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Featured Article:

Go with the Flow: Improving Efficiency in Central Sterile Processing

Robin Anderson, AIA, EDAC, Senior Project Architect, Eppstein Uhen Architects

Wheaton Franciscan Healthcare All Saints Hospital in Racine, Wisconsin is a 313 inpatient bed multibuilding hospital campus that includes the Cardiovascular Institute, St. Luke’s Women’s and Children’s Health Pavilion, and St. Mary’s Hospital. The Central Sterile Processing (CSP) department supports these facilities and the physician office building located on the campus.

Originally built in 1977, the CSP department at All Saints Hospital was in need of renovation to support new technologies and workflow processes; the sterilizing and processing equipment was nearing the end of its useable lifespan. Wheaton Franciscan Healthcare decided to commit the resources to replace the equipment and also improve the flow and functionality of the existing department. In July 2013, the team at Eppstein Uhen Architects (EUA), based in Milwaukee, Wisconsin, began the design of a reimagined departmental layout built upon new operational model based on Lean principles, all within the confines of the existing departmental footprint. The renovation project focused on operational changes and efficiency gained with new equipment to make improvements. It also addressed the department’s lack of adequate staff locker rooms, a breakdown room and secure entrances.

As an organization, Wheaton Franciscan Healthcare partnered with the Virginia Mason Institute to build its Lean capabilities and improve quality. All Saints Hospital became the first site within the WFH organization to pilot the Lean process improvement objectives of the organization. This renovation project was the first to use a Lean-led design process to maximize value for the customer while reducing waste.

Identify Value
EUA began the process by developing a project vision and documenting the current state. The vision statement
developed by the cross-functional design team, consisting of staff and administrators from CSP, Surgical Services, Materials Management, Facilities and Information Systems, was:
Provide quality products to support safe and excellent patient care within the project schedule and budget.

The team identified these project drivers:

- Develop pull system: products delivered at right time to right place;

- Develop standardized work;

- Create pleasant and supportive work environment;

- Improve efficiency and workflow with new equipment and space layout;

- Provide customer satisfaction.

EUA led the team through a Voice of the Customer exercise to identify who the CSP customer(s) and their values were. The project team agreed that CSP has many internal customers but the final customer is the patient, who values CSP’s delivery of safety and quality products.

EUA began documenting the current state by “Going to the Gemba”, a Lean term which means going to the place where the work is done. The EUA team observed flow in the current department and talked with staff about where bottlenecks and frustrations occurred. Staff identified points in the workflow where equipment caused delays. For example, the existing cart washer didn’t dry carts, so staff had to dry them manually, adding additional time to the cycle. EUA created an existing flow diagram to record the findings.

Map the Value Stream
The next step was to create a Value Stream Map (VSM) of the current state and identify all steps in the current work processes. The VSM exercise is enlightening because all stakeholders can see the entire process. One problem that surfaced during the exercise was the current cleaning process for portable pumps, which were transported from inpatient units down to CSP for cleaning and thus created a bottleneck in the Decontamination room. As a result of this discussion, CSP and Environmental Services determined that a better solution was to have EVS clean the portable pumps on the inpatient floors, thus reducing staff motion, equipment transport (and potential to damage equipment), and turn around time. This operational change was made before construction began, helping to realize immediate efficiency.

One critical item to workflow improvement was understanding instrument processing cycle times and determining how they could be improved. A key piece of the future state involved the new washer and sterilization equipment, which are inherently much more efficient. Other ideas proposed for the future state included the purchase of closed case carts to reduce supply waste, using electronic preference cards, and implementing a bar code instrument- tracking system.

Create Flow
EUA used a puzzle play exercise to determine ideal adjacencies and flows. This activity, involving the entire cross-functional design team, revealed the need to create a dedicated room for vendor instrument drop-off and pickup. Under the new system, vendors are now able to drop off instruments in a secure room. The instruments are returned to that room after surgery once they have been processed, creating better flow for CSP staff. Another function that was discovered was the need for a soiled instrument drop-off room adjacent to Decontamination. In the revamped process, couriers from various departments bring used instruments to an anteroom where instruments are placed in a pass-through cabinet. CSP staff no longer need to leave the department to retrieve them, reducing their footsteps and increasing productivity.

