- Surgical tray standardization is an opportunity for cost reduction without impacting patient care.
- Lean methodology can be employed to generate and sustain results.
- Provider experience highlights steps to reduce instrument variance in orthopedics and gynecology.
of surgical instruments will be used during a case, on average
Optimizing surgical tray standardization to reduce costs and improve operational efficiencies
Key components and success factors
As hospitals and health systems continue to work to manage costs while maintaining quality, surgical tray standardization remains an untapped opportunity for many organizations. Over time, the number of instruments on a surgical tray grows as preferences shift and new surgeons join the team. The use of some instruments may also be simultaneously declining with these changes. The combination of these factors results in unnecessary costs to purchase, process and manage the instruments.
The operating room, however, is a unique environment in which the inherent culture is to provide each surgeon with their individual preferences for instrumentation for each surgical procedure. This status quo of surgeon autonomy creates challenges in arriving at a consensus on reducing instrument selections.
Clinical studies highlight cost and quality implications
Extensive research supports the benefits of instrument standardization. Eliminating tray redundancy can lead to both direct and indirect cost savings while positively impacting operating room processes.
The financial significance of unused items on a surgical tray can be substantial. Researchers have conducted many studies on this topic, and a literature review confirms the impact on intraoperative inefficiencies across service lines.
One study that evaluated four surgical services (otolaryngology, plastic surgery, bariatric surgery, and neurosurgery) found that an average of 87% of reusable instruments on surgical trays went unused. Study respondents reported that surgical teams utilized only 21.9% of the instruments on neurosurgery trays. The low levels of use across the four specialties suggests that facilities could achieve cost savings by evaluating and adjusting tray composition.1
An analysis of vascular trays netted similarly low results, with 22.9% use rates for vascular trays and 12.5% for aortic trays.2 Another evaluation of neurology and orthopedics found that 58% of instruments were used at least once during the 38 audited cases.3 The authors went a step further, to create and test standardized trays which resulted not only in cost savings but also had a positive impact on quality, safety and efficiency.4
Figure 1: Surgery volumes for select procedures by site of care
US Market, 2022–2032
Note: Analysis excludes 0–17 age group only. Inpatient forecast indicates discharges and includes surgical MS-DRGs for select procedures. Wound Debridement includes Wound Debridement – Major, Wound Debridement – Minor. Outpatient forecast indicates volumes for select procedures. Site of care detail with negligible volumes was excluded. ASC = ambulatory surgery center; HOPD = hospital outpatient department. Sources: Impact of Change®, 2022; HCUP National Inpatient Sample (NIS). Healthcare Cost and Utilization Project (HCUP) 2019. Agency for Healthcare Research and Quality, Rockville, MD; Proprietary Sg2 All-Payer Claims Data Set, 2019; The following 2019 CMS Limited Data Sets (LDS): Carrier, Denominator, Home Health Agency, Hospice, Outpatient, Skilled Nursing Facility; Claritas Pop-Facts®, 2022; Sg2 Analysis, 2022.
Principles of tray management
When configured properly, surgical instrument trays equip staff with the minimum instruments required to perform the highest number of procedures within a specialty. Multiple tray standardization initiatives conducted recently by the team at Vizient reveal many ways to evaluate and streamline instruments and provide additional value, including saving staff time preparing and maintaining the trays, reducing sterilization and purchasing expenses and providing lighter trays that are safer to handle and transport.
Vizient tray management engagements employ a proven methodology to ensure success. The stages in Vizient’s process include assessing the current state, designing new trays based on the organization’s unique needs, deploying the new trays and continuously sustaining and maintaining the results. Figure 2 details this methodology and the components required.
In the assessment stage, collaborators typically explore four considerations, beginning with defining which instruments should be included to ensure consistency in data and decision-making. For example: an instrument “held by the surgeon” at least 50% of the time.
Next the quantities utilized of each instrument are evaluated. Observation and data collection are required to document the actual number and name of instruments used in each operation from induction through closure.
