Hospital systems across the United States have implemented quality improvement initiatives to reduce more than 5 million tons of waste annually.(1) These strategies often focus on surgical services and are designed to minimize environmental impact and decrease healthcare costs that are frequently passed on to patients.(2,3) Additionally, physicians have identified excess sterile instrumentation as a key source of waste.
Unused sterile instruments and single-use materials are a major source of waste in hospital operating rooms.(4) A recent study reported instrument utilizations rates of 13–22% and a negative correlation with surgical tray size.(5) Eliminating unnecessary surgical instrumentation can potentially save $10,000–$20,000 annually for a single surgeon.
Research has reported savings across multiple departments, including neurosurgery, gynecology, urology, otolaryngology, and plastic surgery, all of which have documented tens of thousands of dollars through previous studies.(5-8)
OPERATION PROCESS
Our institution uses surgical instrumentation preference cards (SIPCs) to ensure necessary instrumentation is available for each surgeon and procedure across four surgical facilities. Each facility was constructed or acquired at a different point in time and has a unique history leading to specific location needs. This resulted in unique SIPCs at each facility with a unique mix of inpatient and outpatient procedures across all four sites as well as unique instrumentation needs at each site.
For example, because of differences in site construction, the sterile light covers are not uniform. This discrepancy has posed a challenge to standardization of SIPCs across all sites and is ultimately what has prevented our institution from undertaking an analysis like the one described in this quality improvement project.
Currently, SIPCs are specific to each surgeon, procedure, and location. Therefore, even for the same procedure and surgeon, SIPCs are not the same across facilities nor are all SIPCs for the same procedure and surgeon updated together.
Despite these differences, surgical trays are assembled at a centralized facility that is directly affiliated with the hospital system. Figure 1 illustrates the supply chain of surgical instruments at our multi-site institution.
As advancements in surgical technology are made, new instrumentation is added to SIPCs; however, an audit is rarely completed to remove items that are no longer needed, resulting in gradually increasing preference cards and excess costs.
The purpose of this study was to analyze cost savings following a manual update of SIPCs. Each unique procedure was segmented into two categories: 1) the site in which the procedure was performed most frequently, or primary site; and 2) sites where the procedure was performed less frequently, or secondary sites. Definitions of the organizational process are included in Table 1.
INTERVENTION
Initially, through an in-person institutional perioperative committee and emails to chairs of all surgical departments at the institution, 18 surgeons volunteered to participate in the quality improvement project. Surgeons across general surgery–5, otolaryngology–5, plastic surgery–4, orthopedic surgery–2, and ophthalmology–2 ultimately participated in this study.
The three most common operations in 2021 for each surgeon were selected to evaluate SIPC accuracy with both inpatient and outpatient surgeries occurring under general anesthesia being included for considered for inclusion. Ultimately, 49 unique procedures were evaluated out of a possible 54 because of surgeon availability.
Each of these procedures was performed at between one and four surgical sites, with nine being performed at only the primary site, 18 performed over two sites, 19 occurring at three sites, and three procedures performed across all four sites in the health system.
Student researchers met each surgeon at the primary site before the procedure to assess the contents of the preference card. Unnecessary items were recorded and changes to individual preference cards were made within a central database. Information collected from the primary site was compared with corresponding SIPCs from each secondary site/surgeon/procedure so updates could be made.
Next, changes in cost for the updated SIPCs were calculated using 2022 supplier price data and the distribution of savings was analyzed. Finally, data analysis to calculate annual savings based on frequency was performed to serve as the focal point of our quality improvement review.
Cost savings were calculated for total and open items that were removed from SIPCs following the review. Overall annual savings were also analyzed by multiplying the annual frequency of the case performed by the cost savings of the individual SIPC. Total expenses were defined as total gross expenses for disposable and reusable items removed from SIPCs. An additional calculation was completed for items removed from SIPCs with instructions to open the instrumentation before procedures.
RESULTS
Following the conclusion of SIPC review, 18 surgeons and 49 procedures were evaluated and updated. There were up to four procedure sites for each surgeon resulting in 111 unique updated SIPCs. Initial total cost of all instrumentation across 111 SIPCs accumulated to approximately $4.2 million annually, and the open costs contained within those same SIPCs totaled approximately $2.3 million annually.
After removing non-essential instrumentation from SIPCs, the total and open annual costs of preference cards were found to be $3.87 million and $2.25 million, respectively. More specifically, total cost savings from a one-time preference card update totaled $337,007 annually and open cost savings yielded a reduction of $56,254 annually (Figure 2).
Finally, the average annual total savings for 49 procedures was $6,879 and average annual open cost savings was $1,152. Detailed comprehensive procedural costs are presented in Table 2.
When further breaking down cost savings, the number of sites where a given case was performed was considered. Of the 49 procedures analyzed, nine were performed at a single site, 20 at two sites, 17 at three sites, and three at all four sites in the health system. Total cost savings at the most common site for each of the 40 multi-site procedures yielded $144,009 in annual savings with $7,697 in open cost savings.
