Operating Room Stanford - Case Study

t
os
CASE: OIT-41
DATE: 11/23/2004
rP
PROCESS IMPROVEMENT IN STANFORD
HOSPITAL’S OPERATING ROOM
I’ll tell you something. When you’ve got a patient there, you haven’t got time to get on the
telephone or anything. And I think that’s what’s happening. Now they want us to write this thing,
like this paper and all that. You just have to take care of your patient.
yo
—Operating room nurse, Stanford Hospital and Clinics
The office was silent as each of the four operating room (OR) Material Flow Committee (MFC)
members considered the question before them. What was the next step for process improvement
in the OR? Finding an answer to this question was urgent. Though notable progress had been
made in the recent past, complaints from surgeons, nurses and technicians regarding the
availability of surgical instrumentation had reached an all-time high. Executives at the highest
op
levels of the organization were demanding a solution. The MFC had been formed to create and
implement a plan of action. It was June 2004 and Martha Marsh, CEO of Stanford Hospital and
Clinics (SHC) was expecting an answer in just under a week; it was crucial they all be in
agreement on how to move forward.
tC
The committee consisted of Sridhar Seshadri, vice president for Process Excellence, Nick Gaich,
vice president for Materials Management, Candace Reed, director of the Sterile Processing
Department (SPD), and Joann Rickley, director of the OR. Seshadri was a recent addition to
SHC’s senior management team. An alumnus of the Wharton School of the University of
Pennsylvania, Seshadri joined SHC in June of 2003. Prior to SHC, Seshadri was the vice
president and general manager of Healthcare Solutions with GE Medical Systems. Healthcare
Solutions was responsible for adapting GE’s Six Sigma methodology and offering it to
No
healthcare providers to increase quality and efficiency of care delivery. His new role in SHC
Process Excellence required that he integrate the ideas and concerns of all stakeholders in order
to ensure a project’s success. Gaich was a sixteen-year veteran of SHC. Gaich had seen change
efforts come and go at SHC; he felt that it was time to embrace instrumentation sterilization and
processing as a core competency and invest in the compensation and training of employees in
that area. Reed was a former OR nurse who had since received an MBA and returned to health
care as a consultant and medical sales representative. Reed had SHC as a client prior to her
acceptance of the director position; thus Reed was acutely aware of which areas were most in
Do
Kate Surman and Elena Pernas-Giz prepared this case under the supervision of Professor Stefanos Zenios as the basis for class
discussion rather than to illustrate either effective or ineffective handling of an administrative situation.
Copyright © 2004 by the Board of Trustees of the Leland Stanford Junior University. All rights reserved. To order copies or
request permission to reproduce materials, e-mail the Case Writing Office at: cwo@gsb.stanford.edu or write: Case Writing
Office, Stanford Graduate School of Business, 518 Memorial Way, Stanford University, Stanford, CA 94305-5015. No part of
this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any
means –– electronic, mechanical, photocopying, recording, or otherwise –– without the permission of the Stanford Graduate
School of Business.
This document is authorized for educator review use only by FEROZ IKBAL, Tata Institute of Social Sciences until Apr 2020. Copying or posting is an infringement of copyright.
Permissions@hbsp.harvard.edu or 617.783.7860
Process Improvement in Stanford Hospital’s Operating Room OIT-41 p. 2
t
need of capital investment. She believed SHC should focus on investment in additional
instruments and information technology to improve efficiencies. Rickley had been with SHC for
os
7 years. In her leadership position, she managed a significant portion of the OR budget and she
had a unique understanding of both the surgeons’ and OR nurses’ perspectives. She felt strongly
that instrumentation issues resulted in large part from low morale and a lack of cross-functional
camaraderie and teamwork. Seshadri had created the committee knowing that each individual
would bring a unique outlook to the project. While he believed that each of these areas was
rP
important, the fact remained that given SHC’s limited time and resources, the team had to select
which would be most crucial to attack next.
HISTORY OF SHC
Stanford University’s medical school began in San Francisco in 1858 as the Medical Department
of the University of the Pacific. After a series of location changes and expansions, SHC was
yo
established on Stanford University’s campus with satellite locations throughout the Bay Area.
SHC was a nonprofit organization that provided general acute medical care and tertiary medical
care and served as the primary teaching hospital for the Stanford University School of Medicine.
In an effort to take advantage of economies of scale and to enhance purchasing power, in 1997
SHC merged with the University of California San Francisco Medical Center, UCSF/Mount Zion
Medical Center, and Lucile Packard Children's Hospital at Stanford to form UCSF Stanford
op
Health Care. This merger was short-lived due to many cultural and logistical obstacles that
prevented the forecasted increased efficiencies from being realized. Losses in the two years
following the de-merger in 1999 totaled $74 million. As a result, SHC’s Board of Directors
sought new leadership. In 2002, the board hired Martha Marsh as president and CEO. Marsh
was the former director of Hospital and Clinics at University of California-Davis Medical Center
tC
and COO of University of California-Davis Health System. Marsh focused the attention of
SHC’s management and staff on gaining financial stability through renegotiating managed care
and vendor contracts, as well as enhancing patient admissions and discharge systems to improve
patient flow. The new leadership team was credited for a dramatic financial turnaround; in 2002
SHC reported a net income of $12.5 million despite a predicted loss of $10 million.
OVERVIEW OF SHC STATISTICS

