Virginia Mason Medical Center in Seattle decreased its sterile processing error rate from 3 percent to 1.5 percent over 37 months, according to a study in The Joint Commission Journal on Quality and Patient Safety.
The hospital used the Virginia Mason Production System, an adaptation of Lean techniques, to improve the quality of surgical instrument processing. Here are 15 quality improvement techniques the hospital used to successfully decrease its error fate from 3 percent of surgical cases to 1.5 percent:
Redefine operator roles
• The quality improvement team separated assembling the tray and packing the tray into two roles.
• The team developed a "cockpit check" role to check quality between assembly and packing.
Physically change space
• The operators were aligned to facilitate a smooth flow.
• The QI team integrated a cockpit check station between assembly and sterilization.
Perform mistake-proofing
• The cockpit check role used a short checklist to check for key packaging tasks.
• The team refined the checklist for each instrument set to provide just-in-time reminders on details of instrument assembly.
• Staff implemented a "stop the line" process to gather sterile processing leaders when an error was discovered.
• Staff used color coding to group components that function together and shadow boards — outlines of the instruments — to ensure each instrument was matched correctly with packing.
Monitor quality
• The QI team developed a Daily Defect Sheet to monitor errors and share with staff.
• Errors were categorized by error type and frequency.
• Staff conducted a daily audit of completed trays.
Train staff
• Staff were trained to be certified registered central service technicians during work hours.
Provide continuous feedback
• The sterile processing team conducted daily huddles to discuss the daily defect sheet.
• The team discussed weekly target reports.
• There was an ongoing review of Lean ideas submitted by staff.
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The hospital used the Virginia Mason Production System, an adaptation of Lean techniques, to improve the quality of surgical instrument processing. Here are 15 quality improvement techniques the hospital used to successfully decrease its error fate from 3 percent of surgical cases to 1.5 percent:
Redefine operator roles
• The quality improvement team separated assembling the tray and packing the tray into two roles.
• The team developed a "cockpit check" role to check quality between assembly and packing.
Physically change space
• The operators were aligned to facilitate a smooth flow.
• The QI team integrated a cockpit check station between assembly and sterilization.
Perform mistake-proofing
• The cockpit check role used a short checklist to check for key packaging tasks.
• The team refined the checklist for each instrument set to provide just-in-time reminders on details of instrument assembly.
• Staff implemented a "stop the line" process to gather sterile processing leaders when an error was discovered.
• Staff used color coding to group components that function together and shadow boards — outlines of the instruments — to ensure each instrument was matched correctly with packing.
Monitor quality
• The QI team developed a Daily Defect Sheet to monitor errors and share with staff.
• Errors were categorized by error type and frequency.
• Staff conducted a daily audit of completed trays.
Train staff
• Staff were trained to be certified registered central service technicians during work hours.
Provide continuous feedback
• The sterile processing team conducted daily huddles to discuss the daily defect sheet.
• The team discussed weekly target reports.
• There was an ongoing review of Lean ideas submitted by staff.
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