Inventory management of surgical supplies and sterile instruments in hospitals: a literature review

Procurement process and shortages of essential medicines in public health facilities: A qualitative study from Nepal

Ensuring access to essential medicines remains a formidable challenge in Nepal. The specific reasons for the shortage of essential medicines within Nepal have not been extensively investigated. This study addresses challenges associated with access to essential medicines, procurement process difficulties, and functionality of inventory management systems at different levels of public health facilities. Fifty-nine semi-structured in-depth interviews were conducted with health managers and service providers at provincial and local levels in six randomly selected districts of Bagmati province, Nepal. Interviews were audiotaped and transcribed verbatim, and the results were analyzed using the inductive approach and were later mapped within the four domains of "Procurement of essential medicines". The major barriers for the effective management of essential medicines included delays in the procurement process, primarily locally, leading to frequent stock-out of essential drugs, particularly at the health post level. Additionally, challenges arise from storage problems, mainly due to insufficient storage space and the need to manage additional comorbidities related to COVID-19. Other identified challenges encompass the absence of training on logistics management information systems, a lack of information technology resources in primary health facilities, inadequate qualified human resources to operate the IT system, and insufficient power backup. Moreover, unrealistic demand estimation from the service points, inadequate transportation costs, and manual inventory management systems further contributed to the complex landscape of challenges. This study identified procurement delays as the primary cause of essential medicine shortages in Bagmati Province, Nepal. We recommend implementing comprehensive procurement guidelines, collaborative training, and dedicated budgets to address this issue. Improving the procurement and inventory management process in low-resource settings requires a well-trained workforce, suitable storage spaces, and enhanced coordinated administrative tiers within health facilities at different levels to ensure the year-round availability of essential medicines in these settings.

Integrated procurement and reprocessing planning for reusable medical devices with a limited shelf life

We present a new model formulation for a multiproduct dynamic order quantity problem with product returns and a reprocessing option. The optimization considers the limited shelf life of sterile medical devices as well as the capacity constraints of reprocessing and sterilization resources. The time-varying demand is known in advance and must be satisfied by purchasing new medical devices or by reprocessing used and expired devices. The objective is to determine a feasible procurement and reprocessing plan that minimizes the incurred costs. The problem is solved in a heuristic manner in two steps. First, we use a Dantzig-Wolfe reformulation of the underlying problem, and a column generation approach is applied to tighten the lower bound. In the next step, the obtained lower bound is transformed into a feasible solution using CPLEX. Our numerical results illustrate the high solution quality of this approach. The comparison with a simulation based on the first-come-first-served principle shows the advantage of integrated planning.

Budget Impact Analysis of Minimally Invasive versus Open Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disease: A European Hospital Perspective

Purpose

When traditional therapies fail to provide relief from debilitating lower back pain, surgeries such as transforaminal lumbar interbody fusion (TLIF) may be required. This budget impact analysis (BIA) compared minimally-invasive (MI)-TLIF versus open (O)-TLIF for single-level fusion from an Italian hospital perspective.

Methods

The BIA compared costs of 100 MI-TLIF and 100 O-TLIF procedures from an Italian hospital perspective over a one-year time horizon. The base case included costs for length of hospital stay (LOS), blood loss, and sterilizing surgical trays. The scenario analysis also included operating room (OR) time and complication costs. Base case inputs were from the Miller et al meta-analysis; scenario analysis inputs were from the Hammad et al meta-analysis. The device costs for MI-TLIF and O-TLIF procedures were from Italian tender prices for Viper Prime™ System and Expedium™ Spine System, respectively.

Results

Base case deterministic analysis results showed cost savings of €207,370 for MI-TLIF compared with O-TLIF. MI-TLIF costs were lower for LOS (€215,277), transfusion for blood loss (€16,881), and surgical tray sterilization (€28,232), whereas device costs were lower for O-TLIF (€53,020). The probabilistic result was similar, with MI-TLIF resulting in savings of €211,026 (95% credible interval [CR]: €208,725 - €213,327). All 1000 base case probabilistic sensitivity analysis runs were cost saving. Deterministic scenario analysis results showed cost savings of €166,719 for MI-TLIF. MI-TLIF costs were lower for LOS (€190,813), transfusion for blood loss (€16,881), surgical tray sterilization (€28,232), and complications (€2076), whereas O-TLIF costs were lower for OR time (€18,263) and devices used (€53,020).

Conclusion

Despite the increase incremental cost for medical device innovation and OR time, this study demonstrates the economic savings of MI-TLIF compared to O-TLIF from a European hospital perspective. The findings will be useful to policy and hospital decision makers in assessing purchasing, funding and reimbursement decisions.

Taking Action Against Clinician Burnout Through Reducing the Documentation Burden With an Operating Room Supply Scanning Approach

Documenting surgical supply items in the operating room can be a burdensome task for circulating nurses because of manual input within the electronic medical record. This can lead to documentation fatigue and contribute to nursing burnout. The aim of this quality improvement project was to design and implement a supply item scanning process and evaluate the effect on intraoperative documentation completion time, room turnover time, picklist documentation accuracy, nurse satisfaction, and burnout. The sample included nine acute care hospitals throughout the United States, with 189 total circulating nurses and 31 718 procedures occurring during the study timeframe of 8 months. Results indicated that nurses were able to complete documentation on average 37.33 minutes sooner, and the operating room turnover time decreased by 1.88 minutes. Although nurses reported that their perceived picklist documentation accuracy did not improve, and the presence of new scanning technology did not influence their hospital employment decision, subjective feedback was mostly positive, with most responses citing the helpfulness of scanning for documentation. This study shows that an interdisciplinary team can effectively work to optimize documentation efficiency and performance improvement using a scanning intervention. Lessons learned through this process can translate into optimizations elsewhere in the electronic medical record.