Once the proposed layout was created, the resulting new flow was analyzed. Users could see how the proposed vendor drop-off and pick-up room and breakdown room would improve the flow of supplies coming in and out of the department. Through the analysis, a connection between Materials Management and CSP for the delivery of sterile supplies was removed. In the new layout, sterile supply deliveries for CSP go directly from the loading dock into the breakdown room, reducing a process step and improving infection control procedures.

The new department layout also improves environmental aspects:

- Hand-washing sinks are located at entrances into Decontamination and Clean areas.

- Seamless epoxy floors improve cleanliness and appearance.

- New ambient and task lighting is better for inspecting instruments, especially in the packing workstations.

- The new mobile prep/pack workstations allow for flexibility.
(The electrical connection for these workstations comes down from the ceiling so the
workstations can be rearranged or added if processes change.)

- The new equipment provides improved ergonomics for staff; the decontamination sink workstations are height adjustable.

- Staff have adequate locker room space with showers and a dedicated break room.

- Cheerful paint colors have improved staff morale while providing a visual guideline for the allowable height of stored items.

Construction started in January 2014. Phasing was critical, since CSP needed to remain operational throughout the 8 month construction period. Fortunately, All Saints Hospital had two small CSP areas in other parts of the campus to use during the interim phases. CSP staff worked with EUA, Riley Construction and STERIS to create two fully functional CSP satellite locations in the adjacent patient towers which required installing new sterilizers temporarily during the renovation of the main department. When the main department was complete, the new sterilizers were moved to their permanent locations. The CSP staff moved into the renovated space over Labor Day weekend in 2014.

Establish Pull
The CSP staff have worked in the renovated department for 3 months and are very happy with the renovated space and improved workflow. Val Giani, manager of CSP, says her staff love coming to work in the renovated department. The staff are thrilled with the ergonomics of the height adjustable decontamination sinks. The new pack and prep workstations have all the supplies staff need located at their fingertips. Staff also appreciate having adequate locker room and break space as well as the overall aesthetics of the department.

The additional capacity of the new washer/disinfectors and sterilizers has improved throughput and reduced cycle times. The additional capacity of the cart washers to also wash containers has freed up one employee who used to wash containers by hand. Val Giani reports that the new washer/disinfectors save 20 minutes per cycle and the new plasma sterilizers save 30 minutes per cycle. She also stated that the department has also seen vast improvement in cleanliness of instruments as a result of the investment in new equipment.

Improved flow from the cart washers to the case cart picking area to the clean lift has reduced the time needed to fill case carts. In the previous layout, one employee spent an average of 14 hours per day filling case carts, almost two entire shifts. With the new layout, case cart picking time is down to one eight-hour shift.

Perhaps the best outcome from the renovation project was the report from a recent surprise visit from the Joint Commission. The inspector’s report was glowing; he said he was very impressed with the renovated department’s layout, organization and management. In particular, the inspector thought that the ante room for soiled instrument drop off with a pass through cabinet was such a great feature that he will recommend its implementation by other hospitals.

Seek Perfection: Lessons Learned
One major lesson learned from the renovation project was the value of creating satellite CSP locations. Even though staff did have to push carts farther to reach the satellite CSP locations during the construction, Val Giani said the temporary locations were much preferable to working in a trailer or sending instruments offsite for processing. Another benefit of having satellite CSP areas is that All Saints Hospital now has redundancy in CSP capacity and equipment to deal with isolation cases and any equipment downtime due to maintenance. CSP staff will continue to refine their operational improvements and process changes in the renovated space as All Saints Hospital continues on its Lean journey.

Throughout the Lean-led design process, the cross-functional team focused on creating operational changes and efficiency supported by the facility design. Along the way, the team always came back to the project drivers to verify that the design solution supported the project vision. The renovation project outcomes show that the facility design and operational improvements meet the project vision to provide quality products to support safe and excellent patient care within the project schedule and budget.

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