No
In fiscal year 2003, SHC generated $900 million of net patient service revenue with 430 active
beds, 1,875 medical staff members and 675 house staff members including interns and residents.
The hospital had internationally recognized Centers of Excellence in the areas of oncology,
cardiovascular disease, neuroscience, transplantation, and surgical services. In 2003, SHC
admitted 19,446 patients for a total of 109,954 days of care. It also handled 38,147 emergency
patient visits and 262,267 hospital outpatient visits. Stanford’s 53 clinics managed 347,606
patient visits in specialties ranging from internal medicine to dermatology to physical medicine
Do
and rehabilitation. (See Exhibit 1 for a complete list.) In July of 2003, US News and World
Report included SHC in the “top 15 best hospitals” in the nation. In the four years prior to 2004,
t
SHC was named the hospital of choice by consumers in both San Francisco and San Jose,
according to the National Research Corporation.1
os
PROCESS EXCELLENCE AT SHC
The financial turnaround in 2002 marked the successful execution of the first steps of Marsh’s
vision for SHC. Next, Marsh sought to develop an ongoing culture of continuous improvement
rP
within the organization. Marsh recognized that this would be a challenging undertaking given
the skepticism of change that was prevalent at SHC. The staff’s current lack of confidence was
largely due to past experience with and perceptions about external consultants. Firms were
regularly hired to make recommendations but were rarely involved with implementation.
Consequently, successes were infrequent and frustrations were common. Marsh firmly believed
that this element of SHC’s culture was not permanent, however. She believed that SHC would
shift toward a culture of process improvement once change was driven from within the
yo
organization and support emanated from the most senior levels of management.
With this goal in mind, Marsh created the position of vice president of Process Excellence.
Seshadri was hired to fill the role based on his work experience and contagious enthusiasm for
process improvement. When Seshadri assumed his role at SHC, he established several initial
criteria for project selection. First, the project had to make a significant impact toward
increasing capacity or improving service excellence in order to draw the attention of senior
op
management. Second, the project needed to target highly visible and well-respected areas of the
hospital. Third, the project needed to have a reasonable chance at success. Seshadri was aware
that the best project candidates were also likely to be the riskiest. In addition, any failure would
be highly visible and add to the difficulty of launching future projects. Fourth, and most
importantly, the project had to be aligned with SHC’s mission: “To care for the patient, each
tC
other and about what they do. To educate patients and families, and other customers; and to
advance our own knowledge and to discover new treatments and technologies, and discover new
ways of improving care.”
The OR Improvement Project
Selection
No
Using his established criteria, Seshadri chose the OR as one of the first two areas of focus.2 The
OR generated a third of the hospital’s revenue; even a small percentage of increased efficiency
would result in significant bottom line impact. The OR was comprised of 33 suites.3 In fiscal
year 2003 the OR generated almost $13 million in net direct income with 24,104 cases and
59,615 hours of surgery. The urgency of OR improvement was driven primarily by three
factors- local market changes, increasing surgical volumes (number of cases and hours of
1
The Consumer Choice Award was determined by consumer perceptions on multiple quality and image ratings collected in the
Do
National Research Corporation’s annual Healthcare Market Guide Study® (HCMG). Winners were those hospitals that
consumers chose as having the highest quality and image in top markets throughout the U.S. National Research Corporation,
“Consumer Choice Awards,” http://www.nationalresearch.com/ccahosp00.html (18 June 2004)
2
The second major area was to design the workflow at Stanford’s brand-new Cancer Center. The Cancer Center work was a
“green-field” project since the work environment was new, whereas the OR project was a “brown-field” project where it was
much harder to make change starting from scratch.
3
The OR consisted of the main OR with 21 suites and the Ambulatory Surgical Center (ASC) with 12 suites. ASC was typically
used for outpatient procedures or routine inpatient cases.
t
surgery), and decreased physician and staff satisfaction. The market changes placed some of the
OR’s revenue stream in jeopardy; competing healthcare providers had announced their intention
os
to build new facilities in the Bay area.4 In many cases, the surgeons at SHC were operating in
suites built more than forty-five years ago; state-of-the-art facilities elsewhere could draw some
surgeons away from SHC. At the same time, the number of procedures demanded annually was
rising as a result of increased life expectancy in the United States and the aging of the Baby
Boomer generation. SHC predicted that case volume would increase 18 percent between 2004
rP
and 2008. (See Exhibit 2 for breakdown of percentage increase by service line—SHC and
national trends.) Also, surgeons were adopting robotic and microsurgical techniques at an
increasing rate, and though less invasive to the patient, these procedures consumed more hours in
the OR because of their complexity. Hospital administrators forecasted an 18 percent increase in
the demand for surgery hours between 2004 and 2010. SHC leadership knew that surgeons, if
were dissatisfied with their access to the OR and with their overall OR experience, would be
more likely to perform their surgeries at competing hospitals.
yo
There were other critical reasons why Seshadri chose the OR as one of his lead projects. The OR
at SHC was home to world-renowned surgeons; thus the area provided high visibility and, with a
successful project, the potential to set a powerful precedent for the process excellence initiatives.
Additionally, in a recent internal survey of OR surgeons, anesthesiologists and nurses, two-thirds
of those sampled expressed dissatisfaction with the OR environment. Even though patient care
op
remained world class and outcomes were excellent, it was frustrating for medical professionals to
function in an environment that required extra work to compensate for inefficient procedures.
Focusing senior management’s attention on the area would send a clear and necessary signal that
the well being of OR staff was important to those at the top of the organization.
Most importantly, process improvement in the OR would have direct and positive impact on the
tC
patient and staff experience, which aligned the project with SHC’s mission. Though excellent
patient outcomes were maintained via “workarounds”,5 the inefficiencies and outdated facilities
often caused cases to be rescheduled; this inconvenienced patients, surgeons, and OR staff.
Implementation
The OR Improvement Project was divided into four separate tasks: timely chart completion, on-
time surgery starts, efficient room-turnover, and streamlining the provision of instruments and
No
supplies to surgeons before a case. By the spring of 2004, tangible progress had been made on
the first three projects. On-time chart completion rates had risen from a baseline of 34% to 62%
in four months and had progressed to the phase of continuous improvement. A three-month pilot
comparing ideal to actual times to ensure optimal surgery starts had been completed and was
poised for a full-scale deployment. Additionally, a new pilot was ready to begin in several
service lines based on a room-turnover matrix that outlined the steps required to clean and set-up
an OR between cases. In order to ensure the success of these projects, Seshadri recruited an
experienced and well-respected nurse manager, Freida Acu, to act as a full-time task force
Do
leader. Each project had a high-energy team leader and several team members. Team leaders
were responsible to Acu for the success of their projects. The teams were assisted by a physician
4
Palo Alto Medical Foundation, “News,” http://www.pamf.org/news/2004/0604_sancarlos.html (6 June 2004)
5
A “workaround” was a set of steps required to provide effective patient care but which was not necessarily standard procedure.
from the Advisory Board6 who provided guidance around national best practices. Prior to
t
adopting this model, Seshadri and the sponsors7 had discussed several options, including
os
outsourcing the entire project to consultants from GE, Johnson & Johnson or a specialized
boutique firm, being a part of a collaborative with the Institute for Healthcare Improvement8, and
keeping the project in-house either entirely or in part.
Instrumentation was the next hurdle. The issue had come onto the radar screen in January of
rP
2004, when the project’s sponsors began to hear rumblings about instrumentation issues in the
OR—ranging from a lack of necessary instruments to an unacceptable length of time required to
complete sterile processing to strained communication between the OR and sterile processing
staffs. There was consensus among SHC leadership that if this issue was not addressed
immediately, other gains could be negated. In response to this need, Seshadri formed the MFC,
consisting of Gaich, Reed, and Rickley to explore improvement in the OR instrumentation and
supplies process. Once the investigation was complete and project selected, they would be
yo
deployed in the same model as other projects.
First, the MFC sponsored a pilot project called the “Early Morning Instrument Prep”, in which a
neurosurgery nurse arrived at 5:30 a.m. daily to check the supplies and instruments in selected
neurosurgery rooms. This project provided early data into possible sources of problems. The
MFC members took this data back to their teams to brainstorm solutions. Based on this team
op
input, SHC hired Implementation Specialists for Healthcare (ISH), a firm with specialization in
sterile processing and surgical service solutions. ISH played the role of Instrument Captain (IC)
in the OR. Five ICs, dressed in black scrubs to be immediately recognizable, were stationed in
the OR at all times and were responsible for correcting any instrument problems that came up
before, after, or during a surgery. In addition, the ICs documented and tracked the frequencies
and types of problems in order to identify the root causes of instrumentation errors. An
tC
instrumentation error was defined as any instance in which an OR nurse identified a missing
instrument during or after preparation for a case. Within two months, six clear causes emerged
(see Exhibit 3 for problem frequencies):
1. Preference Card (PC) Inaccuracy

A PC was a comprehensive list of all supplies and instruments that a specific
surgeon needed for a specific procedure.9 The PC drove the automated creation
No
of a Pick List. The list was then used by a technician to create a case cart10 that
6
The Advisory Board Company was a membership of 2,100 of the country's largest and most progressive health systems and
medical centers. The Advisory Board provided best practices research and analysis to the health care industry, with a focus on
business strategy, operations, and general management issues. A longtime SHC partner, The Advisory Board delivered
educational presentations to staff and helped streamline throughput. The Advisory Board Company, “In Brief,”
http://www.advisoryboardcompany.com/public/inbrief.asp (10 June 2004).
7
The sponsor team included Marsh, Michael Peterson,the COO, Nancy Lee, the vice president for Clinical Services, Dr. Ronald
Pearl, Chairman of Anesthesia, and Dr. Thomas Krummel, the Chairman of Surgery. The sponsors reviewed the progress of
these projects once a month.
Do
8 The Institute for Healthcare Improvement (IHI) was a not-for-profit organization driving the improvement of health by
advancing the quality and value of health care. The Institute for Healthcare Improvement, “About Us,”
http://www.ihi.org/ihi/about (4 July 2004)
9
Supplies, also known as consumables, were any item used for surgery that would be consumed during the case, such as gauze,
sutures, or gloves. Instruments were reusable tools.
10
Case carts were stainless steel rolling shelves; once loaded with supplies and instruments for a procedure these carts were
wheeled into the OR. Material-intensive cases required multiple case carts. Case carts were separately washed and sterilized
by SPD following each surgery.
t
included all the appropriate instruments and supplies for a scheduled surgery. At
SHC, inaccurate or incomplete PCs accounted for an estimated 30 percent of all
os
instrumentation errors. (See Exhibit 4 for a sample PC and Exhibit 5 for a sample
Pick List.)
2. Case Cart Preparation Errors
rP
Case cart technicians who picked incorrect items despite the presence of a correct
PC caused approximately 30 percent of instrumentation errors. Incorrect location
indicators for instruments exacerbated these user errors. To pick an instrument, a
technician used the bin number listed next to the instrument name on the PC.
Because many of these bin numbers had been entered into the OR information
systems incorrectly, the technician could pick from the right bin according to the
PC, but still place the wrong instrument on the case cart. Few, if any, case cart
yo
technicians could identify each type of surgical instrument by sight.
3. Instrument Assembly Inaccuracy

