Unleashing Efficiency:Unleashing Efficiency: A Vanderbilt University Medical Center

C C t St d2-29-2012

Case Cart Study

Vanderbilt University Hospital Perioperative Enterprise

P t ti G lPresentation Goals• Strategic ObjectiveStrategic Objective • Statistical Information• Current State Supply & Instrument FlowCurrent State Supply & Instrument Flow• Current State OR• Future State OR Case Cart FlowFuture State OR Case Cart Flow• Metrics• Impact on Surgical SuitesImpact on Surgical Suites• Point of Use Technology• TimelineTimeline

Perioperative Enterprise OverviewPerioperative Enterprise Overview• 83 operating rooms in 7 primary procedural locations-3 free-standing Ambulatory Surgery Centers in community g y g y y

• Over 50,000 procedures annually• Level 1 Trauma Center, Children’s Hospital Transplant

Center • Robotically assisted surgery, transplant center, advanced

imaging services350 Surgeons fellows and residents350 Surgeons, fellows and residents300 Anesthesiology faculty and staff1000 Nurses, scrub technicians,

clinical technicians anesthesia techniciansclinical technicians, anesthesia technicians

P i ti E t iPerioperative Enterprise• Vanderbilt University • Ambulatory Surgery Centers• Vanderbilt University

Hospital VOR

• 35 ORs

Ambulatory Surgery Centers Cool Springs Surgery Center

• 5 ORs Nashville Surgery Center

• 6 ORs• 35 ORs Cardiac Hybrid OR

• 1 OR Medical Center East

6 ORs Vanderbilt Bone &Joint

• 3 ORs Total ASC ORs-14

Medical Center East• 11 ORs

Women’s Center3 OR

• Monroe Carroll Jr. Children's Hospital

16 ORs• 3 ORs Free Electron Laser

• 3 ORs

16 ORs

•• Total VUMC ORs 83Total VUMC ORs 83

Total VUH ORs Total VUH ORs -- 5353

Surgical PODg

Total Surgical Quarterly Case VolumesFY 2001 to Present

12,250 12,500 12,750 13,000 13,250

FY 2001 to Present

Increase (Decrease) % from Prior Year:FY00 - 8.0%FY01 - 5.6%FY02 - 4.6%

10 25010,500 10,750 11,000 11,250 11,500 11,750 12,000 FY03 - 3.8%

FY04 - 6.3%FY05 - 13.7%FY06 - 10.3%FY07 - 4.1%FY08 - (.7)%FY09 - (.2)%FY10 - 14.1%

8 2508,500 8,750 9,000 9,250 9,500 9,750

10,000 10,250

CA

SES

FY11 - 5.4%

6,500 6,750 7,000 7,250 7,500 7,750 8,000 8,250

5,000 5,250 5,500 5,750 6,000 6,250

CCT Construction Update and Interiors Planp

7

3RD FLOOR O.R. PLANCLEAN/SOIL SERVICE ELEVATOR

FUTURE ELEVATOR CORE

12 NEW OR’S & CORES = GAIN OF 10 OR’S NEW PACUOF 10 OR’S

17 EXISTING OR’S & CORES TO REMAIN

OR’S 2 & 4 REPLACED BY SUPPORT FUNCTIONS

NEW PACU

NEW SURG. PATH

CRITICAL CARE TOWER – PROJECT OUTLINE NORTH

Strategic ObjectivesStrategic ObjectivesRedesign OR Supply Chain and Case Cart Systems in

support of expansion of VUMC

• Design and implement an offsite case cart and supply chain management system

pp p

supply chain management system• Streamline and improve existing processes to

better support supply and instrument needs of the physicians

• Reduce clinician involvement in supply chain functionsfunctions

• Minimize inventory at all locations*

*Minimal clinical impact, data driven

Improvement Framework:Improvement Framework: Toyota Production System Lean Principles Th L th d l i i i t tThe Lean methodology is a rigorous improvement system designed to transform waste into value from the customer’s perspective.