Outsourcing the Management of Reusable Medical Devices in a Chain-Wide Care Setting: Mixed Methods Feasibility Study

BACKGROUND

Managing reusable medical devices incurs substantial health care costs and complexity, particularly in integrated care settings. This complexity hampers care quality, safety, and costs. Studying logistical innovations within integrated care can provide insights to medical devices use among staff effectively.

OBJECTIVE

This study aimed to establish the feasibility of a logistical intervention through outsourcing and a web portal. The goal was to provide insights into users' acceptability of the intervention, on whether the intervention was successfully implemented, and on the intervention's preliminary efficacy, thus benefiting practitioners and researchers.

METHODS

This paper presents a mixed methods feasibility study at a large chain-wide health care provider in the Netherlands. The intervention entailed outsourcing noncritical reusable medical devices and introducing a web portal for device management. A questionnaire gauged perceived ordering and delivery times, satisfaction with the ordering and delivery process, compliance with safety and hygiene certification, and effects on the care delivery process. Qualitative data in the form of observations, documentation, and interviews were used to identify implementing challenges. Using on-site stocktaking and data from information systems, we analyzed the utilization, costs, and rental time of medical devices before and after the intervention for wheelchairs and anti-pressure ulcer mattresses.

RESULTS

Looking at the acceptability of the intervention, a high user satisfaction with the ordering and delivery process was reported (rated on a 5-point Likert scale). With respect to preliminary efficacy, we noted a reduction in the utilization of wheelchairs (on average, 1106, SD 106 fewer utilization d/mo), and a halted increase in the utilization of anti-pressure ulcer mattresses. In addition, nurses who used the web portal reported shorter ordering times for wheelchairs (-2.7 min) and anti-pressure ulcer mattresses (-3.1 min), as well as shorter delivery times for wheelchairs (-0.5 d). Moreover, an increase in device certification was reported (average score of 1.9, SD 1.0), indicating higher levels of safety and hygiene standards. In theory, these improvements should translate into better outcomes in terms of costs and the quality of care. However, we were unable to establish a reduction in total care costs or a reduced rental time per device. Furthermore, respondents did not identify improvements in safety or the quality of care. Although implementation challenges related to the diverse supply base and complexities with different care financers were observed, the overall implementation of the intervention was considered successful.

CONCLUSIONS

This study confirms the feasibility of our intervention, in terms of acceptability, implementation success, and preliminary efficacy. The integrated management of medical devices should enable a reduction in costs, required devices, and material waste, as well as higher quality care. However, several challenges remain related to the implementation of such interventions.

Optimizing spine surgery instrument trays to immediately increase efficiency and reduce costs in the operating room

Background

Over-crowded surgical trays result in perioperative inefficiency and unnecessary costs. While methodologies to reduce the size of surgical trays have been described in the literature, they each have their own drawbacks. In this study, we compared three methods: (1) clinician review (CR), (2) mathematical programming (MP), and (3) a novel hybrid model (HM) based on surveys and cost analysis. While CR and MP are well documented, CR can yield suboptimal reductions and MP can be laborious and technically challenging. We hypothesized our easy-to-implement HM would result in a reduction of surgical instruments in both the laminectomy tray (LT) and basic neurosurgery tray (BNT) that is comparable to CR and MP.

Methods

Three approaches were tested: CR, MP, and HM. We interviewed 5 neurosurgeons and 3 orthopedic surgeons, at our institution, who performed a total of 5437 spine cases, requiring the use of the LT and BNT over a 4-year (2017-2021) period. In CR, surgeons suggested which surgical instruments should be removed. MP was performed via the mathematical analysis of 25 observations of the use of a LT and BNT tray. The HM was performed via a structured survey of the surgeons' estimated instrument usage, followed by a cost-based inflection point analysis.

Results

The CR, MP, and HM approaches resulted in a total instrument reduction of 41%, 35%, and 38%, respectively, corresponding to total cost savings per annum of $50,211.20, $46,348.80, and $44,417.60, respectively.

Conclusions

While hospitals continue to examine perioperative services for potential inefficiencies, surgical inventory will be increasingly scrutinized. Despite MP being the most accurate methodology to do so, our results suggest that savings were similar across all three methods. CR and HM are significantly less laborious and thus are practical alternatives.

Automating Perioperative Inventory Management: A Quality Improvement Project

Preference cards are a foundation for perioperative inventory management processes; however, they can add to nurses' perceived workload, introduce variability into supply management processes, and increase costs. The purpose of this quality improvement project was to implement an automated perioperative inventory management system to decrease nurses' workload and increase their efficiency. Goals included improving preference card accuracy, decreasing add-on supplies, and decreasing the supply costs for each procedure. Using a preintervention-postintervention survey design, the project team evaluated the outcomes of workload, preference card accuracy, add-on supplies, and procedural cost. Nurses' perception of workload decreased in the supply management processes and cost of supplies categories and increased in the documenting supply use category. A four-month 7.7% improvement in preference card accuracy reduced the average procedure supply cost by $86.72 for each procedure and saved the hospital $260,467. The number of add-on supplies was reduced by 4,177 for a 20% reduction.

