Maryland, for example, there were five carts of suture, much of which was not routinely
used; no master suture database; and no one to organize or streamline the amount of suture in stock. There were frequent requests from surgeons and residents to order new suture and complaints from these same surgeons and residents who claimed that the facility did not stock the suture they needed. Staff members complained that there was too much suture in stock to find what they needed easily, and materials management staff members were confused about which suture was used for which procedures and what needed to be ordered. This abundance of unorganized, not easily found suture represented an exorbitant expense to the facility. Perioperative staff members and materials management personnel needed to know what was
doi: 10.1016/j.aorn.2012.02.005
© AORN, Inc., 2012
May 2012
Vol 95
No 5 ●
AORN Journal
631
May 2012
Vol 95
No 5
already in stock and what was actually used. To better manage a supply budget and to accurately project supply costs, managers need to know caseload projections according to specialty.2 Another way to control cost is by standardizing the number and types of supplies purchased. By confirming what suture is used by each specialty service, eliminating unused suture, and standardizing the length and color of suture (eg, gaining consensus on whether to use 18-inch or 30-inch suture, dyed or undyed) to limit the amount on the shelf, a manager can achieve significant savings.3
WALSH
mine, and compared them so to create a master list of regularly used suture. I took all of their requested par levels and averaged them by adding the par levels given to me by all the specialty coordinators and dividing this number by the number of services that used the suture. This gave me the average number of boxes needed to sustain a week’s worth of surgery. It also gave me a starting point for the par levels; if a service needed more later on, then the par level could be adjusted accordingly to ensure that all suture needs would be met at any point during a week. After I completed the master list, I sent an BEGINNING THE e-mail to all perioperative staff members and STANDARDIZATION PROCESS To begin the process, I created a detailed list of spoke at a staff meeting and a meeting with the what was currently in stock, including needle size, evening and night shift staff to announce that all suture size, suture color, order number, and number suture not on the list would be removed from of boxes of each type stock. I explained on the shelf. Because how the list had been surgeons continued to compiled and that I asked the specialty service coordinators to perform surgeries the suture removed create a list of the suture they used on a while this cataloguing from stock would regular basis for each of their services. I compared their lists to mine to create a process was occurstill be available master list. ring, I had to have a from me if needed. way of knowing Many staff members whether I had counted were skeptical about a suture or not. To do whether this process this, I placed a yellow adhesive dot on counted would work, but I pressed forward. I combatted boxes so that if a box was moved from the suture the skepticism by communicating with staff memcart, I would still know that it had been counted. bers routinely and going into the rooms first thing I asked the staff not to throw the boxes away but in the morning and again at noon to ask whether to place them in a “recycle bin” where I could the staff members had sufficient suture for the check them at a later time if I needed to clarify day. After a few weeks of using the system, the counted number of boxes of a certain type of everyone saw that suture was not in short supply suture. At the end of this week-long process, my and that I was readily available to help. If somelist was 10 pages long. thing was missing, I would get it back on the Next, I needed to know what suture was used shelf within the day. routinely and what was not. I spoke to the speI asked specialty service coordinators to inform cialty service coordinators and asked them to crethe surgeons they worked with about this process. ate a list of the suture that they used on a regular The surgeons were surprisingly accommodating basis for each of their services. I also asked them and helpful. They provided input on the process, to include in the list how many boxes of each and, if they had a specific request, they would suture they used per week. I took those lists and come to me directly, and we would discuss what 632
AORN Journal
SUTURE COST SAVINGS IN THE OR they needed and whether there was an acceptable alternative already in stock. After removing the unused suture, I packed it into boxes and stored it in a room where we stored orthopedic implants from vendors so to create more space in the center core area where the other carts had to reside. It was a centrally located room to which everyone had access. I was then faced with the task of organizing the remaining suture by size and type. This process took approximately two weeks and reduced the number of suture carts from five to three. I kept a fourth cart to store miscellaneous suture (eg, suture from a different vendor, venous clips, cardiac wire). After the initial sorting process, I made space on the suture room shelves for the suture we chose to keep. I kept the boxes of unused suture for an additional two months to confirm that it was not needed. At the end of this period, I returned all unopened boxes of suture to the suture companies for credit. I donated opened boxes to the facility’s collection