• Reduce the number of steps in the surgical tray preparation process
• Reduce the number of exceptions (missing instrumentation) on a weekly basis
• Review and update the preference cards
• Improved and increased communication between Central Services and the Operating Room (OR), leading to improved relationships between the two departments

• Overhead Paging System: Put into place to help Central Services become and feel more part of the team. They can now hear the Operating Room overhead pages, are more aware of when cases finish, and can better anticipate when dirty carts will be coming down to decontamination.
• Operating Room/Central Services Liaison: Created this new position to assist Central Services and the Operating Room in solving problems that exist between the two departments. The individual in this position works in both Central Services and the Operating Room, has a good base of expertise in both areas, and is a go to person for both areas with a good rapport in both areas. 
• Central Services Dispatcher: Takes all phone calls from the Operating Room when needing instruments and supplies for cases that are occurring. This is one dedicated person who carries a portable phone in Central Services and they are then responsible to follow through with all requests. 
• Case Cart Stocking: Moved case cart stocking from the busiest part of the day to later in the day when more people and instruments are available to completely stock the carts. This resolved a lot of our incomplete case cart problems, and now the case carts go up to surgery complete.
• Remodeling: Remodeled part of Central Services department which allowed us to bring more instruments and supplies from the Operating Room core down to one central area. This change also made the flow of stocking case carts more fluid so it was a quicker process. 
• Loaner Set Process: Changed the responsibility of all loaner sets from the purchasing agent to the Operating Room/Central Services liaison. The liaison is responsible for making sure all loaners are here for a day's cases and are in close contact with all the Reps, changing the location so that all loaners are now stored in one area, and assisting in developing a new policy which outlined the loaner process so that expectations were consistent. 
• Blue Light: Developed a mechanism to allow off-shift decontamination staff to know when dirty case carts had come down from the Operating Room. The blue light is visible and now flashes when the elevator has come from the Operating Room to Central Services.
• Preference Card Clean Up: Collaboration between Operating Room team leaders and surgeons to clean up preference cards in an effort to make them more accurate. This has allowed the case carts to be stocked with only what is needed versus supplies that have just “always been there.”
• Shift Changes: Made shift changes to accommodate when Central Services stocked case carts as well as other changes to include overlapping shifts, which allowed us to get instruments processed and resterilized in a more timely fashion.
• Big Board Communication: Enhanced our existing computer system so that it would inform all of the staff processing instruments to know what the Operating Room is waiting for, so that these instruments can be processed as a priority. 

Summary of Results

Gundersen Lutheran was experiencing a high incidence of incomplete instrumentation trays going to surgery. Only 86 percent of trays were assembled correctly. After launching a multidisciplinary team from Surgery and Central Service that used "lean" techniques to improve workflow processes, measured by on time and accurate instrumentation for surgical cases, the team was able to achieve results at 99.6 percent. This pilot supported the continued use of lean techniques at Gundersen Lutheran.

• Improved the process from a 62-step surgical tray preparation down to 27 steps.
• Reduced the number of exceptions/incomplete case carts.  Exceptions went from 100+ to under 20 when measured on a weekly basis.
• Improved preference card clean up over the timeframe that we did the study. 
• Improved communication and trust between Central Service and OR.

Lessons Learned

• All the “right” people need to be at the table and they can’t be afraid to say what is on their mind.
• Communication must go back to the departments impacted by this work. 
• Senior Leadership support is essential – know your boundaries, but don’t be afraid to ask for what you need.
• The time spent is worth the outcome.
• Post project communication is important.

Bryan Erdmann
Administrative Director of Perioperative Services and Anesthesia
Gundersen Lutheran
gerdman@gundluth.org

[Storyboard presentation at IHI's National Forum, December 2006]