Operating Room Performance Optimization Metrics: a Systematic Review

Literature proposes numerous initiatives for optimization of the Operating Room (OR). Despite multiple suggested strategies for the optimization of workflow on the OR, its patients and (medical) staff, no uniform description of 'optimization' has been adopted. This makes it difficult to evaluate the proposed optimization strategies. In particular, the metrics used to quantify OR performance are diverse so that assessing the impact of suggested approaches is complex or even impossible. To secure a higher implementation success rate of optimisation strategies in practice we believe OR optimisation and its quantification should be further investigated. We aim to provide an inventory of the metrics and methods used to optimise the OR by the means of a structured literature study. We observe that several aspects of OR performance are unaddressed in literature, and no studies account for possible interactions between metrics of quality and efficiency. We conclude that a systems approach is needed to align metrics across different elements of OR performance, and that the wellbeing of healthcare professionals is underrepresented in current optimisation approaches.

Environmental Sustainability in the Cardiac Catheter Laboratory

The health care sector contributes to nearly 5% of global carbon emissions with the exponential growth of medical waste posing a significant challenge to environmental sustainability. As the impact of climate change on individuals and population health becomes increasingly more apparent, the health care system's significant impact on the environment is also raising concerns. Hospitals contribute disproportionately to health care waste with the majority arising from resource intensive areas such as operating theatres and cardiac catheter labs (CCLs). Despite the growing volume of cardiac procedures worldwide, initiatives to reduce waste from CCLs have received limited attention, overlooking opportunities for significant reduction in operational costs and carbon footprint. We aim to raise awareness of the current landscape of waste management in CCLs. We identify areas of resource optimisation and highlight practical strategies and frameworks employed elsewhere in health care to reduce waste. Importantly, we hope to empower health care workers in CCLs to make a meaningful change to their practice and contribute towards a more sustainable future.

Standardization of laparoscopic trays using an inventory optimization model to produce immediate cost savings and efficiency gains

Perioperative services comprise a large portion of hospital budgets; the procurement and processing of surgical inventories can be an area for optimization in operational inefficiency. Surgical instrument trays can be customized as procedure-specific or standardized as trays that can be used in numerous procedure types. We conducted an interventional study to determine the cost savings from standardizing laparoscopic surgery instrument trays. A single-period inventory optimization model was used to determine the configuration of a standardized laparoscopic (SL) tray and its minimal stock quantity (MSQ). Utilization of instruments on the general surgery, gynecology, and gynecological oncology trays was recorded, and daily demand for trays (mean, SD) was assessed using daily operating room (OR) case lists. Pre- and post-intervention costs were evaluated by reviewing procurement data and quantifying medical device reprocessing (MDR) and OR processes. The SL tray was trialled in the OR to test clinical safety and user satisfaction. Prior to standardization, the customized trays had a total inventory size of 391 instruments (mean instruments per tray: 17, range: 12-22). Daily demand was an MSQ of 23 trays. This corresponded to a procurement cost of $322,160 and reprocessing cost of $41,725. The SL tray (mean instruments per tray: 15, mean trays/day: 9.2 ± 3.2) had an MSQ of 17 trays/day. The total inventory decreased to 255 instruments, corresponding to a procurement cost of $266,900 with savings of $55,260 and reprocessing cost of $41,562 with savings of $163/year. After 33 trial surgeries, user satisfaction improved from 50% to 97% (p < .05). Standardization to a single SL tray using the inventory optimization model led to increased efficiency, satisfaction, and significant savings through aggregating specific service demands. The inventory optimization model could provide custom solutions for various institutions with the potential for large-scale financial savings. Thus, future work using this model at different centres will be necessary to validate these results.

Addressing Surgical Instrument Oversupply: A Focused Literature Review and Case-Study in Orthopedic Hand Surgery

BACKGROUND

Instrument oversupply drives cost in the operating room (OR). We review previously reported methodologies for surgical instrument reduction and report a pilot methodology for optimizing instrument supply via ethnographic instrument tracking of thumb carpometacarpal (CMC) arthroplasties. Additionally, we report a cost analysis of instrument oversupply and potential savings of tray optimization methods.

METHODS

Instrument utilization was tracked over 8 CMC arthroplasties conducted by 2 surgeons at an ambulatory surgery center of a large academic hospital. An optimized supply methodology was designed. A cost analysis was conducted using health-system-specific data and previously published research.

RESULTS

After tracking instrument use in 8 CMC arthroplasties, a cumulative total of 59 out of the 120 instruments in the Hand & Foot (H&F) tray were used in at least 1 case. Two instruments were used in all cases, and another 20 instruments were used in at least 50% of the cases. Using a reduced tray with 59 instruments, potential cost savings for tray reduction in 60 cases were estimated to be $2086 without peel-packing and $2356 with peel-packing. The estimated cost savings were lower than those reported in literature due to a reduced scope and exclusion of OR time cost in the analysis.

CONCLUSIONS

Instrument oversupply drives cost at our institution's ambulatory surgery center. Ethnography is a cost-effective method to track instrument utilization and determine optimal tray composition for small services but is not scalable to large health systems. The time and cost required to observe sufficient surgeries to enable supply reduction to motivate the need for more efficient methods to determine instrument utility.

Breast Surgery Cost Savings Through Surgical Tray Instrument Reduction

INTRODUCTION

Removing unnecessary instruments from surgical trays used in the operating room conserves resources and time. We aimed to assess the cost savings impact of breast surgical tray instrument reduction.

METHODS

Breast surgeons at a single institution reviewed the standard surgical tray used for lumpectomies and mastectomies and removed underutilized instruments to create a breast-specific tray. This tray was used for all breast surgeries performed throughout the 2019 calendar year. Data for breast-specific tray usage, instrument reprocessing costs, and instrument maintenance costs for inspection, sharpening, aligning, and lubricating were retrospectively obtained.