for developing countries and took some potentially usable suture to the other hospital in our organization. Occasionally, someone would ask for a suture that had been removed from stock. I took the request to the specialty service coordinator involved to determine whether the suture would be routinely used and need replacement or whether it was a one-time request. For a one-time request, we asked the suture company representative to give us a trial box of suture, and then the surgeon put it through the value analysis process if he or she believed the suture was going to be needed routinely. TRACKING AND ORDERING Next, I needed to involve materials management personnel. These staff members order the suture, and they needed to have a process that was easy to follow and that did not require extensive suture knowledge to manage. I began the tracking and ordering process as a trial. At the start of this trial, I ordered suture twice a week, kept track of orders, and did a stock count before placing any order. This system gave me a general idea of
www.aornjournal.org
weekly usage. I used this data to predict a usage level that would allow materials management personnel to order routinely used suture without having to perform the more complicated process that I was completing twice a week. After about a month of performing the twice weekly checks, I was confident that the par levels that I created would accurately stock all services during the week. After I determined these par levels, I began ordering suture on a weekly basis. I did this for approximately one month to ensure that I was not missing anything and that the par levels were accurate. One of the materials management staff members still has to count and track suture, but the process is a much faster process now that there are fewer sutures to track. I consulted with materials management personnel on a process that would fit with the workflow, and we decided to have a technician provided by the suture company order suture for us. We streamlined the process by asking the technician to use the list we provided and have me or one of the materials management team members sign off on the order. I made sure that the technician understood what I expected and the process I needed her to follow. For a month after she started ordering suture, I checked the order sheets after she completed them to ensure that she was ordering based only on the par levels. At this point, the process was complete and materials management personnel were able to take over the ordering from the technician. We were able to handle the entire process and finally had control over what was on the shelf and how it was ordered. Requests for any new suture must now go through the specialty service coordinators who analyze the cost of the new suture and determine whether it is possible to use an already stocked suture. This is not always possible, but it is important to evaluate. COST SAVINGS During this project, OR procedure volumes increased from the previous year. Suture cost could be expected to go up as well, but we actually saw a decrease in suture cost because of the new AORN Journal
633
Vol 95
WALSH
No 5
9,000
$1,600,000.00 $1,400,000.00
Suture cost
$1,200,000.00
$1,335,898.08
8,937
8,900 8,850
$1,224,156.23
8,800
$1,000,000.00
8,750
$800,000.00 8,688
$827,995.74
$600,000.00 $400,000.00
8,950
8,700 8,650 8,600
8,620
Procedure volume
May 2012
8,550 $200,000.00
8,500
$0.00
8,450 FY08
FY09 Suture cost
FY10
Procedure volume
Figure 1. Comparison of suture spending and surgical procedure volume for fiscal years (FY) 2008, 2009, and 2010.
tracking and ordering process. In 2009, the facility spent in excess of $1.3 million for suture. After this change in 2010, the expenditures for suture were just over $800,000 (Figure 1). This was a 38% decrease in suture costs, or $500,000 in savings during the course of one year. This savings could translate into money being available to spend on patient transfer devices, new OR beds or headlights, or new trays of instruments.
project more easily achievable by breaking it into small steps and having short-term goals. Eventually, we reached our long-term goals by creating a process in which everyone is involved and shares the responsibility.
CONCLUSION The results of this process change provided not only significant savings for the OR but also encouraged teamwork between clinical staff members and materials management and purchasing personnel. This contributes to the sense of shared responsibility among the specialties in the OR to aim for the best result for all the customers (ie, patients, surgeons). The knowledge that even the smallest change can have a big effect when it comes to budgetary issues was important for us to realize. Clinical staff members now have a better understanding of how individual or departmental actions can result in cost savings in everyday tasks. I made the
2.
634
AORN Journal
References 1.
3.
Snapshots: health care costs. Health care spending in the United States and selected OECD countries. April 2011. The Henry J. Kaiser Family Foundation. http://www .kff.org/insurance/snapshot/OECD042111.cfm. Accessed February 10, 2012. Perioperative Management Resources: Budgeting. Denver, CO: AORN, Inc; 2004. Sharpen your supply budget. AORN J. 2006;84(Suppl 2):S45.
Susanna S. Walsh, BSN, RN, is the robotics program manager at Mercy Medical Center in Baltimore, MD. She was a service line coordinator for gynecology, genitourinary, and robotic surgery at Bayview Medical Center, Baltimore, MD, at the time this article was written. Ms Walsh has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.