Collaborators also must assess and define the trays, instruments, procedures and surgeons they will include in the initiative. The team can then observe surgeons and procedures where a specific tray is listed on surgeons’ preference cards.
Finally, closely evaluate how many trays of each type should be held in inventory. Utilization records of immediate use, sterilization and projected procedural volumes might indicate the need for a larger quantity of a specific instrument tray.
A multidisciplinary team evaluates all of the information and data to design and deploy the tray standardization initiative, with goals of cost containment and performance improvement.
While evidence-based innovations are abundant in healthcare, many disseminate slowly or never gain traction.5 This makes the fourth step, sustain, critically important.
To create sustainable change, Vizient’s approach to surgical tray standardization incorporates a multidisciplinary team, constant innovation and adaptation of tray configurations, a defined timeline and partnerships with key stakeholders. A diverse and engaged team draws on differing experiences, knowledge and expertise to accomplish a unified goal as it allows for the pursuit of opportunities to maintain long-term outcomes. Engaging stakeholders throughout the process helps ensure success and creates a sense of shared ownership.
Figure 2. Vizient Tray Management
Show the whole picture to help determine the most relevant insights
- Conduct on-site interviews
- Tour departments
- Observe procedures
- Review tray management process and associated staff roles and responsibilities
- Evaluate relevant policies and procedures
- Develop recommendations for best practices
- Show the whole picture to help determine the most relevant insights
Collaborate to identify and build the best solution
- Engage stakeholders
- Create implementation plan
- Establish clear scope and objectives for plan
- Identify barriers to success and mitigation strategies
- Collaborate to identify and build the best solution
Implement to realize improvements
- Implement plan
- Develop and implement communication plan for stakeholders
- Implement to realize improvements
Through management systems and continuous engagement, transform culture to
achieve lasting results
- Measure success using defined metrics
- Update and create required policies and procedures
- Educate and train staff and physicians
- Through management systems and continuous engagement, transform culture to achieve lasting results
As part of a savings initiative, the supply chain team at Renown Heath partnered with Vizient to participate in a multidisciplinary process aimed at addressing redundancy in their highest utilized surgical instrument trays in orthopedics and gynecology.
“The healthcare system is under immense pressure to deliver improved care while reducing the overall cost,” said Kirtan Patel, Value Analysis Program Leader at Renown Heath. “Further, surgical case volumes are projected to continue increasing, so healthcare organizations must implement practices that enable them to manage this volume while reducing the overall cost per case.”
The project began with analyzing the surgical schedule and observing the procedures directly to determine which instruments to include. Common usage patterns of instrument trays in orthopedics and gynecology, combined with a detailed review of preference cards, sterile processing department (SPD) reports and repair logs, helped Renown Health surface the information needed to tackle the cost savings opportunity. The academic medical center has three locations, which provided even greater variance in tray configurations with hundreds of preference cards among surgeons across the facilities.
Actual instrument usage data collected from direct observation, combined with analytics and expertise, led the team to recommend the removal of unused instruments based on lean methodology approaches. The industry standard is 17%; however, the elimination needs vary based on the starting redundancy status of the trays.
At each stage of the project, key stakeholders were engaged to share their expertise. Armed with the usage patterns, the multidisciplinary instrument tray management team (see list in Table 1) met to aggregate their insights and needs that existed intra-operatively.
Table 1: Tray Management Stakeholders
The team began the process of sorting the data and working toward tray standardization. As a best practice, only instruments that were used more than 50% of the time were recommended for inclusion, with a few exceptions for patient safety in case of rare or unexpected events. The team brought orthopedic and gynecology surgeons into the discussion to make these determinations.
In addition to individual instruments, the trays themselves were also compared to determine overlap or redundancy and to identify opportunities for consolidation. The surgeons reviewed recommendations the team put forth for similar procedures to use the same tray and then made the final recommendations. Finally, the tray quantities and inventories were assessed with daily case volume information.