RESULTS

The breast-specific tray was reduced from 82 to 65 instruments. The cost of reprocessing each instrument is $1.69. After 30 tray sterilizations, each tray was sent for maintenance at a cost of $2.00 per instrument. With 10 breast-specific trays in circulation, the trays were used a total of 656 times during the calendar year. Each tray was sent for maintenance an average of two times during this time period. Thus, instrument reduction resulted in $18,847 in instrument reprocessing and $680.00 in maintenance savings, with total annual cost savings of $19,527.

CONCLUSIONS

Optimizing surgical trays by removing unused instruments yields significant cost savings and contributes to improved efficiency in the sterile processing department. As efforts to eliminate wasteful practices and reduce costs within the health care system continue, opportunities remain for standardization of trays across all surgical departments and institutions.

Development of a "Scissor-Tip-Separator" for adjustment of scissor blade separation and prevention of scissor blade damage during steam sterilization

Background

Reprocess reusable surgical instruments during steam sterilization; damage occurs to sharp scissor blades in close position, so steam cannot reach the blades. Surgical instruments' management requires standards to ensure patient safety and prevent harmful pathogens, especially in the COVID-19 pandemic. Although various devices can separate scissor blades, they do not prevent damage to cutting edges. To address the above problem, we developed a new scissor protector, the "Scissor-Tip-Separator," and evaluated its efficacy.

Methods

The "Scissor-Tip-Separator" design follows the steam sterilization guideline that instrument tips must be separated. The locking handles and V groove mechanism keep the scissor blades separated while preventing damage to the cutting edges. For efficacy assessment, purposive sampling was performed to select 44 Thai perioperative nurses at Ramathibodi Hospital, Bangkok, Thailand, to evaluate the "Scissor-Tip-Separators" in 450 sterile instrument containers. All participants evaluated surgical scissors placed in the "Scissor-Tip-Separators" during instrument setup, following a problem record checklist. At the end of the fifth use, participants were asked to complete the "Scissor-Tip-Separator" Effectiveness Scale, which was used to test the structural design of the "Scissor-Tip-Separator" in terms of function, usability, and safety. The Adenosine Triphosphate surface test was also used to validate the "Scissor-Tip-Separator" cleanliness. Data were collected from August 2020 to November 2020, then analyzed via descriptive statistics.

Results

The "Scissor-Tip-Separator" met the cleaning validation criteria, and in 44 uses, the physical property remained the same. The scissor shank was discovered loose from the handle before it had been unlocked (0.2–0.4%) at the 45^th use. Based on participants' opinions, the overall instrument effectiveness was high in terms of function, usability, and safety.

Conclusion

The "Scissor-Tip-Separator" regulates scissor blade separation under sterilization guidelines; it prevents damage to cutting edges, thus ensuring patient safety. It protects against losses in a sterile field and can prevent hand injuries.

Surgical Tool Datasets for Machine Learning Research: A Survey

This paper is a comprehensive survey of datasets for surgical tool detection and related surgical data science and machine learning techniques and algorithms. The survey offers a high level perspective of current research in this area, analyses the taxonomy of approaches adopted by researchers using surgical tool datasets, and addresses key areas of research, such as the datasets used, evaluation metrics applied and deep learning techniques utilised. Our presentation and taxonomy provides a framework that facilitates greater understanding of current work, and highlights the challenges and opportunities for further innovative and useful research.

The Association of Immediate-Use Steam Sterilization with the Incidence of Orthopaedic Surgical Site Infections: A Propensity Score-Matched Cohort Study

BACKGROUND

Immediate-use steam sterilization (IUSS), formerly termed "flash" sterilization, has been historically used to sterilize surgical instruments in emergency situations. Strict guidelines deter its use, as IUSS has been theorized to increase the risk of surgical site infections (SSIs), leading to increased health-care costs and poor patient outcomes. We sought to examine the association between the use of IUSS and the rate of orthopaedic SSIs.

METHODS

The cases of 70,600 patients who underwent orthopaedic surgery-total knee or hip arthroplasty, laminectomy, or spinal fusion-from January 2014 to December 2020, were retrospectively reviewed for IUSS use. Of this group, 3,526 patients had had IUSS used during surgery. A propensity score-matched (PSM) analysis was conducted to account for known predictors of SSIs and included a total of 7,052 patients. The risk difference (RD), relative risk (RR), odds ratio (OR), and McNemar test compared the SSI risk for patients whose procedure had included the use of IUSS and those whose procedure had not included IUSS.

RESULTS

After propensity score matching, 111 (1.57%) of the 7,052 matched patients developed an SSI. Of the 111 patients, 61 (54.95%) were in the IUSS group and 50 (45.05%) were in the non-IUSS group. The estimated probability for developing an SSI was 1.42% for the patients in the non-IUSS group versus 1.73% for the patients in the IUSS group (RR = 0.82 [95% confidence interval (CI)]: 0.57 to 1.19], RD = -0.3% [95% CI: -0.9% to 0.27%]).There was no evidence that the proportion of SSI was greater in the IUSS group (McNemar test, p > 0.29).

CONCLUSIONS

SSI rates were not significantly different between IUSS and non-IUSS patients undergoing orthopaedic surgery. Future prospective studies are warranted to further explore the utility of IUSS during orthopaedic procedures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An Overview of Hospital Capacity Planning and Optimisation

Health care is uncertain, dynamic, and fast growing. With digital technologies set to revolutionise the industry, hospital capacity optimisation and planning have never been more relevant. The purposes of this article are threefold. The first is to identify the current state of the art, to summarise/analyse the key achievements, and to identify gaps in the body of research. The second is to synthesise and evaluate that literature to create a holistic framework for understanding hospital capacity planning and optimisation, in terms of physical elements, process, and governance. Third, avenues for future research are sought to inform researchers and practitioners where they should best concentrate their efforts. In conclusion, we find that prior research has typically focussed on individual parts, but the hospital is one body that is made up of many interdependent parts. It is also evident that past attempts considering entire hospitals fail to incorporate all the detail that is necessary to provide solutions that can be implemented in the real world, across strategic, tactical and operational planning horizons. A holistic approach is needed that includes ancillary services, equipment medicines, utilities, instrument trays, supply chain and inventory considerations.