Instruments needed to be disassembled for decontamination and reassembled after
sterilization was complete. About 15 percent of instrumentation errors resulted
from incorrectly assembled and even damaged or broken instruments.
op
4. Supply Replenishment
In addition to instrumentation, SHC administration was also tracking supply use
in the OR. It was estimated that 40% of supplies were unused following a
surgical procedure; these items had to be restocked by SPD personnel.
tC
5. Inadequate Instrument Tracking

A set was a group of instruments packaged together for use during a specific type
of surgical procedure. SPD employees were expected to scan these sets as they
passed by tracking stations located at various places in the process flow. The
tracking system updated instrument location and tracked employee productivity.
Scanning was a manual process and employees often failed to complete it. Some
instruments in the system had not been scanned for months despite frequent
No
usage, thus they appeared to be lost when the case cart technicians tried to locate
them.
6. Infection Control Turnaround Time

Due to last minute schedule changes, unexpected patient needs and the lack of a
process to “conflict check” (ensure that the same instrument would not be needed
in two places simultaneously), instruments were often needed again immediately
after use. The six hours required for sterile processing prevented immediate
Do
turnover of instruments.
t
SUPPLY CHAIN MANAGEMENT AT SHC
os
Structure
Historically, the responsibility for instrumentation processing fell under two departments.
Materials Management controlled the decontamination and sterilization of instruments, while the
OR staff managed the instrument assembly and case carts preparation. In March 2003, based on
rP
an external consultant’s recommendation, the surgical supply channel was centralized under the
Materials Management department. Though the transition was considered crucial to SHC’s
effort to improve continuity of care, execution was more challenging than expected. It became
evident that OR nurses had been completing a significant amount of instrumentation assembly.
Under the consolidated system, assembly and loading functions were removed from the OR floor
and relocated next to sterile processing. The combination of sterile processing and assembly was
then captured within SPD. Following the reorganization, employees transported case carts
yo
(including used instruments and unused supplies) by elevator from the second floor OR to the
ground level SPD. There the instruments were disassembled, sterilized, and then reassembled by
SPD technicians. Supplies not in use were housed on the same floor as SPD; instruments,
however, were stored in one of two rooms, referred to as the East and West cores, located in the
OR until they were needed for surgery. Complicating things further, in May 2004, an IT
solution, Picis, was introduced to help automate instrument and supplies tracking, and to enhance
scheduling.
op
Process Flow Challenges
As of 2004 there were over 50,000 instruments flowing throughout the OR system. In 2003
there were 15,057 surgical cases in the main OR and 9,391 cases in the ASC. (See Exhibit 2 for
detailed breakdown of cases and case hours by service line.) Each instrument needed to be
tC
sterilized, processed, and delivered to the correct surgeon for the correct case at the correct time.
Each step in the process flow added complexity to that objective.
The process began when a surgeon needed to schedule a patient for surgery—that surgeon’s
administrative staff called SHC to schedule a case; this could be anywhere from several weeks to
one day in advance of the requested surgery date.11 The day prior to an operating day, the entire
No
OR schedule was printed from the OR information system, Picis, which also generated a list of
PCs for the scheduled surgeries. As an added complication, Picis had been launched very
recently with less than half of all PCs entered into the system. Thus the master PC list had to be
manually reviewed for any missing or incomplete PCs. OR management expected that even
after this issue was resolved, there would be an ongoing need to enter new PCs and manually
review the system due to medical innovations and resulting new surgical procedures. By noon of
the day prior to surgery, the Preference Card Clinical Coordinator corrected all errors and issued
the final surgery schedule (with the understanding that unscheduled emergency cases would be
Do
accommodated).
11
Cases were scheduled into pre-allocated blocks of time. Those blocks were assigned to specific surgical groups (SHC, LPCH,
PAMF or Community) by specialty according to which operating rooms contained the specific equipment required for that
specialty. Surgeons within those groups were given priority to schedule cases during their assigned blocks. Forty-eight hours
prior to surgery, any unclaimed block time was released to the waitlist that included surgeons who lacked scheduling priority.
The schedule was locked the day prior to surgery after which point the scheduler was permitted to add emergency cases only.
Those who were unable to find space remained on the waitlist. In 2004, the waitlist ranged from 8-25 cases per day.
t
At 4:00 p.m. the lead case cart technician accessed Picis for the Pick List. This list typically
os
contained many errors because there was no naming standard used when the Picis database was
created; it would be several months before these flaws were resolved. By 5:00 p.m., a case cart
technician picked supplies for the cart and then moved it to the East or West Core, depending on
the room that the surgery was scheduled. Once the case cart arrived in the OR it was rechecked
for accuracy by a core technician, nurse, or instrument captain. If a required instrument was not
rP
on the case cart as expected, that staff member tried to locate it; this process could take anywhere
from “two minutes to two hours,” according to one IC. There was a bar code on every
instrument set that was supposed to be scanned as that instrument traveled to different locations
throughout the system. In practice, however, busy staff often neglected to scan, which meant
that tracking was inconsistent and the instrument location registered in the computer was
frequently different than the instrument’s physical location. If the technician checked the
tracking system and still did not locate the instrument, the technician called SPD. If the
yo
instrument was not there or was not scheduled to finish sterile processing and assembly by the
scheduled surgery start time, the technician checked the other surgical suites for available
instruments.
Some of the OR staff circumvented this process by sharing instruments between suites. Once an
instrument was identified as missing from the case cart, the nurse or technician found another
op
surgical team using the same instrument and arranged to borrow the instrument during the
surgery. Between uses, the instrument was flash sterilized. The Association for the
Advancement of Medical Instrumentation (AAMI) defined flash sterilization as “the process
designated for the steam sterilization of patient care items for immediate use.”12 There were
some concerns that flash sterilization did not provide as effective infection control as the
complete sterile processing procedure and SHC policy formally limited the use of flash
tC
sterilization to emergency situations such as if an instrument was dropped during surgery.13 The
incidence of flash sterilization was not tracked at SHC. The sterilization equipment produced a
printout with each use that had to be initialed by a staff member, but these printouts were a part
of the equipment’s maintenance record, not the patient’s medical record. SPD management
noted that by encouraging the decreased use of flashing, the incidence of its use had dropped.
If above methods of locating a missing instrument failed, the technician notified an OR manager,
No
who contacted the surgeon to ask if the instrument could be omitted from the case cart or
substituted with another tool. If it could not, surgery was delayed or canceled. (See Exhibit 6
for a floor map and Exhibit 7 for a process flow map.)
MANAGEMENT CHALLENGES IN THE OR
Because SHC was an academic medical center, there was not just one individual who was
ultimately responsible for the entire organization; rather, the CEO of SHC managed the hospital
Do
12
Association for the Advancement of Medical Instrumentation. Flash sterilization: steam sterilization of patient care items for
immediate use (ANSI/AAMI ST37-1996). Arlington (VA): Association for the Advancement of Medical Instrumentation;
1996.
13
The appropriate use of flash sterilization was under debate. The U.S. Department of Health and Human Services Centers for
Disease Control (CDC) restricted the use of flash sterilization to emergency situations while AAMI recommended processes to
allow for effective flash sterilization rather than warning against it altogether. 40 percent of U.S. hospitals surveyed reported
routine use of the technique in an article titled “Sacred Cow Survey” in OR Manager September 1998 Vol 14, No 9, page 14.
t
staff and facilities, while the dean of the Medical Center managed the medical school, faculty,
and residents. Though the costs of operations were incurred by the hospital, the amount of
os
control that the hospital could place on physicians was limited. A physician was not a hospital
employee, and thus free to practice at another facility at any time. If a prominent physician were
to leave SHC in response to restrictions imposed by hospital administration, SHC would also
lose that physician’s medical expertise, patients, and revenue stream.
rP
In addition to challenges posed by SHC’s administrative structure, the OR culture was
particularly complex because it was organized into silos. Not surprisingly, anesthesiologist,
surgeons, nurses, and supply distribution staff all had a variety of opinions about how the OR
would function most efficiently.
Surgeons
yo
Typically, hospitals had a single group of surgeons who reported to a single chief of staff, but at
SHC there were three groups of practicing surgeons. SHC’s unique multi-group system added a
great deal of complexity to OR management; multiple constituencies with varying interests and
incentive structures all vied for the same OR space. As of 2004, the three groups included 150
SHC and Lucile Packard Childrens’ Hospital (LPCH) physicians, 75 Palo Alto Medical
Foundation (PAMF) physicians, and 25 community physicians.
op
SHC surgeons were Stanford Medical School faculty or associate faculty members. They
reported to the Stanford chief of staff, who reported to both the CEO of SHC and the dean of the
Medical Center. Stanford and LPCH surgeons were salaried and also collected a fee per case. A
surgeon’s salary was sometimes lower at SHC as compared to the salary at a non-academic peer
institution because a percentage of a physician’s workweek was dedicated to research funded
tC
separately by Stanford University and grants. Although faculty had teaching duties in addition to
patient care14, they were assisted by medical residents. The instrumentation needs of LPCH
surgeons varied with the size and developmental stage of pediatric patients. SHC and LPCH
patients were seen on a fee-for-service basis and were generally referred to a SHC or LPCH
surgeon based on the surgeon’s expertise in a particular area. Often, a health maintenance
organization (HMO) would outsource a particular type of specialized surgery, such as heart
transplant, to SHC because its own hospitals did not have capacity for that procedure.
No
PAMF was an affiliate of Sutter Health, an HMO. PAMF, therefore, functioned on a pre-paid
basis as opposed to SHC’s fee-for-service model. PAMF patients belonged to one of the
Preferred Provider Organizations or HMOs that contracted with PAMF, and those patients were
restricted and/or provided with financial incentives to seek care from a surgeon within the
managed care group. Therefore, PAMF patients were generally not free to choose between SHC
and PAMF surgeons. The contract between SHC and PAMF established that PAMF surgeries
would be completed at SHC.
Do
On May 18, 2004, PAMF announced the selection of a site in San Carlos, California,
approximately 10 miles away from SHC, for the construction of a new medical center. The plans
14
Teaching duties included lecturing, on–the–job training, and leading students through rounds. Rounds involved a physician
leading a group of residents to review the status of current patients. This occurred once a week and gave the faculty member a
chance to test each student’s comprehension.
t
for this 475,000-square-foot campus included a 110-bed acute care hospital, laboratory and
radiology services, outpatient surgery, an urgent care center, emergency services, and medical
os
offices for over 150 primary care and specialty physicians. The impact of the new facility on
SHC’s contract with PAMF had not yet been finalized, but it was clear that the volume of PAMF
cases performed at SHC would decline.
Community surgeons practiced in the local area and gained privileges at SHC following an
rP
extensive credentialing process. These surgeons typically had practice privileges at more than
one hospital, thus they had the flexibility to perform a surgical procedure in whichever location
was most convenient.
Impact of OR Instrumentation on Surgeons

