Surgical Reprocessing (SRP) Performance Dashboard for Improved

Service

Team Members:John Rodriguez

Jose Gonzalez

Surgical Reprocessing Team Members

Patricia Meuschel RN,MSM

Opportunity Statement

Some delays in the start of cases in the Operating Room are the result of issues in SRP. SRP focused on ways to improve service to the OR, by reducing the time to prepare and deliver case carts.

Goal: To reduce the number of delays in the OR related to SRP.

Most Likely Causes

Tray Assembly Issues: Chemical Indicators are one of the 4 checks used to monitor sterilization process. If missing the tray is not used & replaced

Packaging Issues: Instruments trays are packaged to insure items inside remain sterile. If damaged the tray is not used & is replaced

Instrument Issues: Lists of instrumentation required, based on Surgeon preference have been established. If omitted must be obtained, prior to start of surgery

Solutions Implemented

• Education & re-training of SRP staff• Daily Rounds to each OR for SRP issues• OR/SRP Liaison Committee• Reengineering picking of Case Carts• Develop standards for timely Case Cart

delivery • Reorganization of department flow

Solutions Implemented

• Tray Trakker Computer System– Updated tray lists– Current location of trays– Consistent naming of trays– Accountability of tray assembly– Organized department with tray locations– PM schedule for instruments– Information for new instrument purchases– Inventory of instruments in trays

ResultsDecontamination - Percentage of time 2 Instrument Washers are functioning as designed

BELIMED WASHER/DECOM FUNCTIONING 100% DAILY

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Jul 0

2

Sep 0

2

Oct 0

2

Nov 02

Dec 0

2

Jan 0

3

Feb 0

3

Mar

03

Apr 03

Results

15

4 4

23

0

3

1

3

1

0

4

8

12

16

20

Jul-0

2

Aug-02

Sep-0

2

Oct-0

2

Nov-02

Dec-0

2

Jan-0

3

Feb-0

3

Mar

-03

Apr-03

JulyN-1030

AugN-938

SeptN-957

OctN-999

Nov.N-897

DecN-877

JanN-998

FebN-885

MarN-922

AprilN-919

Delays in Scheduled Cases Related to SRP Problems

Results

SterilizationBI INDICATORS

0%

20%

40%

60%

80%

100%

Jul 0

2

Sep

02

Oct 0

2

Nov 02

Dec 0

2

Jan 0

3

Feb 0

3

Mar

03

Apr 0

3

Results

Tray Accuracy

7

3

02 2

1 12

02

14

9

3 3

8

3

6

1

4

0

18

29

16

1920

12

26

15

8

14

0

5

10

15

20

25

30

Jul 0

2

Aug 02

Sep 0

2

Oct 0

2

Nov 02

Dec 0

2

Jan 0

3

Feb 0

3

Mar

03

Apr 03

Missing Integrators Incomplete Packaging Missing Instruments

JulyN-6283

AugN-5794

SeptN-5732

OctN-6147

Nov.N-5811

DecN-6023

JanN-6435

FebN-5964

MarN-6720

AprilN-6239

Next Steps

Continue to monitor process & reevaluate for continued improvements