Climate Change and Gastroenterology: Planetary Primum Non Nocere and How Industry Must Help

Climate change is a global emergency. Increasing awareness has led to policy changes regarding global industry emissions. The healthcare industry carbon footprint is large and growing more and more. Gastroenterology, with its heavy reliance on industry, is a major contributor toward this growth. For a significant change toward reducing the field's carbon footprint, it would involve serious industry commitment. At present, there are no clear guidelines or regulations on controlling healthcare-related industry emissions and improving sustainability. This narrative review aims to provide practical suggestions at each step of the supply chain can lead to greater sustainability.

Dynamic Discrete Inventory Control Model with Deterministic and Stochastic Demand in Pharmaceutical Distribution

This paper presents an inventory control problem in a private pharmaceutical distribution company from the Republic of Serbia. The company realizes that distribution within nine neighbouring countries and inventory control in the pharmaceutical supply chain is centralized. In order to constitute a conceptual model of the problem, we propose the modern control theory concept. The conceptual model is based on the specific practical assumptions and constraints of the supply chain. Thereafter, a dynamic discrete mathematical model of inventory control is formulated to reflect elements of the system and their relations. The model considers multiple pharmaceutical products, variable lead time, realized stochastics and deterministic demand, and different ordering policies (Lot for Lot and Fixed Order Quantity). Deterministic demand is represented as a sales forecast for each product per month, while stochastic demand is generated as a random variation of sales forecast in a range of ±20%. Two objective functions are defined as the maximization of the difference between planned average inventory level and realized average inventory level, and the minimization of stock-out situations. We develop a procedure for the determination of reorder points and the number of deliveries to achieve proposed objective functions. The model overcomes shortages of theoretically-based distribution requirements planning models and offers solutions to the limitations in inventory control practice. Real-life data, collected over two years, are used for the validation of the proposed model and the solution procedure. Numerical examples illustrate the model application and behaviour.

Research, development, and evaluation of the practical effect of a storage inflow and outflow management system for consumables in the endocrinology department of a hospital

Background

This study was designed for the research and development (R&D) and application of a storage inflow and outflow management system enabling departments to perform efficient, scientific, and information-based consumable management.

Methods

In the endocrinology department of a hospital, expert and R&D teams in consumable management were set up, and an information-based storage inflow and outflow management system for consumables was designed and developed. The system was operated on a personal computer and was divided into three modules: public consumables, bed consumables, and quality control management. The functions of the system included storage inflow and outflow, early warnings, response to user queries, and statistics on consumables. Data were derived from the hospital information system (HIS,ZHIY SOFTWARE HIS VERSION4.0) and a questionnaire survey. Economic indicators, work efficiency of consumable management, nurse burnout, consumable stockroom management, and staff satisfaction were compared under manual management, Excel-based management, and the consumable storage inflow and outflow management system. The results of the questionnaire were analysed using the R software, version 4.1.0.

Results

Dates were obtained from manual management, Excel-based management and the consumable storage inflow and outflow management system. Under these three methods, the daily prices of department consumables per bed were 53.43 ± 10.27 yuan, 38.65 ± 8.56 yuan, and 31.98 ± 7.36 yuan, respectively, indicating that the new management system reduced costs for the department. The time spent daily on consumable management was shortened from 119.5 (106.75, 123.5) min to 56.5 (48.5, 60.75) to 20 (17.25, 24.25) min. Nurses’ emotional fatigue and job indifference scores, respectively, decreased from 22.90 ± 1.65 and 8.75 ± 1.25 under manual management to 19.70 ± 1.72 and 6.90 ± 1.37 under Excel-based management and to 17.20 ± 2.04 and 6.00 ± 1.30 under the novel system; the satisfaction of the warehouse keeper and collection staff, respectively, increased from 76.62% and 80.78% to 91.6% and 90.5% to 98.8% and 98.5% under the three successive systems.

Conclusions

The storage inflow and outflow management system achieved produced good results in the storage and classification of consumables.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01744-y.

Inventory Optimization in the Perioperative Care Department Using Kotter's Change Model

BACKGROUND

Perioperative services have been scrutinized in the context of cost containment in health care, particularly in the procurement and reprocessing of surgical instruments. Although solutions such as surgical instrument inventory optimization (IO) have been proposed, there is a paucity of literature on how to implement this change. The purpose of this project was to describe the implementation of an IO using Kotter's Change Model (KCM).

METHODS

This study was conducted at a tertiary academic hospital across the four highest-volume surgical services. The IO was implemented using the steps outlined by KCM: (1) create coalition, (2) create vision for change, (3) establish urgency, (4) communicate the vision, (5) empower broad-based action, (6) generate short-term wins, (7) consolidate gains, and (8) anchor change. This process was evaluated using inventory metrics, operational efficiency metrics, and clinician satisfaction.

RESULTS

Total inventory was reduced by 37.7%, with an average tray size reduction of 18.0%. This led to a total reprocessing time savings of 1,333 hours per annum and labor cost savings of $39,995 per annum. Depreciation cost savings were $64,320 per annum. Case cancellation rate due to instrument-related errors decreased from 3.9% to 0.2%. The proportion of staff completely satisfied with the inventory was 1.7% pre-IO and 80.0% post-IO.