At the time that process improvement was brought into the OR, surgeons were reporting high
levels of frustration over the failed and delayed delivery of instruments as well as the delivery of
yo
broken, unusable instruments. Surgeons did not interact directly with the SPD staff. As a result,
some surgeons did not understand the complexity of SPD’s work. Some surgeons were known
to take instruments with them when they practiced at other facilities. An SPD employee
described a particularly long search for several instruments that ended when they discovered that
the surgeon had the missing instruments, along with two other full sets, in the trunk of his car. It
was also common practice for surgeons to schedule elective cases the night prior to the surgery
op
despite the rule that only emergencies should be scheduled at that time. When questioned about
this practice, one surgeon stated that it made sense because the OR should be fully utilized; the
SPD’s preparation lead-time was not considered when scheduling cases.
Surgeons relied heavily on nurses to prevent and resolve instrumentation-related issues. Some
surgeons felt that the nurses were entirely at fault for instrumentation-related problems. One
tC
surgeon said, “When a nurse insists that an instrument is not available during a surgery and then
suddenly it becomes available, I know that the nurse was not trying hard to find the instrument.”
Some surgeons pointed to a lack of accountability and work ethic among some of the nurses. For
example, they found it disruptive when nurses left in the middle of a case because their shift had
ended. The surgeon then had to begin working with a new set of nurses. If a case proceeded into
the evening shift, there could be a rushed effort to pay nurses overtime to keep them on the case,
especially if sufficient replacements were not available. Tensions could mount quickly in the
No
fast-paced environment of the OR and harsh words were often exchanged. In contrast, strong
working relationships tended to emerge between surgeons and the nurses who were seen as
proactive and hard workers. These nurses obtained star status among the surgeons.
Operating Room Nurses
There were 154 OR nurses at SHC working in both the main OR and ASC throughout the day,
evening and night shifts. All SHC nurses belonged to the Committee for Recognition of Nursing
Do
Achievement (CRONA) union. They were paid on an hourly basis. Day shift nurses were
assigned to cases based on their area of specialty, while night and weekend shift nurses acted as
generalists due to the lighter load of cases.15
15
Nurses were expected to be proficient in one of the three major service lines- orthopedic surgery, neurosurgery, or
cardiovascular surgery, and to also be able to serve in at least one of the other areas, such as general surgery, plastic surgery, or
gynecology.
t
Impact of Operating Room Instrumentation on Nurses
os
SHC nurses felt that they were going above and beyond their official roles in an effort to prevent
instrumentation problems in the OR. Nurses often absorbed the brunt of the process flow
challenges that arose in the provision of instrumentation to the OR because they served as
intermediaries between surgeons and the SPD. As a result, nurses used proactive efforts to
ensure the availability of all instrumentation at the start of surgery. Many commonly stepped out
rP
of an ongoing procedure to inspect the case cart for the following surgery. If a missing
instrument was discovered, the nurse would call SPD and initiate the search for that tool. If SPD
was not able to locate it, the urgency level increased. The nurse searched for the instrument in
the core. If the instrument was not available in there, the process of informal collaboration with
other nurses began. In the extreme case that none of these avenues worked, a nurse would take
the elevator down to the ground floor and personally search for the instrument. If the instrument
was found and still needed to go through decontamination, the nurse waited with the instrument
yo
until decontamination was complete for fear that otherwise, the work would not be completed in
a timely fashion.
To avoid this stressful and time-consuming search for missing items, some nurses kept critical
instruments in their personal lockers. In addition, because the nurses who hoarded instruments
were able to produce them when needed, those nurses were more likely to attain star status in the
op
OR. This practice further complicated the instrumentation deficiencies because these
instruments were out of general circulation and designated as missing.
Some nurses who had been in the SHC environment for a long time used failed systems to their
advantage. These nurses were known to purposefully maintain incomplete PCs. The nurse
would then be able to independently supplement the incomplete case cart, while another nurse
tC
who was not familiar with that particular PC would only find out from the surgeon during the
case. This process helped certain nurses appear to be more prepared then their peers.
When the ICs were introduced in the OR, several nurses provided feedback to the MFC that
while they liked the idea of the IC role, they believed it would be a more effective tool if those
positions were filled with SHC staff rather than external consultants.
No
Sterile Processing Department
There were 11 case cart employees and 18 sterile processing employees working throughout the
day, evening, and night shifts in SPD. After a few weeks of on-the-job training, new employees
began working in SPD and were paid on an hourly basis. The night shift was the most heavily
staffed, which allowed SPD employees to work on instruments with which they were most
familiar. The day and weekend shift staff tended to act in more of a generalist role. Those
individuals who made a career in this area sought training to advance within the field and to
Do
assume additional responsibilities.
Impact of Operating Room Instrumentation on SPD Employees