As depicted in Figure 3, when exclusively accounting for savings obtained through updating preference cards at secondary sites, a total annual savings of $149,995 was observed along with an annual open cost savings of $42,162.
Finally, Figure 4 provides a further breakdown of secondary sites’ observed annual savings. The second most common site for a procedure was observed to have $143,608 in total savings with $38,499 of that amount in open annual savings. In contrast, the third most common site of a procedure was observed to have $4,414 total annual savings and $3,295 in open annual savings along with $1,974 total annual savings and $367 open annual savings at the three quaternary sites.
NEXT STEPS
A comprehensive review of 49 procedures resulted in an annual total cost savings of $337,007 and annual open cost savings of $56,254. This affirms and quantifies the value of maintaining current surgical instrumentation preference cards in concurrence with previous investigations.(5-8)
Our findings were consistent with multisite healthcare systems which identified secondary locations with lower frequency as the greatest sources of financial waste. Finally, this quantification of inefficiencies has allowed for steps to be taken to improve the consistency of SIPCs across all sites so that when a card is updated at one site within the health system, concurrent changes are made for all sites where that procedure is performed.
Despite the value observed within this study, there are multiple opportunities for further expansion. First, working with hospital administration to broaden physician participation may limit potential volunteer bias in this study. By incorporating a wider cross section of surgeons within the healthcare system, we believe a greater rate of savings will be observed. Additionally, creating an accurate model to track costs of sterilization and transportation of reusable instrumentation is a key component of quantifying true realized cost savings.
The final consideration moving forward is to characterize physician satisfaction with the new preference card system. By ensuring preference cards are continuously updated across all sites, the accuracy of instrumentation at secondary sites notably improved. Quantifying this improvement in SIPC accuracy within the context of physician satisfaction is another significant way that this project adds value to the health system.
OPERATIONAL IMPLICATIONS
This review was limited to 49 procedures, representing fewer than 10% of the total cases performed in the health system. A thorough review of all procedures within the healthcare system will provide significant additional cost savings for the institution.
If savings rates were to remain consistent across the remaining procedures in the hospital system, annual total cost savings would be more than $4 million and annual open cost savings would be more than $700,000 annually. Total cost savings were slightly less than previous literature suggests a one-time preference card update would yield, but there are numerous factors that we believe play into this difference.
First, an established system of open versus held instrumentation already helped to mitigate potential sources of waste. Additionally, all surgeons participating in this study were volunteers and displayed some level of initiative in maintaining consolidated surgical preference cards. It is reasonable to believe that these individuals are more likely to be actively managing the size of their preference cards and are going to have lower cost savings potential.
The most notable component of our findings was not in the gross savings of a one-time preference card update but in the distribution of where the savings were observed. Not only did total cost savings at secondary sites total more than primary sites ($149,995 to $144,009), but also open cost savings were nearly six times greater at secondary sites ($42,162 to $7,697).
This distribution becomes even more impressive when accounting for the percentage of procedures that were performed at secondary sites. Of all cases included in this analysis, 64% were performed at the primary site of the procedure in question; therefore, on a per-case basis, total annual savings at secondary sites for a surgery were 92% greater per case than at primary sites for a procedure.
When focusing only on open costs, this discrepancy becomes significantly greater with a 486% increase in annual open savings per case at secondary sites. Ultimately, the most plausible reason for this discrepancy between primary and secondary sites is because of the incentives motivating physicians to update SIPCs.
At primary sites where physicians expect to be performing cases repeatedly, surgeons have strong reason to update cards to ensure accuracy and simplicity for future cases. However, at secondary sites that vary from typical routine, the probability that physicians will see benefit from updating an SIPC is diminished and therefore there is weaker incentive to update the given SIPC.
To try to harness this savings potential demonstrated in this study, our institution created a new position to directly update SIPCs to ensure that adjustments made at the primary surgical site (where cards are generally most accurate and consolidated) are translated to all other sites where a procedure is performed. This will ensure that SIPCs of surgeons who did not volunteer will continue to be consolidated, but also that SIPCs do not return to the state they were before the quality improvement project.
The distribution of cost savings is particularly relevant for this study. First, it highlights the most efficient opportunities for cost-reduction measures and the potential for standardization of SIPCs across all sites within a healthcare institution. By ensuring consistency of SIPCs across locations within a health system, the large proportion of cost savings at secondary sites can be reduced to a level more proportional with the number of procedures performed. It also allows for more sustainable long-term waste reduction as all future consolidation of preference cards will then be automatically applied to all locations in the healthcare system.
Second, while harder to quantify, the differences in cost savings across multiple sites points to larger challenges that multisite healthcare institutions encounter. With transportation of instrumentation to multiple sites across a city comes increased transportation costs along with increased opportunity for lost or damaged instrumentation.
Additionally, the time cost of an incorrectly filled surgical tray is magnified as cases must be delayed for proper instrumentation. These additional costs are partially captured through the juxtaposition of open costs versus total costs, but we acknowledge that the true cost savings are not fully quantified. However, it is indisputable that by removing excess instrumentation and creating consistency within a healthcare system, you are reducing waste in more ways than are quantified in this study.
References
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