CONCLUSION

This is the first study to describe the successful implementation of KCM to facilitate change in the perioperative setting. This success contributes to the growing body of literature supporting KCM as a valuable change management tool in health care.

Factors influencing procurement behaviour and decision-making: an exploratory qualitative study in a UK healthcare provider

Background

In 2016 the UK Department of Health and Social Care published the results of a comprehensive review of efficiency in hospitals, identifying “unwarranted variation” in procurement (or purchasing) practices for materials, supplies and devices. Addressing this variation in materials and supplies procurement practice has been identified as particularly important for creating efficiencies in health service delivery. However, little is known about the behaviour and experiences of front-line individuals who make these procurement decisions, which has implications for the development of strategies to improve efficiency. The objective of this study is to improve understanding of the factors influencing procurement behaviour and decisions among requisitioners who use an internal electronic procurement portal for medical supplies and equipment, and identify areas where efficiency could be improved.

Methods

Qualitative semi-structured individual interview study, following approximately 70 h of exploratory observations on site. The study context was a large London National Health Service (NHS) healthcare provider (the Trust), where we focussed primarily on purchases managed by a large hospital. Participants were drawn from requisitioners from multiple directorates across the Trust (n = 15; of these n = 2 clinical staff members, n = 13 non-clinical).

Results

Four factors stood out in our analysis as directly affecting procurement decisions: (1) a high level of variation in electronic purchasing and inventory management procedures throughout the Trust, (ii) an inaccurate and cumbersome search facility on the internal electronic procurement platform, exacerbated by poor IT skills training and support (iii) an inefficient purchase approvals system and (iv) multiple working sites and cluttered environments. We observed that these factors led requisitioners to employ a variety of strategies or so-called ‘workarounds’ to overcome the challenges they encountered, including stockpiling, relying on internal and supplier relationships, by-passing procedures to save time, purchasing outside existing agreements to save cost, and (re) delegating purchasing responsibilities among requisitioner staff - which both addressed and created difficulties.

Conclusions

Working with the assumption that staff ‘workarounds’ indicate where main issues lie, we offer four possible explanations to why they occur: (a) to maintain services and prepare for future care requirements, (b) to save on costs for the organisation, (c) to develop skills and development in purchasing and (d) to break silos and work collaboratively. These four explanations help provide initial starting points for improving efficiencies in health supplies’ procurement processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07065-0.

The design and evaluation of a novel algorithm for automated preference card optimization

BACKGROUND

Inaccurate surgical preference cards (supply lists) are associated with higher direct costs, waste, and delays. Numerous preference card improvement projects have relied on institution-specific, manual approaches of limited reproducibility. We developed and tested an algorithm to facilitate the first automated, informatics-based, fully reproducible approach.

METHODS

The algorithm cross-references the supplies used in each procedure and listed on each preference card and uses a time-series regression to estimate the likelihood that each quantity listed on the preference card is inaccurate. Algorithm performance was evaluated by measuring changes in direct costs between preference cards revised with the algorithm and preference cards that were not revised or revised without use of the algorithm. Results were evaluated with a difference-in-differences (DID) multivariate fixed-effects model of costs during an 8-month pre-intervention and a 15-month post-intervention period.

RESULTS

The accuracies of the quantities of 469 155 surgeon-procedure-specific items were estimated. Nurses used these estimates to revise 309 preference cards across eight surgical services corresponding to, respectively, 1777 and 3106 procedures in the pre- and post-intervention periods. The average direct cost of supplies per case decreased by 8.38% ($352, SD $6622) for the intervention group and increased by 13.21% ($405, SD $14 706) for the control group (P < .001). The DID analysis showed significant cost reductions only in the intervention group during the intervention period (P < .001).

CONCLUSION

The optimization of preference cards with a variety of institution-specific, manually intensive approaches has led to cost savings. The automated algorithm presented here produced similar results that may be more readily reproducible.

Point-of-use hospital inventory management with inaccurate usage capture

Many hospital supply chains in the US follow a “stockless” structure, often implemented with the acquisition of new systems promising improved efficiencies and responsiveness. Despite vendor promises, supply chain gains from new technology are often unfulfilled or result in a reduction of performance. A critical component of achieving promised gains is the hospital’s ability to accurately and consistently capture hospital inventory use. In practice, recording demand with perfect, 100% accuracy is infeasible, so our models condition on the level of accuracy in a particular hospital department, or point-of-use (POU) inventory location. Similar to previous literature, we consider actual net inventory and recorded net inventory in developing the system performance measures. We develop two models, optimizing either cost or service level, and we assume a periodic-review, base-stock (or par-level) inventory policy with full backordering. In addition to choosing the optimal order-up-to level, we seek the optimal frequency of inventory counts to reconcile inaccurate records. Results from both models provide insights for supply chain managers in the hospital setting, as well as hospital administrators considering the adoption of similar technologies or systems.

Opportunities and challenges for contactless healthcare services in the post-COVID-19 Era

This study examines the opportunities and challenges involved with contactless healthcare services in the post-COVID-19 pandemic era. First, we reviewed the literature to analyze contactless or contact-free healthcare services that have been utilized in pre-and during the COVID-19 pandemic periods. Then, we interviewed medical experts and hospital administrators to gain knowledge about how healthcare providers are currently working to mitigate the spread of COVID and preparing for the post-pandemic period. Thus, we analyzed the evolution and utilization of contactless services during the three different time periods: pre-, during-, and post-COVID-19. The results indicated that in the post-COVID-19 era, a new normal of hybrid healthcare services would emerge. While some of the contactless services that have been practiced during the pandemic may revert to the traditional face-to-face services, those innovative contactless healthcare services that have been proven effective during the pandemic would be practiced or even advanced in the post-pandemic period due to the accelerating technological developments. This study suggests many potential opportunities and daunting challenges for healthcare institutions, policymakers, and consumers regarding the implementation of contactless services in the post-COVID-19 era.