The individuals working in SPD experienced high turnover rates. In part, this could be attributed
to industry norms. However, the failures of the SHC instrumentation processes added additional
stress. SPD employees found themselves on the receiving end of angry calls from OR nurses
t
and staff several times a day. The repeated urgent calls to locate missing instruments interrupted
the flow of work and caused more instruments to be delayed. This created a disincentive to
os
spend time searching for instruments. Also, the wide range of instruments that flowed through
the system at SHC made reassembly after cleaning especially challenging as compared to local
community hospitals without a focus on research and unique tertiary care procedures. SPD
employees were not as well trained as nurses to test an instruments to see if it was still in
working order, which meant that time was wasted on processing broken instruments. SPD
rP
employees were doing their best to process the 32,000 instruments that flowed through the
system each day, yet they found themselves often blamed and berated for failures.
Unlike many at SHC who expressed displeasure with the changes that resulted in instrument
assembly moving out of the OR, SPD employees considered it to be a significant improvement.
There was a feeling of excitement about reporting to Materials Management because concerns
were considered in more detail than they had been when SPD reported to the OR director.
yo
Through the years, SPD staff watched as instruments were lost, broken and hoarded but the role
that nurses and surgeons played in contributing to that outcome was ignored prior to the change
in management. This happened in part because nurses had played a key role in preventing
delays. Their proximity to instrument assembly had allowed them to step in and assist SPD.
Relocation of instrument assembly meant that nurses could no longer help save processing time.
Added transport time between floors exacerbated delays. SPD employees largely felt that these
op
delays were highlighting issues that had always existed and the fact that management was now
paying attention gave them hope for future improvement. One SPD employee expressed her
excitement about learning how to assemble more complicated instruments now that the nurses
were not available to assist. She felt that her increasing knowledge of instrumentation assembly
would ultimately allow her to advance her career. SPD employees also expressed hope for the
Picis system which, once its issues were resolved, would automate many tasks and provide staff
tC
with better information to work with when preparing instrumentation.
NEXT STEPS
Seshadri weighed all of these factors as he discussed options with the team. SHC posed a
distinctive challenge in his mind because, unlike his previous employer GE, Seshadri knew,
“SHC would have to take baby steps in the process improvement effort because the hospital did
No
not yet have organization-wide culture and systems in place to drive change.” Although there
were many possible next steps, each of the following options had emerged:
1. Prioritize Picis
SHC could put all other changes on hold until the implementation issues
surrounding Picis were corrected. These problems were consuming valuable staff
time and made it difficult to design an additional process improvement project.
The current status of Picis also made it difficult to measure any process
Do
improvement outcomes.
2. Focus on Culture and Organizational Dynamics

A key obstacle to process excellence in the OR was the SHC culture. Silos
prevented information from flowing across job functions. The high value placed
on seniority and experience often stifled new ideas from new members of the
t
team. The hierarchical structure also prevented ideas from quickly reaching the
top levels of the organization. Low morale translated into high turnover and the
os
resultant loss of intellectual capital. Perhaps operational changes should be put on
hold until a culture that embraced change could be put in place.
3. Redesign the Current Process Flow

Cultural issues aside, the OR process flow appeared to be unstructured. Heroic
rP
efforts by nurses and technicians were required on a daily basis to ensure that
instruments and supplies were in the right place at the right time. There was a
general confusion about the exact role of clinical versus non-clinical personnel.
Also, some OR staff had voiced their objection to employing external consultants
to fill the IC role. SHC administrators could redesign the current process and
reallocate labor resources to reduce instrumentation errors and improve OR
efficiency.
yo
4. Outsource
The entire instrumentation provision process could be outsourced. There was a
working model for this option at SHC outside of the OR, in the supply
management for the medical floors. There, a single distributor provided just-in-
time delivery of supplies to the appropriate floor as needed according to an
op
automated inventory system. Instrumentation provision entailed much more
complex processes, however. Exploring the viability of this option required SHC
to decide whether or not instrumentation provision was a core competency. It
also required an assessment of the downside risks to outsourcing this vital
function.
tC
5. Educate
Investing in education to improve the accuracy of instrumentation handling
throughout all levels of the OR, including SPD employees, nurses, and surgeons,
could likely have a significant impact on efficiency by reducing the number of
items broken, lost, and hidden for later use. Technological investments would
also allow for “just in time” training in SPD specifically. IT systems were
available through which employees could use online tools to aid in the assembly
No
of complicated instruments. Also, cross training in SPD would allow instrument

assemblers and sterile processing employees to fill in for one another based on the
workload. However, the high turnover of these employees might mean that the
additional investment would be lost to SHC and gained by the next organization
that the employee worked for—essentially helping the competition.
6. Invest in Additional Capital

Organizational culture and turnover issues had existed as long as any employee
Do
could remember. As a result, it might be most expedient to simply invest in

additional instrumentation and to open additional OR suites to absorb the
predicted increase in volume without attempting to improve efficiency. Earlier in
2004, SHC had been able to recruit a world-renowned surgeon away from a
competing hospital. Clearly this surgeon was undeterred by the current
t
circumstances. Perhaps that was a sign that business as usual was the way to
proceed, buffered by additional investment to reduce the negative impact of the
os
inefficiencies. If there were extra sets of equipment, it would not matter if some
were hoarded, misplaced, lost, or broken; additional rooms would minimize the
impact of delays.
Each of these options had strong proponents. It was up to the four OR MFC members to
rP
synthesize all of the information and input that they had gathered and present a solution to the
CEO.
yo
op
tC
No
Do
t
Exhibit 1
Overview of Stanford Hospitals and Clinics
os
Centers of Excellence Clinics at Stanford
• Clinical Cancer Center • Bariatric Surgery for Morbid Obesity
• Breast & Breast Cancer Surgery
• Heart Center • Cardiology (Cardiovascular Medicine)
• Cardiothoracic Surgery
rP
• Neurosciences • Colon & Rectal Surgery
• Cyberknife • Dermatology
• Endocrinology & Metabolism
• Surgical Services • Gastroenterology
• Gastrointestinal Surgery
• Transplantation • General Surgery
• Bone Marrow Transplant • Gynecology
• Kidney/Pancreas Transplant • Hand & Upper Extremity Surgery
• Liver Transplant
yo
• Heart & Lung Transplant
• Heart & Heart/Lung Transplant • Hematology
• Hepatology
• Infectious Disease
Medical Services • Integrative Medicine (Alternative)
• Internal Medicine
• Anesthesia
• Interventional Neuroradiology
• Blood Center
• Kidney & Pancreas Transplant
• Cath Angio Laboratory
• Liver Transplant
op
• Clinical Nutrition
• Nephrology (Kidney)
• Diabetes Education
• Neurology
• Emergency Medicine
• Neurosurgery
• Infection Control
• Nuclear Medicine
• International Medical Services
• Nutrition
• Lab Services
• Obstetrics
• Life Flight
• Oncology (Cancer)
• Neurodiagnostics Laboratory
tC
• Ophthalmology (Eye)
• PET/CT
• Oral & Maxillofacial Surgery
• Pharmacy, Inpatient
• Orthopaedic Surgery
• Radiology
• Otolaryngology (Ear, Nose & Throat)
• Rehabilitation Services
• Pain Management
• Social Services
• Pediatrics
• Transport Program
• Physical Medicine & Rehabilitation
• Trauma Service
• Pigmented Lesion and Melanoma
• Vascular Laboratory
No
• Plastic & Reconstructive Surgery

• Positive Care
• Psychiatry & Behavioral Medicine
• Pulmonary Medicine (Lung)
• Radiation Oncology
• Reproductive Endocrinology & Infertility (REI)
• Rheumatology & Immunology
• Sleep Clinic
• Spine Clinic-Orthopaedic
• Spine Clinic - Neuro
•
Do
Stanford Family Practice

• Stanford Medical Group at Blake Wilbur
• Stanford Medical Group at Hoover
• Stoma & Wound Care
• Urology
• Vascular Surgery
• Women's Health @ Stanford
Source: Stanford Hospital and Clinics.
t
Exhibit 2
Case Volume Trends
os
SHC Surgical Service Cases
FY2003 SHC FY2003 SHC Case National Volume Trend SHC Forecast (2003-
Case Volume Hours (2003-2008) 2007)*
rP
Orthopedics 4,521 10,317 +9% High
General 3,574 7,939 +9% Low
Head and Neck 2,281 5,027 +3% Medium
Neurosurgery 1,953 7,158 +13% High
Gynecology 1,765 3,430 -7% Low
yo
Urology 1,103 3,100 +2% Low
Plastic 1,102 3,098 Not Available High
Vascular 751 2,453 -5% High
Cardiac 721 4,289 +25% High
Transplant 482 2,372 Not Available High
Thoracic 396 941 -2% Medium
op
*Low = 0-10%, Medium = 11-24%, High
= 25% +

tC
No
Do
t
Exhibit 3
Instrumentation Error Root Frequencies
os
Number of errors
Preference Cards 300
rP
Case Cart Preparation 296
Instrument Assembly Accuracy 147
Supply Replenishment 104
Instrumentation Tracking 99
Infection Control 54
yo
Total 1,000
*Reported causes of 1000 documented instrumentation errors between 3/01/2004-5/01/2004

