1. Surgical Reprocessing (SRP) Performance Dashboard for Improved Service Team Members : John Rodriguez Jose Gonzalez Surgical Reprocessing Team Members Patricia Meuschel RN,MSM

2. 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.

3. 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

4. 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

5. 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

6. Results Decontamination - 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 02 Sep 02 Oct 02 Nov 02 Dec 02 Jan 03 Feb 03 Mar 03 Apr 03

7. Results 15 44 2 3 0 3 1 3 1 0 4 8 12 16 20 Jul-02 Aug-02 Sep-02 Oct-02 Nov-02 Dec-02 Jan-03 Feb-03 Mar-03 Apr-03 Delays in Scheduled Cases Related to SRP Problems

8. Results Sterilization BI INDICATORS 0% 20% 40% 60% 80% 100% Jul 02 Sep 02 Oct 02 Nov 02 Dec 02 Jan 03 Feb 03 Mar 03 Apr 03

9. Results Tray Accuracy 7 3 0 22 11 2 0 2 14 9 33 8 3 6 1 4 0 18 29 16 19 20 12 26 15 8 14 0 5 10 15 20 25 30 Jul 02 Aug 02 Sep 02 Oct 02 Nov 02 Dec 02 Jan 03 Feb 03Mar 03 Apr 03 Missing IntegratorsIncomplete PackagingMissing Instruments

10. Next Steps Continue to monitor process & reevaluate for continued improvements