Striving for the IDEAL• DEFECT FREE, exactly what the patient needs

p pKim, Spahlinger, Kin, & Billi, 2006

• ONE by ONE, customized to each individual patient• ON DEMAND, exactly as requested• IMMEDIATE RESPONSE, to problems or changes, p g• NO WASTE (motion, excess processing, waiting, confusion, excessive

inventory, rework/defects, over production, transporting)• Safe for patients, staff, and cliniciansSafe for patients, staff, and clinicians

Physically, Emotionally, ProfessionallyJimmerson, 2008

Operational Models EvaluatedOperational Models EvaluatedRemain On Site

Approximately $9M renovation cost to prepare case carts onsite Approximately $9M renovation cost to prepare case carts onsite

Insufficient square footage with no additional growth opportunity

Insufficient square footage to relocate existing departments

Off site

•• Metro CenterMetro Center

I ffi i S f f f h Insufficient Square footage for future growth

Unable to meet timeline for required occupancy

Hybrid (Metro/Instruments and O&M Supplies)Hybrid (Metro/Instruments and O&M Supplies) Hybrid (Metro/Instruments and O&M Supplies)Hybrid (Metro/Instruments and O&M Supplies)

Cost prohibitive

Multiple Touch points/Handling for increased points of failure

Insufficient Square footage for Staging of carts

Vanderbilt Case CartVanderbilt Case Cart Operations Center (CCOC) @ Brick Church Pike

• AdvantagesState of the art facility and equipmenty q pSized for 10 years with additional growth opportunity

• 51,000 sq. ft. Adjacent to current O&M Distribution CenterAdjacent to current O&M Distribution CenterTo include both instruments and supplies

• Allow for move out of Metrocenter locationV d bilt t ffVanderbilt staff 24/7 OperationMet timeline for Critical Care Tower

Owens & Minor Warehouse StatsTotal VUH OR

Owens & Minor Warehouse Stats

Total Warehouse Square Footage 102,000 NA

Total Dedicated Employees to VUMC 46 NA

VUH Ship- tos 253 18

MCJCH Ship- tos 95 NA

Clinic Ship tos 260 NAClinic Ship- tos 260 NA

VUMC Annual Lines 1,315,020 189,500

VUMC Avg. Orders 63,708 7,400

Total Warehouse Bin Locations 12,366 NA

VUMC Annual Purchases $ 52,000,000 $15,800,000

Prior State Case Cart FlowINSTRUMENT PROCESSING

Prior State Case Cart FlowMETRO

C C

Instrument Storage

Dis

trib

uted

Supp

lies

Case CartsE

E

OR Core

C t l

Case Cart Staging

BRILEY

Einstruments

OM Warehouse

Central Supply

(Supply Build)

BRILEY

Distributed SuppliesWarehouse pp

Daily Supply OperationsDaily Supply Operations

OM receives order and prints license plate OM receives order and prints license plate to identify PO Items and location in LUM to identify PO Items and location in LUM PickPick

Vanderbilt supply chain performs daily Vanderbilt supply chain performs daily manual manual inventory to stock shelves to par inventory to stock shelves to par levellevel

Vanderbilt supply chain places order via Vanderbilt supply chain places order via EDI to Owens & MinorEDI to Owens & Minor

The completed tote is scanned by another electric eye and The completed tote is scanned by another electric eye and diverted to proper shipping lane. set up by hospital diverted to proper shipping lane. set up by hospital

departments.departments.

An electric eye scans the tote and An electric eye scans the tote and diverts the tote to the next pick diverts the tote to the next pick zone.zone.

OM scans barcode, OM scans barcode, picks the product, and picks the product, and places it into the toteplaces it into the tote

Daily Supply OperationsDaily Supply Operations

O&M sorts Low Unit of O&M sorts Low Unit of

O&M makes multiple DeliveriesO&M makes multiple Deliveries Vanderbilt Vanderbilt manuallymanually receives Carts receives Carts and delivers to the appropriate supply and delivers to the appropriate supply location specified on license plate for location specified on license plate for

put awayput awaySTORAGE AREAS FOR PUT AWAYMeasure totes by Measure totes by

departmentdepartment

p yp ySTORAGE AREAS FOR PUT AWAY

Central Supply BulkCentral Supply Bulk

Central Supply Low Unit of Central Supply Low Unit of MeasureMeasure

Prior MetroCenter Instrument Tray Build OperationPrior MetroCenter Instrument Tray Build Operation

Dirty instrument cart is scanned Dirty instrument cart is scanned to Decontaminationto Decontamination

Instruments are scanned to Sink and sent to DecontaminationInstruments are scanned to Sink and sent to Decontamination

Instrument trays are Instrument trays are assembledassembled

Instrument racks are sent through Instrument racks are sent through sterilizersterilizer

Tray Rack is removed from Tray Rack is removed from sterilizer for cool down of >1.5 sterilizer for cool down of >1.5

hrs.hrs.