Integrating Quality Tools and Methods to Analyze and Improve a Hospital Sterilization Process

Healthcare facilities are facing major issues and challenges. Hospitals continuously search approaches to improve operations quality, optimize performance, and minimize costs. Specifically, an efficient hospital sterilization process (HSP) allows reusable medical devices (RMDs) to be more quickly available for healthcare activities. In this context, this paper describes an integrated approach developed to analyze HSP and to identify the most critical improvement actions. This proposed approach integrates four quality tools and techniques. Firstly, a structured analysis and design technique (SADT) methodology is applied to describe HSP as a hierarchy of activities and functions. Secondly, the failure modes and effects analysis (FMEA) method is used as a risk assessment step to determine which activity processes need careful attention. Thirdly, a cause–effect analysis technique is used as a tool to help identify all the possible improvement actions. Finally, priority improvement actions are proposed using the quality function deployment (QFD) method. To validate the proposed approach, a real sterilization process used at the maternity services of Hedi-Cheker Hospital in the governorate of Sfax, Tunisia, was fully studied. For this specific HSP, the proposed approach results showed that the two most critical activities were (1) improving the coordination between the sterilization service and the surgery block and (2) minimizing the average duration of the sterilization process to ensure the availability of RMDs in time.

Radiofrequency Identification Track for Tray Optimization: An Instrument Utilization Pilot Study in Surgical Oncology

BACKGROUND

Surgical instrument tray reduction attempts to minimize intraoperative inefficiency and processing costs. Previous reduction methods relied on trained observers manually recording instrument use (i.e. human ethnography), and surgeon and/or staff recall, which are imprecise and inherently limited. We aimed to determine the feasibility of radiofrequency identification (RFID)-based intraoperative instrument tracking as an effective means of instrument reduction.

METHODS

Instrument trays were tagged with unique RFID tags. A RFID reader tracked instruments passing near RFID antennas during 15 breast operations performed by a single surgeon; ethnography was performed concurrently. Instruments without recorded use were eliminated, and 10 additional cases were performed utilizing the reduced tray. Logistic regression was used to estimate odds of instrument use across cases. Cohen's Kappa estimated agreement between RFID and ethnography.

RESULTS

Over 15 cases, 37 unique instruments were used (median 23 instruments/case). A mean 0.64 (median = 0, range = 0-3) new instruments were added per case; odds of instrument use did not change between cases (OR = 1.02, 95%CI 1.00-1.05). Over 15 cases, all instruments marked as used by ethnography were recorded by RFID tracking; 7 RFID-tracked instruments were never recorded by ethnography. Tray size was reduced 40%. None of the 25 eliminated instruments were required in 10 subsequent cases. Cohen's Kappa comparing RFID data and ethnography over all cases was 0.82 (95%CI 0.79-0.86), indicating near perfect agreement between methodologies.

CONCLUSIONS

Intraoperative RFID instrument tracking is a feasible, data-driven method for surgical tray reduction. Overall, RFID tracking represents a scalable, systematic, and efficient method of optimizing instrument supply across procedures.

Resource optimization for cancer pathways with aggregate diagnostic demand: a perishable inventory approach

This work proposes a novel framework for planning the capacity of diagnostic tests in cancer pathways that considers the aggregate demand of referrals from multiple cancer specialties (sites). The framework includes an analytic tool that recursively assesses the overall daily demand for each diagnostic test and considers general distributions for both the incoming cancer referrals and the number of required specific tests for any given patient. By disaggregating the problem with respect to each diagnostic test, we are able to model the system as a perishable inventory problem that can be solved by means of generalized G/D/C queuing models, where the capacity [Formula: see text] is allowed to vary and can be seen as a random variable that is adjusted according to prescribed performance measures. The approach aims to provide public health and cancer services with recommendations to align capacity and demand for cancer diagnostic tests effectively and efficiently. Our case study illustrates the applicability of our methods on lung cancer referrals from UK's National Health Service.

Approaches to the rationalization of surgical instrument trays: scoping review and research agenda

Background

Surgical Tray Rationalization (STR) consists of a systematic reduction in the number of surgical instruments to perform specific procedures without compromising patient safety while reducing losses in the sterilization and assembly of trays. STR is one example of initiatives to improve process performance that have been widely reported in industrial settings but only recently have gained popularity in healthcare organizations.

Methods

We conduct a scoping review of the literature to identify and map available evidence on surgical tray management. Five methodological stages are implemented and reported; they are: identifying research questions, identifying relevant studies, study selection, charting the data, and collating, summarizing and reporting the results.

Results

We reviewed forty-eight articles on STR, which were grouped according to their main proposed approaches: expert analysis, lean practices, and mathematical programming. We identify the most frequently used techniques within each approach and point to their potential contributions to operational and economic dimensions of STR. We also consolidate our findings, proposing a roadmap to STR with four generic steps (prepare, rationalize, implement, and consolidate) and recommended associated techniques.

Conclusions

To the best of our knowledge, ours is the first study that reviews and systematizes the existing literature on the subject of STR. Our study closes with the proposition of future research directions, which are presented as nine research questions associated with the four generic steps proposed in the STR roadmap.