op
tC
No
Do
t
Exhibit 4
Stanford Hospital and Clinics
os
Operating Room Preference Card
STANFORD HOSPITAL AND CLINICS WORKSHEET OPERATING ROOM
MD004 M_CORONARY ARTERY BYPASS GRAFT(CABG)W/CPB/IMA/REDO
rP
SURGEON[S] PROCEDURE[S] UTILIZING THIS CARD
PHYSICIAN NAME HERE CHES3426 chest CABG w IMA; EVH w CPB CHES3308 Chest CABG
DR PREFERENCES
Allis clamps on towels rather than pericardial suture.
Use baby laps in chest; not Raytec
Use DLP tourniquet as choker for aortic root cannula, aortic and venous cannulae
FOR REDO’S = LIKES SARNS 6.5 METAL TIP FOR ARTERIAL CANNULA
yo
Remove marker on Sarns
Use 4-0 RB-1 for aortic root cannula
rd rd
Use DLP aortic root 20014. Will connect this to the 3 line instead of the PA vent. Have 20ga needle in the 3 line.
Will use Research Medical retrograde cannula in addition to the aortic root cannula
Use DLP suction on top suction
Use 22g. cathalon for IMA; not olive tip.
Use marking pen to lien vein graft.
op
Pour cold after each anastomosis
Does proximals while cross clamped.
Use Octopus for multi-dos caradioplegia
Cannulation: 4-0 RB-1 Prolene – aortic

3-0 SH-1 Prolene – 2 stage venous
4-0 SH-1 – Retrograde.
tC
$-0 RB-1 – antigrade

Decannulation: 3-0 SH-1 aortic oversew
Graft suture: 7-0 Prolene 18” distals
6-0 Prolene 18: (only uses one stich)
5-0 Prolene 24” proximals.
Use a grey clip for rubber shod on Prolene.
Cell saver on Redo cases and multi valves only

If radial artery to be taken pick #5684
No
Slave Monitor
SET UP FOR ENDO VEIN HAREST:

Place 3-chip Storz camera video at patient’s right foot of table.
Place slave monitor at patient’s left side, below cautery unitl.
Drape prep table with folded ¾ sheet for instruments
Place this table under Mayo trays for person harvesting
Place 2 lifts under foot of OR table with Bipolar pedal on top of one.
Use Monocryl 4-0 PS-2 for closure
Benzoin, ½ inch steri-strips, and Peg Ace wrap
PREP
Do
Prep: Duraprep to chest and abdomen;

Prep chin to toes, bedline to bedline
Betadine paint to perineum
Betadine scrub and paint circumferentially to legs
5/12/2004 09:44:53 page 1 of 5
t
os
POSITION/DRAPE
POSITION: Supine with arms at sides. Gel roll under shoulders. Gel headrest Pad arms with arm protectors.
rP
DRAPE: Plastic impervisus sheet under legs, folded towel for groin, ¾ sheet, feet wrapped in double towel secure with small tower
clip.
Towers, ioban drape, chest drape
STERILE SUPPLIES
Inv./Stock# Item Description Mfg.Cat.# Qty Hold Comments
OR/1554 PACK CUSTOM ADULT HEART CS OF 2 V51MJUSL 1
OR/46122 PACK CUSTOM HEART CABG-1 CS OF 10 V51CGUSF 1
yo
OR/10575 PACK LEG SUPPORT OR 9016 1
OR10549 BASIN SET OR AND ASC 9053 1
OR/10574 PACK ANCILLARY OR 9047 3
OR/59307 DRAPE ¾ FANFOLD 9349 CS OF 20 9349 1
OR/22656 GLOVE SURGEONS BIOGEL SZ.7 ½ PO 30475 1

op
OR/45796 CONTAINER URINE CRITICORE 153200 1
OR/43596 DURAPREP 24 ML 8630 2
OR/68628 IONSERT NOVARE 66 MM N-10126 1
OR/1965 ADAPTER METAL STERILE 9286 1

tC
OR/10895 CANNULA AORTIC ROOT 14 GA VENT 20014 1
OR/21336 CANNULA RETROPLEGIA 15FR 94535 1
OR/1314 TUBING HI PRESSURE LINE 48 INCH 4F 42370-01 1
OR/6257 CATH MULTI PERFUSION W/O VENT 14000 1

No
OR/6930 TEMP PROBE HEART 18MM 503-0310 1
OR/1363 UNIT IV PLACEMT QUIK 22 X 1 4070 1
OR/4355 CLIP SPRING GREY 6MM CSOFT6 1
OR/4402 CAUTERY BLADE EXTENSION 138107 1
OR/52955 KIT VASO VIEW UNIPORT CS OF 5 USB10243 1
OR/30500 PACK ONE SOURCE PERF CELL SAVE TK2S00 1 FOR PERFUSION
Do
OR/1274 SOLUTION IRRIG NACL 3L BAG 7972-08-08 1 FOR PERFUSION
OR/11625 PACEMAKER AV SEQUENTIAL 000 1
5/12/2004 09:44:53 page 2 of 5
t
os
STERILE SUPPLIES
rP
OR/2159 CHEST DRAIN ATR 2002-000 2002-000 1
OR/17746 PACEMAKER CORD GREY 5430VL 0
OR/1518 TUBING IV ADMIN 1857 1857-48-48 0
OR/68456 PATCH DEFIBRILLATION ANTERIOR P-121-T1 0 USE FOR REDO’S
OR/1100 TUBING SET CYSTO BLADDER IRRIG 6536-01-01 0
yo
OR/4354 SUMP PERICARDIAL DLP 12010 12010 0
OR/10724 TUBING KASLOW K 10 OR 0333 0
OR/2222 CANNULA SARNS 22FR 13020 0
OR/62254 CANNULA EXTENDED SOFT FLOW 7FR 4949 0
OR/9493 DEFOGGER ENDOSCOPIC DF-3120 0

op
OR/4231 LIGACLIP TIANIUM SMALL LT100 0
OR/4350 SUCTION TIP CARDIAC SOFT 6FR 10053 0
OR/5118 PUNCH VASCULAR GOOSEN 4.8MM DP48 0
OR/6191 STAOCKINETTE IMPERVIOUS LARGE 85512 0

tC
OR/10733 DRESSING PEG ACE 4 IN OR D404 0
OR/10734 DRESSING PEG ACE 6 IN OR 30-426

EQUIPMENT
OR/11652 TABLE ATTACHMENT 000 2

No
OR/11653 CAUTERY SOLID STATE 000 1
OR/11650 CAUTERY SPARK GAP 000 2
OR/11676 DEFIBRILLATOR MACHINE 000 1
OR/11645 HYPOTHERMIA MACHINE 000 1
OR/11647 HYPOTHERMIA BLANKER 000 1
OR/11651 LEG HOLDER 000 2

Do
OR/11641 MOTOR STRYKER 000 1
OR/76329 CHEST ROLLS 10076 1
5/12/2004 09:44:53 page 3 of 5
t
MDOO4 M_CORONARY ARTERY BYPASS GRAFT(CABG)W/CPB/IMA/REDO
os
STERILE SUPPLIES
rP
OR/11648 FOOT PEDAL STRYKER NONE 1
OR/11679 HEADLIGHT AND LIGHT SORUCE 000 1
OR/11677 STOOL TALL SITTING 000 1
OR/11955 PREP TABLE 000 3
OR/11623 IV POLE 000 4
yo
OR/76330 DONUT HEAD PAD 10104 1
OR/11643 DEFIBRILLATOR MACHINE ADULT 000 1
OR11646 ARM SLEDS 000 0
OR/26384 VA11 STORZ 9070B VCR/PRINT/INS 000 0

op
EQUIPMENT
OR/11626 SET BASIC HEART 000 1
OR/38631 SET CV SCISSORS AND NEEDLE HLDRS 000 1
OR/11667 SET CAD 000 1

tC
OR/39368 RETRACTOR CANADIAN 34-1398 1
OR/15329 FORCEPS TITANIUM STRAIGHT 000 2
OR/11961 NEEDLE HLDR CASTROV LOCK 7 INCH 32-0448 2
OR/39425 RETRACTOR RAKE RULTRAC 4100-IMR06 1
OR/24044 PADDLE INTERNAL DEFIB 6.0CM 1785A 1