Q&A performed for sterility with Q&A performed for sterility with tray to container verificationtray to container verification

P i M t C tPrior MetroCenter Instrument Tray Build Operation

Transport Carts are loaded with Transport Carts are loaded with trays and scanned to Trucktrays and scanned to Truck

Truck delivery to VUHTruck delivery to VUH Instruments loaded in home Instruments loaded in home location in VUH basement and location in VUH basement and

OR Core for case cart assemblyOR Core for case cart assembly

Prior Central Supply Case Cart Build OperationPrior Central Supply Case Cart Build Operation

DPC/Pick Ticket print off DPC/Pick Ticket print off based on the day’s based on the day’s scheduled casesscheduled cases

Supply Chain staff picks items for case carts in order Supply Chain staff picks items for case carts in order of printof print Instruments are added to CartInstruments are added to Cart

scheduled casesscheduled cases

Completed Case carts are stagedCompleted Case carts are staged Completed Cart is Completed Cart is scanned to Cart Liftscanned to Cart Lift

Prior OR Case Cart OperationsPrior OR Case Cart Operations

Case Cart arrives in OR Core via Cart Lift

Case Cart is scanned to the OR

Suture and additional specialty items added to cart

Case Carts are staged in the OR until Case is ready to be performed

Cart is scanned to the room when case is ready to be performed

Redesigned State Case Cart FlowINSTRUMENT PROCESSING

MCN DOCK

g

CASE CART BUILD

SUPPLY BUILD

1. Instruments, Standard case cart items

Case Cart Staging

CCOCcart items

3. COMPLETE

OR Core

2. Patient Specific,

1. Specialty Cart and Back-up SuppliesOM

Warehouse 2. Patient Specific, suture, implants clinical decision required

Warehouse

Case Cart Operations Center LocationCase Cart Operations Center Location

Briley O&M WarehouseBriley O&M Warehouse

Case Cart Operations CenterCase Cart Operations Center• 51,000 Square Feet51,000 Square Feet20,000sf in Sterile Processing

• All New High Speed Sterile Processing Equipmentg p g q p• 14 Instrument Assembly Tables• Vendor Check-in area

St ETO ( ) H2O2 Pl G St ili ti• Steam, ETO (gas), H2O2 Plasma Gas Sterilization31,000sf in Sterile Stores

• Includes storage for 4500 instrument trays• Includes storage for 4500 instrument trays• Storage space 200 case carts• Storage for over 3250 Supply SKUs

CCOC Plan for SuccessCCOC Plan for Success• Vanderbilt owned and operated facility All new sterilizer equipment and boiler/plant facility All new sterilizer equipment and boiler/plant facility Managed by experienced operating room nurses Staffed by seasoned VUH CSP employees

• Track record of off site instrument processing• Track record of off-site instrument processing 8+ years at Metro Center Facility Proven truck transport and logistics schedule

• Robust instrument tracking system• Robust instrument tracking system Quickly identifies where instruments are Used to identify inventory turns and need forecasting Contains instrument maintenance tracking tools Contains instrument maintenance tracking tools

• Instrument Budget Management New Instrument Inventory Repairs and replacement Repairs and replacement

CCOC Floor PlanCCOC Floor Plan

VCCOC Process FlowVCCOC – Process Flow

Dirty carts arrive from VUMC and are scanned

Instruments enter the decontamination process

VCCOC – Process FlowVCCOC Process Flow

Decontamination process continues

Instruments are staged toInstruments are staged to enter the washer

VCCOC Process FlowVCCOC – Process Flow

Instruments are scanned and assembled into trays

VCCOC – Process FlowVCCOC Process Flow

Trays are scanned, sterilized and then placed in carts

Supplies are scanned and added to the carts per the DPC

VCCOC – Process FlowVCCOC Process Flow

C l t d t dCompleted carts are scanned and staged for delivery to

VUMC based on the case start timetime

Completed carts arrive at the TVC dock and are delivered to

the various ORs

Day in the Life at VCCOCDay in the Life at VCCOC…• Case Carts 2,400 carts/month

120 cart/weekdayy

• Instruments 60,600 instruments/week12 000 instruments/weekday12,000 instruments/weekday

• Supplies 70,000 supplies/month3 800 li / kd3,800 supplies/weekday

• FTE’s 40 Total (26 Sterile Processing & 14 Supply)

• Interfaces VPIMS, ORMIS, GIE, PMM, POU, StarPanel, , , , , , ,Censitrac, LDAPS/Users, Censis Data Repository

MetricsMetricsMeasure & Manage

Case Cart Completion and Accuracy

• AccuracyDefinition: Item listed

• Fill RateDefinition: Total items

p y

on DPC matches item on cart

Instrument

requested on DPC vs. total items on cart

Instrument Instrument• Tray• Individual Instrument

Supplies

Instrument• Tray• Individual Instrument

Supplies Supplies• Commodity• Specialty

Supplies• Commodity• Specialty

OPERATING ROOM PROCESS

C C t Th E i tCase Cart: The EpicenterWhat is most important to the case cart?

