Presentation
Addressing Surgical Tray Defects: Insights From Human Factors and Systems Engineering
SessionSurgery (HE6)
DescriptionThe surgical department in a 703-bed hospital was experiencing high variability in surgical tray quality inclusive of contamination, missing or incorrect tools, and dull instruments. This resulted in tray turnovers, operating delays, and even procedure cancellations. Leadership expressed concern that these operational challenges could negatively impact patient outcomes if not resolved. Despite ongoing improvement initiatives led by various operational teams, these defects remained unresolved.
The Human Factors and Innovations (HF&I) Team was engaged by operational leadership to assist in taking a systems-based approach to this challenge of tray quality. The project's goal was to provide a unique lens, understand system complexities, and develop an improved system design to reduce defects and enhance the adaptive capacity within surgical services. The HF&I Team reviewed tray defect data to identify patterns and conducted interviews and observations across the Sterile Processing Department (SPD), Supply Chain, and Operating Rooms (OR). The Functional Resonance Analysis Method (FRAM; Hollnagel et al., 2014) was used to map the entire Surgical Services workflow from the SPD’s perspective. FRAM allowed the HF&I Team to visualize the entire process and uncover critical pain points, inefficiencies, and instances of resilience factors. Unlike traditional retrospective event analysis, this systems-based approach captured real-time interactions and systemic bottlenecks. This allowed the HF&I Team to see how different teams interacted and how their actions influenced the overall system. Qualitative data collection focused on tracking the journey of a surgical tool from decontamination and sterilization through use in surgery and was organized using the Systems Engineering Initiative for Patient Safety (SEIPS) model (Carayon et al., 2006). An iterative data collection process allowed for multiple rounds of observation and refinement, ensuring the team captured the full complexity of the workflow.
The project highlighted key factors contributing to tray defects and increased understanding of interdependencies between departments. This work paved the way for systemic recommendations within the Sterile Processing Department and surgical services. Recommendations included:
• minimizing unused instruments,
• optimizing trays, instruments, and prioritization,
• improving team empathy,
• introduction of specialized roles,
• and optimizing asset management software to reduce delays and prevent procedure rescheduling.
The expected outcomes include a more robust system by reducing waste, along with improved resilience by addressing tightly interconnected workflow components, making it easier to recover from disruptions like missing instruments.
The project approach and inclusion of qualitative data allowed the team to capture real-world complexities often missed in traditional improvement efforts. By observing work as it is done, rather than how work is imagined via policy, the team gained valuable insights into relevant facilitators and barriers contributing to tray defects. The integration of Human Factors, Systems, and Resilience Engineering methodologies in this healthcare context offered a systems approach to visualizing and addressing process complexity. This systems-based approach enabled the team to understand work and identify pain points and develop sustainable interventions that have the potential to transform surgical services.
The proposed solutions are currently under review and awaiting implementation. They are expected to streamline workflows, reduce tight interdependencies, and result in fewer delays within surgical services. An important success of the initiative was encouraging leadership to think differently about how the system functions. The HF&I team were able to guide leadership to recognize the significance of maintaining positive slack in the system, which allows flexibility and recovery when unexpected issues arise. This shift in mindset was key to ensuring that recovery is possible in critical moments, ultimately improving the resilience of the system.
References
Carayon, P. A. S. H., Hundt, A. S., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. BMJ Quality & Safety, 15(suppl 1), i50-i58.
Hollnagel, E., Hounsgaard, J., & Colligan, L. (2014). FRAM-the Functional Resonance Analysis Method: a handbook for the practical use of the method. Centre for Quality, Region of Southern Denmark.
The Human Factors and Innovations (HF&I) Team was engaged by operational leadership to assist in taking a systems-based approach to this challenge of tray quality. The project's goal was to provide a unique lens, understand system complexities, and develop an improved system design to reduce defects and enhance the adaptive capacity within surgical services. The HF&I Team reviewed tray defect data to identify patterns and conducted interviews and observations across the Sterile Processing Department (SPD), Supply Chain, and Operating Rooms (OR). The Functional Resonance Analysis Method (FRAM; Hollnagel et al., 2014) was used to map the entire Surgical Services workflow from the SPD’s perspective. FRAM allowed the HF&I Team to visualize the entire process and uncover critical pain points, inefficiencies, and instances of resilience factors. Unlike traditional retrospective event analysis, this systems-based approach captured real-time interactions and systemic bottlenecks. This allowed the HF&I Team to see how different teams interacted and how their actions influenced the overall system. Qualitative data collection focused on tracking the journey of a surgical tool from decontamination and sterilization through use in surgery and was organized using the Systems Engineering Initiative for Patient Safety (SEIPS) model (Carayon et al., 2006). An iterative data collection process allowed for multiple rounds of observation and refinement, ensuring the team captured the full complexity of the workflow.
The project highlighted key factors contributing to tray defects and increased understanding of interdependencies between departments. This work paved the way for systemic recommendations within the Sterile Processing Department and surgical services. Recommendations included:
• minimizing unused instruments,
• optimizing trays, instruments, and prioritization,
• improving team empathy,
• introduction of specialized roles,
• and optimizing asset management software to reduce delays and prevent procedure rescheduling.
The expected outcomes include a more robust system by reducing waste, along with improved resilience by addressing tightly interconnected workflow components, making it easier to recover from disruptions like missing instruments.
The project approach and inclusion of qualitative data allowed the team to capture real-world complexities often missed in traditional improvement efforts. By observing work as it is done, rather than how work is imagined via policy, the team gained valuable insights into relevant facilitators and barriers contributing to tray defects. The integration of Human Factors, Systems, and Resilience Engineering methodologies in this healthcare context offered a systems approach to visualizing and addressing process complexity. This systems-based approach enabled the team to understand work and identify pain points and develop sustainable interventions that have the potential to transform surgical services.
The proposed solutions are currently under review and awaiting implementation. They are expected to streamline workflows, reduce tight interdependencies, and result in fewer delays within surgical services. An important success of the initiative was encouraging leadership to think differently about how the system functions. The HF&I team were able to guide leadership to recognize the significance of maintaining positive slack in the system, which allows flexibility and recovery when unexpected issues arise. This shift in mindset was key to ensuring that recovery is possible in critical moments, ultimately improving the resilience of the system.
References
Carayon, P. A. S. H., Hundt, A. S., Karsh, B. T., Gurses, A. P., Alvarado, C. J., Smith, M., & Brennan, P. F. (2006). Work system design for patient safety: the SEIPS model. BMJ Quality & Safety, 15(suppl 1), i50-i58.
Hollnagel, E., Hounsgaard, J., & Colligan, L. (2014). FRAM-the Functional Resonance Analysis Method: a handbook for the practical use of the method. Centre for Quality, Region of Southern Denmark.
Event Type
Oral Presentations
TimeTuesday, April 11:30pm - 1:52pm EDT
LocationHarbour C
Hospital Environments (HE)