No
OR/21699 RETRACTOR PARSONNET EPICARDIAL 000 1
OR/11660 CARDIO SAW SARNS 000 0
OR/27573 SAW HALL MICROCHOICE SAGITTAL 5020-022 0 FOR REDO’S
OR/10742 CHOCKER SMALL 0303 0
OR/23244 CAMERA 3 CHIP KSTORX 000 0
OR/63385 SET ENDOSCOPIC VEIN HARVEST 000 0

Do
OR/66942 RETRACTOR HEISS SELF-RETAINING 000 0
5/12/2004 09:44:53 page 4 of 5
t
os
MEDICATIONS
rP
OR/30067 CEFOZOLIN 1GM 000 1
OR/11637 HEPARIN 30CC 000 1
OR/12250 PROTAMINE 250MG 25ML 000 2
OR/12036 PAPAVERINE 30MG ML 2CC 000 1
OR/11615 EPINEPHRINE 1:1000 1 ml 000 1

1CC EPI 9CC NACL
yo
SUTURES
OR/149 PROLENE 5 0 ET M8725 C1 M8725 1
OR/144 PROLENE 6 0 ET 8718H C1-18 INCH 8718H 1
OR/534 PROLENE 7-0 ET 8701H BV1-18 8701H 1
OR/148 PROLENE 4 0 ET 8557H BV1- 8557H 1

op
OR/24629 MONOCRYL 4 0 ET Y496G PS 2 Y496G 0
DRESSINGS
Coverlet, 4x8’s paper tape. Band chest tubes get band gun and staps from perfusion
4”/6” peg bandages to let.
tC
**END OF REPORT**
J2/JAM 02/01/04
No
5/12/2004 09:44:53 page 5 of 5

Do
t
Exhibit 5
Stanford Hospital and Clinics
os
Operating Room Picklist
STANFORD HOSPITAL AND CLINICS PICKLIST O
PREFERENCE CARD: MD004 M_CORONARY ARTERY BYPASS GRAFT(CABG)W/CPB/IMA/REDO

rP
PHYSICIAN NAME HERE CHES3426 chest CABG w IMA; EVH w CPB CHES3308 Chest CABG Off Pump
Location Pick Qty Issue Qty Item Description Mfr. Cat.# Stock#
=SET 1 RETRACTOR CANADIAN 34-1398 39368
=SET 1 RETRACTOR RAKE RULTRAC 4100- 39425

IMR06
=SET 0 RETRACTOR HEISS SELF-RETAINING 66942
000
15--- 0 CAMERA 3 CHIP KSTORZ 23244
yo
000
20--- 1 PADDLE INTERNAL DEFIB 6.0CM 24044
1785A
21--- 1 SET BASIC HEART 11626
000
21--- 1 SET CAD 11667
000
22--- 0 SAW HALL MICROCHOICE SAGITTAL 27573
5020-022
22B--- 0 CARDIO SAW SARNS 11660
000
op
31--- 0 SET ENDOSCOPIC VEIN HARVEST 63385
000
4--- 2 NEEDLE HLDR CASTROV LOCK 7 INCH 11961
32-0448
4---- 1 RETRACTOR PARSONNET EPICARDIAL 21699
000
4----4 2 FORCEPS TITANIUM STRAIGHT 15329
000
5---- 1 SET CV SCISSORS AND NEEDLE HLDRS 38631
000
tC
A 12 1 BASIN SET OR AND ASC 10549

9053
A 13 1 PACK LEG SUPPORT OR 10575
9016
A 61 3 PACK ANCILLARY OR 10574
9047
A 72 1 PACK CUSTOM ADULT HEART CS OF 2 1554
V51MJUSL
A 7SPD 1 PACEMAKER AV SEQUENTIAL 11625
000
A 7SPD 0 PACEMAKER CORD GREY 17746
5430VL
No
A 92 1 DRAPE ¾ FANFOLD 9349 CS OF 20 59307

9349
A 131 1 PACK CUSTOMER HEART CABG-1 CS OF 10 46122
V51CGUSF
B 13 1 GLOVE SURGEONS BIOGEL SZ.7 ½ POWER 22656
30475
B 23 1 TUBING HI PRESSURE LINE 48 INCH 4F 1314
42370-01
B 64 1 UNIT IV PLACEMT QUIK 22 X 1 1363
4070
B 84 2 DURAPREP 24 ML 43596
8530
B 101 0 STOCKINETTE IMPERVIOUS LARGE 6191
Do
85512
B 102 1 SOLUTION IRRIG NACL 3L BAG 1274
7972-08-08
B 111 1 CAUTERY BLADE EXTENSION 4402
138107
5/12/2004 09:45:18 page 1 of 3
t
os
B 124 0 LIGACLIP TITANIUM SMALL LT100 4231
rP
B126 0 CHOCKER SMALL 0303 10742
B131 1 ADAPTER METAL STERILE 9286 1965
B142 0 DRESSING PEG ACE 4 IN OR D404 10733
B142 0 DRESSING PEG ACE 6 IN OR 30-426 10734
C15 1 CHEST DRAIN ATR 2002-000 2002-000 2159
yo
D36 0 DEFOGGER ENDOSCOPIC DF-3120 9493
DA1A4 0 TUBING KASLOW K 10 OR 0333 10724
E71 1 KIT VASO VIEW UNIPORT CAS OF 5 USB10243 52955
G12 1 CLIP SPRING GREY 6MM CSOFT6 4355
G13 1 TEMP PROBE HEART 18MM 503-0310 6930

op
G14 1 CANNULA AORTIC ROOT 14GA VENT 20014 10895
G14 1 CANNULA RETROPLEGIA 15 FR 94535 21336
G14 0 SUCTION TIP CARDIAC SOFT 6 FR 10053 4350
G14 1 CATH MULTI PERFUSION W/O VENT 14000 6257
G15 1 INSERT NOVARE 66MM N-10126 68928

tC
G16 0 PUNCH VASCULAR GOOSEN 4.8MM DP48 5118
G17 0 TUBING IV ADMIN 1857 1857-48-48 1518
G22 0 CANNULA SARNS 22FR 13020 2222
G22 0 SUMP PERICARDIAL DLP 12010 12010 4354
G22 0 CANNULA EXTENDED SOFT FLOW 7FR 4949 62254

No
H32 0 PATCH DEFIBRILLATION ANTERIOR P-121-T1 68456
I22 0 TUBING SET CYSTO BLADEDER IRRIG 6536-01-01 1100
I22 1 CONTAINER URINE CRITICORE 153200 45796
M23 1 PACK ONE SOURCE PERF CELL SAVE TK2S00 30500
OR EQP 4 IV POLE 000 11623
OR EQP 1 MOTOR STRYKER 000 11641
OR EQP 1 DEIBRILLATOR MACHINE ADULT 000 11643

Do
OR EQP 1 HYPOTHERMIA MACHINE 000 11645
5/12/2004 09:45:18 page 2 of 3
t
os
rP
OR EQP 0 ARM SLEDS 000 11646
OR EQP 1 HYPOTHERMIA BLANKET 000 11647
OR EQP 1 FOOT PEDAL STRYKER NONE 11648
OR EQP 2 CAUTERY SPARK GAP 000 11650
OR EQP 2 LEG HOLDER 000 11651
yo
OR EQP 2 TABLE ATTACHMENT 000 11652
OR EQP 1 CAUTERY SOLID STATE 000 11653
OR EQP 1 DEFIBRILLATOR MACHINE 000 11676
OR EQP 1 STOOL TALL SITTING 000 11677
OR EQP 1 HEADLIGHT AND LIGHT SOURCE 000 11679
OR EQP 3 PREP TABLE 000 11955

op
OR EQP 0 VA11 STORZ 9070B VCR/PRINT/INS 000 26384
OR EQP 1 CHEST ROLLS 10076 76329
OR EQP 1 DONUT HEAD PAD 10104 76330
PHARM 1 EPINEPHRINE 1:100 1 ml 000 11615

tC
PHARM 1 HEPATRIN 30CC 000 11637
PHARM 1 PAPAVERINE 30MG ML 2CC 000 12036
PHARM 1 CEFOZOLIN 1GM 000 30067
REMOVE 2 PROTAMINE 250MG 25ML 000 12250
X STOR 1 PROLENE 6 0 ET 8718H C1-18INCH 8718H 144
X STOR 1 PROLENE 4 0 ET 8557H RB1- 8557H 148