The team made adjustments as needed, without compromise to patient care. Using a consistent methodology and a phased approach to change built trust with the surgeons, an important success factor for this initiative.
“Through the partnership with Vizient and their surgical experts, we were able to reduce instruments to only those required to support each surgical case,” said Patel. “This resulted in the removal of waste and improvements in central processing department workload within the health system.”
The tray management initiative allowed Renown Health to remove more than 75,000 instruments from its orthopedic trays and more than 16,000 instruments from its gynecology trays. Additionally, they consolidated 28 trays to 10 trays. Moving forward, adding instruments to trays is a formal process that is managed by an instrument oversight committee.
As an example, each location had different versions of basic bone and arthrotomy trays. After collaborating during the Vizient engagement, stakeholders decided to create one large bone tray that was consistent across facilities. This consolidation reduced configurations from five trays with 399 instruments to one tray with only 79 instruments.
“The work helped us remove items not being used and have a more concise list of items in a tray,” said Cassandra Deen, Sterile Processing Department Manager at Renown Heath. “It also enables the team to borrow trays between ORs, which improves throughput and access to additional trays for all ORs—so rapid turnovers decreased for these trays as well.”
The removed instruments are now available in SPD inventory to be utilized for peel-packed instruments or repurposed for other trays when instruments are lost or broken. Removing infrequently used instruments from the trays and creating peel-packed items is cost-effective because it saves the infrequently used instruments from constant, unnecessary reprocessing, which carries labor and equipment costs and contributes to instrument depreciation.
Estimated cost savings of the new leaner trays was calculated based upon per instrument sterilization, processing, instrument replacement costs and instrument depreciation. Eliminating one instrument that was used 2,000 times a year from a tray would save $920. The removal of these instruments yielded an estimated total annual cost savings of nearly $55,000.
There are viable opportunities in the reorganization of surgical instrument delivery that result in significant cost savings. Lean methodology improves efficiency in instrument tray usage and reduces hospital costs, while it encourages surgeon and staff participation through continuous process improvement.
Surgical administrations nationwide can benefit from evaluating and examining surgical instrument trays. Consistent reassessment is needed to achieve both cost savings and sustainable practices. This case study and the literature indicate that eliminating tray redundancy may be a prime opportunity for the operating room to innovatively reduce costs, streamline processes and ultimately improve care.
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- Stockert EW & Langerman A. Assessing the magnitude and costs of intraoperative inefficiencies attributable to surgical instrument trays. Journal of the american college of surgeons. 2014 Oct;219(4):646-655. doi:10.1016/j.jamcollsurg.2014.06.019. Accessed February 7, 2023.
- Knowles M, Gay SS, Konchan SK, Mendes R, Rath S, et al. Data analysis of vascular surgery instrument trays yielded large cost and efficiency savings. J Vasc Surg. 2021 Jun;73(6):2144-2153. doi: 10.1016/j.jvs.2020.09.043. Epub 2020 Dec 24. PMID: 33359847. Accessed January 5, 2023.
- Lunardini D, Arington R, Canacari EG, Gamboa K, Wagner K, et al. Lean principles to optimize instrument utilization for spine surgery in an academic medical center: an opportunity to standardize, cut costs, and build a culture of improvement. Spine (Phila Pa 1976). 2014 Sep 15;39(20):1714-7. doi: 10.1097/BRS.0000000000000480. PMID: 24979139. Accessed January 5th, 2023.
- Koyle MA, AlQarni N, Odeh R, Butt H, Alkahtani MM, et al. Reduction and standardization of surgical instruments in pediatric inguinal hernia repair. J Pediatr Urol. 2018 Feb;14(1):20-24. doi: 10.1016/j.jpurol.2017.08.002. Epub 2017 Sep 8. PMID: 28967607. Accessed January 5th, 2023.
- Berwick DM. Disseminating innovations in health care. JAMA. 2003 Apr 16;289(15):1969-75. doi: 10.1001/jama.289.15.1969. PMID: 12697800. Accessed February 7, 2023.