C

SchedulingAccuracyCase

CartAccuracyPredictabilityComplianceCompliance

The Operation – ElectiveThe Operation – ElectiveS h d l fSchedule for following day is paused and

run

Pick product Pick instruments

Load clean truck

Transport carts to VUH and deliver

Add patient specific non-stock

items from thetruck and deliver staging area

items from the service

Cart delivered to appropriate room prior to case startroom prior to case start

Th O ti TThe Operation – TraumaY

Receive notification of incoming trauma

Is cart in OR? Perform Case

Remove case cart from OR storage location

Yes

No

Contact VUH CS for cart delivery

Cart is delivered to OR

Initiate build for replacement of trauma cart

C C t Th E i tCase Cart: The EpicenterWhat is most important to the case cart?p

C

Preference CardsAccuracyCase

CartAccuracyMaintenancePost-Case ReviewPost Case Review

PerioperativePerioperative• SchedulingScheduling policyg p y

• Measurement/Management/Enforcement

Design “nurse-friendly” CPT codes

• Doctor Preference Card (DPC)Cleaned Up

Ph i i S ifi• Physician Specific• Improve Accuracy

– Reduced return rate of supplies

On-going maintenance• Post Case Review• Utilization reports by doctor/case (Point of Use)Utilization reports by doctor/case (Point of Use)

C C t Th E i tCase Cart: The EpicenterWhat is most important to the case cart?p

I t t

C

InstrumentsTray Accuracy

Case Cart

Tray AvailabilitySpecialty InstrumentsD il CDaily CensusScanning Compliance

VUH Instrument StatisticsVUH Instrument Statistics• 3837 Trays3837 Trays45% of the trays are stored in CSP55% are stored elsewhere55% are stored elsewhere

• 28 Specialties or Owners of the trays• 78 875 Instruments in Trays78,875 Instruments in TraysTrays contain one to over 200 instruments

• Valued at $16 858 688• Valued at $16,858,688• An Average of 5+ Instrument Trays are

pulled per Procedurepulled per Procedure

Service Level Instrument SpecificsService Level Instrument Specifics• CardiacTrays 261Trays--261 Instruments--3927Value--$680,829$ ,

• OrthopedicsTrays--979 Instruments—15,673Value--$4,460,674

• Neurosurgery• NeurosurgeryTrays--331 Instruments--4668 Value--$1,686,002

VolumesVolumes• WeeklyTrays Processed--2791 Instruments Handled—90,573Missing Items—901Missing Items 901Fill Rate—99.01%86.35% of trays are 100% filled

Annual (last 365)• Annual (last 365)Trays Processed—137,503 Instruments Handled—4,612,662Missing Items—64,359Fill Rate—98.60%80 68% of trays are 100% filled80.68% of trays are 100% filled

C C t Th E i tCase Cart: The EpicenterWhat is most important to the case cart?

C C t S li

C

Case Cart SuppliesInventory management

Case Cart

Storage location- Rooms

Service Centers- Service Centers- Basement- Offsite

C C t O ti C t (CCOC)Case Cart Operations Center (CCOC)• Supplies & InstrumentsSupplies & Instruments

Routinely requested on Doctor Preference Card• Elective and add-on Case Carts

Delivered prior to first case and throughout the day/night Prioritized by scheduling needs

• Pre-built Procedure Specific Trauma/Emergency Carts Ex: Exploratory Lap Exploratory Lap Craniotomy Cardiac Cardiac

Case Cart Operations VUHCase Cart Operations VUH• SuppliesPatient or size specificRoom StockBack-upBack up

• InstrumentsTraumaB kBack-upUnique, including laparoscopic and power equipment

• Implantsp• Trauma Carts• POD Specific Carts

T h l T lTechnology Tools• Maximize Current Censitrac technology forMaximize Current Censitrac technology for

instruments• Point of Use Technology for suppliesgy pp• QSight Utilization and Inventory management for

wound closure products• Starform for electronic scheduling• VPIMS patient tracker