Design Opportunities to Reduce Waste in Operating Rooms

While taking care of the population’s health, hospitals generate mountains of waste, which in turn causes a hazard to the environment of the population. The operating room is responsible for a disproportionately big amount of hospital waste. This research aims to investigate waste creation in the operating room in order to identify design opportunities to support waste reduction according to the circular economy. Eight observations and five expert interviews were conducted in a large sized hospital. The hospital’s waste infrastructure, management, and sterilization department were mapped out. Findings are that washable towels and operation instruments are reused; paper, cardboard, and specific fabric are being recycled; and (non-)hazardous medical waste is being incinerated. Observation results and literature findings are largely comparable, stating that covering sheets of the operation bed, sterile clothing, sterile packaging, and department-specific products are as well the most used and discarded. The research also identified two waste hotspots: the logistical packaging (tertiary, secondary, and primary) of products and incorrect sorting between hazardous and non-hazardous medical waste. Design opportunities include optimization of recycling and increased use of reusables. Reuse is the preferred method, more specifically by exploring the possibilities of reuse of textiles, consumables, and packaging.

Efficiency of Operating Room Processes for Elective Cataract Surgeries Done by Residents in a National University Hospital

Purpose

Operating room processes must be efficient to boost profitability and minimize cost while retaining surgical care quality. This study aims to assess operating room efficiency for resident-performed elective phacoemulsification surgeries done under local anesthesia by measuring different key performance indicators and comparing this with international benchmark data.

Patients and Methods

This is a prospective cross-sectional study done in the Department of Ophthalmology of the Philippine General Hospital, the National University Hospital. The operating room milestones were noted and recorded by a single third-party observer in randomly selected operating rooms from April to June 2019.

Results

Fifty-six phacoemulsification cases in randomly selected rooms fulfilling both inclusion and exclusion criteria were observed. None of the cases started on or before the scheduled 6:30 a.m. cutting time, with an average of 34 (SD 8.53) minutes late. Entry lag was above the median, while exit lag and turnover time were above the 95th percentile compared to benchmarking data. Segment analysis also showed an increased entry lag (35.11% vs 21.5%), significantly higher than benchmarks (t: 10.99, df: 55, p<0.01). Comparison with proposed targets in other studies also showed an increased time for entry lag.

Conclusion

This study determined that entry lag is the performance indicator that should be addressed to improve efficiency. A multidisciplinary approach and group goal-setting are needed to implement changes in the operating room.

Health economic evaluation of a clinical pharmacist's intervention on the appropriate use of devices and cost savings: A pilot study

BACKGROUND

Good management of disposable and reusable supplies may improve surgical efficiency in the operating room (OR) and also corresponds to the best eco-responsible approach. The purpose of this study was to assess the impact of a clinical pharmacist's intervention in the OR on the non-compliant use of medical devices. We also assessed the economic impact of the pharmaceutical intervention.

MATERIALS AND METHODS

We conducted a monocentric prospective study in the OR of a University hospital over one year. Three surgical specialties: urologic, digestive and gynecologic were audited after a preparatory phase to optimize usage of medical devices used for surgeries. The supply costs concerning the three specialties were compared before and after the pharmacist intervention.

RESULTS

One hundred and fifty surgical procedures were audited in digestive (33.3%, n = 50), gynecologic (32%, n = 48) and urologic (34.7%, n = 52) surgeries. With the pharmacist in OR, 51 procedures (34% CI95%[26.4%; 41.6%]) with a non-compliance concerning at least one medical device were found compared to the 50% rate without the pharmacist reported previously (P < .0001). Eighteen percent of surgical procedures had at least one circulator retrieval for the reason "incomplete case cart despite device listed on the case cart list" versus 29.1% before pharmacist intervention (P = .0028). A €33 014 saving associated with the presence of the pharmacist in OR was observed.

CONCLUSIONS

This prospective interventional study showed that the intervention of a pharmacist specialized in the medical device field could significantly reduce non-compliances in medical device use and reduce costs in OR.

Application of a hybrid selective inventory control technique in a hospital: a precursor for inventory reduction through lean thinking

Purpose

The cost of providing healthcare is spiralling up in recent times. On the one hand, patients expect the highest quality of service, while on the other hand, the managers of the healthcare services want to minimise the total operating expenses. Hence, healthcare organisations implement lean thinking (LT) to achieve these twin objectives. LT reduces the eight wastes that are prevalent in the healthcare processes and functions. In particular, if the wasteful inventories related to expensive medical supplies are reduced, the resulting cost savings can help in providing affordable and accessible healthcare.

Design/methodology/approach

Hence, in this paper, a case study of a hospital is presented where LT is implemented. One of the projects was related to inventory reduction in the store of the catheterisation laboratory (cath lab). A hybrid methodology called multi-unit selective inventory control (MUSIC) that combined these three dimensions (3D), namely, consumption value, criticality and lead time or ease of availability was used to classify the medical supplies into different categories.

Findings

Based on the results obtained, various inventory systems and the associated tools and techniques of LT were proposed. For example, a deep dive into the A-class items revealed that some of the medical supplies fell under both vital and scarce categories. Hence, it was recommended that the case hospital should follow the economic order quantity (EOQ) with safety stock approach as these items were to be shipped from other states in India. Subsequently, the focus should be on developing a local supplier and attempts should be made to establish a kanban system with adequate information sharing.

Practical implications

This study demonstrates the step-by-step methodology of MUSIC-3D which would guide the procurement managers to apply the same in their organisation. It also helps them in identifying appropriate elements of LT for inventory reduction before the actual deployment.

Originality/value

None of the papers has utilised the MUSIC-3D methodology as a precursor for inventory reduction, specifically within the domain of LT. Similarly, identifying and proposing different type of inventory systems and various LT practices based on this unique method is a novel attempt.