No
X STOR 1 PROLENE 5 0 ET M8725 C1 M8725 149
X STOR 0 MONOCRYL 4 0 ET Y 496G PS 2 Y496G 24629
X STOR 1 PROLENE 7-0 ET 8701H BV1-18 8701H 534

Do
5/12/2004 09:45:18 page 3 of 3
t
Exhibit 6
Floor Map
os STANFORD
0503 0502
40A
11
40C
01
rP
40B 40D
0504 0505
000C20
43A 43B
Case cart
0506
yo
0542
Caddies
MAIN HALL
0543 41A
10 SPMhere
41B 4
elevator equipment
westcore
elevator 12* case cart
eastcore ETO scope washer
op
sterilizer processing
sterilizer
000E10
000C18
7A
3 scope 0507
8 clean TSO-active 7B
-instrument- 7 0508
assembly -decontam-
LPCH
7C
tC
9*tray Power/scope
6 5 2 & washer 1
Dirty instruments
11
SPM Requirements for SP

1. Decontamination (current)
No
2. Scope Cleaning and washer (Need)

3. Scope Processing (Need) 0512
4. Equipment Processing (Need)
5. Instrument Assembly (Current)
6. Instrument Assembly (Current)
7. Tray Assembly (Current, needs printer)
elevator
8. Sterilization (Current)
9. Tray Assembly (Need laser and bar code printer)
10. Case Cart (Current)
11. Receiving (Need)
Do
12. Cool down (Need). 0513
0514
Process Improvement in Stanford Hospital’s Operating Room OIT-41
s t p. 27
o
Exhibit 7
Process Flow
Ambulatory Surgery Center (ASC)

Noon D-1 3pm D-1 4 pm D-1
Stage Pick
5 pm D-1
r P
5 pm ∆-∅
o
Preference
Print Ticket & Pick sterile
OR Card list Stage Add
Doctor’s Corrections Call Case Report. Preference supplies
Schedules is onto Supplies.
office to Cart Lead. Print Pick Card for ASC & bin yes
sent to checked. Cart individual Add Instruments
schedules schedule Print OR Ticket. both ASC Supplies. Surgery
OR Missing OK? case Instruments. returned to
case with made in Schedule. Print & Main OR. Stage on to
Scheduler. cards cart. SPD.
OR. PICIS. Work- Print cart. Move
y
are
Sheets. schedule to ASC.
attached.
for add-ons.
Preference Card PCCC Case Cart Tech Case Cart Tech Case Cart Tech
no
PCCC ASC Case Cart Tech
p
Clinical Coordinator or
(PCCC) Asst. Nurse Manager 5 pm D-1
Based on SD
assessment:
o
Wait
Check backorder. for
yes
Item.
Call to borrow from
other departments/
C
hospitals. ASC CN
checks Substitute
Notify ASC charge nurse with OK?
(CN) of missing item. surgeon.
t
no
Main Operating Room
o
Surgery is delayed/canceled
5 pm – 5 am ∆-∅ 3 pm D-1
Pick
Supplies. Instru- Print ID last Pick
Send carts Pick ments instrument- location in Assemblers
Stage Are Cart Return instrument
N
Have for 1st instru- ation Report. work on
individual supplies
Yes
2 cases instruments Yes added to sent to Surgery to SPM. & ready it
ments. Case ID all (See below for assembly. carts all
carts for ? available? OR SPD
up to Cart instruments for night.
1st 2 cases Get cart.
OR. for possible
of the
Day. Scheduling. locations*)
No
2 Case Cart Tech Case Cart Tech Core Tech
o
No
Load instrumentation LIT LIT 7 FTEs in PM
Tech (LIT) * OR Core 5 FTEs overnight
Yes
[Separate Sterilization
process] Prep/Pick
Check in In use
D
SP. Notify On cart
Substitute Decontamination
Room OK? Washer
Assembly
No
Yes Flash Yes
Located? Sterile
OK?? Flash Surgery is
delayed/
No No
Source: Stanford Hospital and Clinics. canceled
This document is authorized for educator review use only by FEROZ IKBAL, Tata Institute of Social Sciences until Apr 2020. Copying or posting is an infringement of copyright. Permissions@hbsp.harvard.edu or 617.783.7860

Operating Room Stanford - Case Study

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Operating Room Stanford - Case Study

Uploaded by

Copyright:

Available Formats

t

OVERVIEW OF SHC STATISTICS

The OR Improvement Project

1. Preference Card (PC) Inaccuracy

2. Case Cart Preparation Errors

3. Instrument Assembly Inaccuracy

5. Inadequate Instrument Tracking

6. Infection Control Turnaround Time

MANAGEMENT CHALLENGES IN THE OR

Impact of OR Instrumentation on Surgeons

Operating Room Nurses

Sterile Processing Department

assume additional responsibilities.

Impact of Operating Room Instrumentation on SPD Employees

with better information to work with when preparing instrumentation.

2. Focus on Culture and Organizational Dynamics

3. Redesign the Current Process Flow

of complicated instruments. Also, cross training in SPD would allow instrument

6. Invest in Additional Capital

could remember. As a result, it might be most expedient to simply invest in

• Plastic & Reconstructive Surgery

Stanford Family Practice

Source: Stanford Hospital and Clinics.

*Reported causes of 1000 documented instrumentation errors between 3/01/2004-5/01/2004

Source: Stanford Hospital and Clinics.

STANFORD HOSPITAL AND CLINICS WORKSHEET OPERATING ROOM

MD004 M_CORONARY ARTERY BYPASS GRAFT(CABG)W/CPB/IMA/REDO

Cannulation: 4-0 RB-1 Prolene – aortic

$-0 RB-1 – antigrade

Cell saver on Redo cases and multi valves only

SET UP FOR ENDO VEIN HAREST:

Prep: Duraprep to chest and abdomen;

5/12/2004 09:44:53 page 1 of 5

STANFORD HOSPITAL AND CLINICS WORKSHEET OPERATING ROOM

OR/1554 PACK CUSTOM ADULT HEART CS OF 2 V51MJUSL 1

OR/46122 PACK CUSTOM HEART CABG-1 CS OF 10 V51CGUSF 1

OR10549 BASIN SET OR AND ASC 9053 1

OR/10574 PACK ANCILLARY OR 9047 3

OR/59307 DRAPE ¾ FANFOLD 9349 CS OF 20 9349 1

OR/22656 GLOVE SURGEONS BIOGEL SZ.7 ½ PO 30475 1

OR/43596 DURAPREP 24 ML 8630 2

OR/68628 IONSERT NOVARE 66 MM N-10126 1

OR/1965 ADAPTER METAL STERILE 9286 1

OR/10895 CANNULA AORTIC ROOT 14 GA VENT 20014 1

OR/21336 CANNULA RETROPLEGIA 15FR 94535 1

OR/1314 TUBING HI PRESSURE LINE 48 INCH 4F 42370-01 1

OR/6257 CATH MULTI PERFUSION W/O VENT 14000 1

OR/6930 TEMP PROBE HEART 18MM 503-0310 1

OR/1363 UNIT IV PLACEMT QUIK 22 X 1 4070 1

OR/4355 CLIP SPRING GREY 6MM CSOFT6 1

OR/4402 CAUTERY BLADE EXTENSION 138107 1

OR/52955 KIT VASO VIEW UNIPORT CS OF 5 USB10243 1

OR/1274 SOLUTION IRRIG NACL 3L BAG 7972-08-08 1 FOR PERFUSION

OR/11625 PACEMAKER AV SEQUENTIAL 000 1

5/12/2004 09:44:53 page 2 of 5

STANFORD HOSPITAL AND CLINICS WORKSHEET OPERATING ROOM

OR/17746 PACEMAKER CORD GREY 5430VL 0

OR/1518 TUBING IV ADMIN 1857 1857-48-48 0

OR/68456 PATCH DEFIBRILLATION ANTERIOR P-121-T1 0 USE FOR REDO’S

OR/1100 TUBING SET CYSTO BLADDER IRRIG 6536-01-01 0

OR/10724 TUBING KASLOW K 10 OR 0333 0

OR/2222 CANNULA SARNS 22FR 13020 0

OR/62254 CANNULA EXTENDED SOFT FLOW 7FR 4949 0