Point of Use TechnologyPoint of Use Technology• Increases accuracy of • Meets regulatoryy

Case cart/ par levels DPC used for case pick Reporting specific to case,

h i i ti t

Meets regulatory standards Automatic notification of

expired product tied to lot physician, patient

Less manual intervention Automatic reorder points

with ability to set critical

p p#/serial #

Tracks bone/tissue from point of receipt to i l t tiwith ability to set critical

alerts• Improves Patient

charge capture

implantation Robust reporting for recall

managementR d Cli i l

g p Ties cart/supplies to patient

irrespective of where case is done

Can feed directly into

• Reduces Clinical involvement in supply chain processes

Can feed directly into ORMIS or Medipac

How We Got There (Highlights)How We Got There (Highlights)Phasing it all in…

Point Of Use

Specialty Carts

Stay/Go CriteriaPoint Of Use

Scheduling Policy

Preference Room StockTrauma/Emergency

CartsPreference CardCleansing

Room Stock CartsCCOC

SuppliesCCOC

Instruments

CASE CART OPERATIONS CENTER REPORTSCENTER REPORTS

June % of Inventory Value

June 2010 Physical Value

October % of Inventory Value

October 2010 Par Value

November % of Inventory Value

November 2010 Par Value

January % of Inventory Value

January 2011 Par Value

% Change November 2010 ‐Janaury 2011

% change June JanValue Physical Value Value Par Value Value Par Value Value Value Janaury 2011 ‐ Jan

Consigned Implants 16.47% $2,275,195 16.76% $2,306,291 17.56% $2,327,075. 17.24% $2,263,654.05 -2.73% ‐0.50%

Owned Implants 26.42% $3,648,984 28.55% $3,927,995 28.39% $3,763,077. 30.38% $3,989,844.79 6.03% 9%

42.90% 45.32% 45.95% 48.42%

Briley 18.14% $2,504,997 14.90% $2,049,701 15.93% $2,111,992 14.49% $1,903,028.73 -9.89% ‐23%

Central Supply 8.55% $1,180,869 9.78% $1,345,047 10.14% $1,344,021 10.02% $1,316,404.72 -2.05% 11%

26.69% 24.68% 26.07% 24.93%

Suture (PANDAC) 2.16% $298,934. 1.63% $224,270.4 1.81% $239,289.0 1.65% $216,363.87 -9.58% ‐28%( )

Suture (Non-PANDAC) 0.13% $17,611.37 0.13% $17,290.57 0.13% $17,290.57 0.13% $17,200.00 -0.52% ‐0.50%

Suture Caddies 1.14% $157,936.8 1.13% $155,567.18 1.20% $158,871.83 1.28% $168,033.74 5.77% 3.60%

CORE Standard 13.34% $1,841,874 13.37% $1,838,678 13.96% $1,849,864. 13.77% $1,808,100.38 -2.26% ‐1.80%

CORE JIT 2.96% $408,786. 2.96% $407,558. 3.25% $431,095. 3.03% $397,287.83 -7.84% ‐3%

Room Stock (Scan) 0.13% $17,383.41 0.15% $20,571.49 0.14% $18,315.25 0.12% $16,328.25 -10.85% ‐6%

Floor Charge EX (No Scan) 0.21% $29,407.04 0.29% $40,408.58 0.00% $30,661.63 0.17% $21,865.75 -2.73% ‐26%

Specialty Carts 5.21% $719,281. 5.08% $699,510. 5.47% $725,306. 5.18% $680,679.04 -6.15% ‐4.40%

MCE Nonchargeable Robot Supply 1.80% $248,580. 1.92% $264,380. 1.79% $237,680. 1.42% $185,880.00 -21.79% ‐25%

Bi Plane Carts 3.33% $460,53 3.34% $459,413. 3.41% $451,733. 1.12% $147,363.62 -67.38% ‐68%

30.41% 30.00% 31.15% 26.66%

Total Inventory Value $13 810 379 $13 756 686 $13 254 542 $13 132 034 -0 92% ‐5%Total Inventory Value $13,810,379. $13,756,686 $13,254,542. $13,132,034. -0.92% ‐5%

SUMMARYSUMMARY• Very complexVery complex• Many moving parts

Hi h i k• High riskPatient careSurgeon and staff satisfaction

• Significant improvement in performanceg p p

QUESTIONSQUESTIONS