process redesign for improving the traceability of medical instruments: case study of a hospital
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Process Redesign for Improving Traceability of Medical Instruments: Barcode vs RFID
Afrooz Moatari-Kazerouni ESG-UQAM, Montreal, Canada
Under the direction of Ygal Bendavid
LATECE Seminar May 6th, 2015
Laboratoire de recherche sur les technologies du commerce électronique
Presentation outline
• Traceability: what, why, how?
• Case study context and approach
– Documenting “As-Is”
– Evaluating “What-If”
• Traceability value proposition
2
Traceability is…
“The ability to track forward the movement of products through specified stages of the supply
chain and trace backward the history, application or location of products under
consideration.”
3
Why track & trace?
Reducing Asset Cost
Efficient Workflow
Retain Surgical Items
4
Infection Control
Costly Time
Technician Training
How track & trace?
5
Context of study
• Case study at a hospital in Montreal, Canada
• Construction of a new building
– Dilapidated infrastructure
– Space deficiencies
• Transfer of the most acute and critical cares to the new infrastructure
– Central Sterilization Department (CSD), Operating Room (OR)
6
– Canadian Council on Health Services Accreditation
– Operating Room Nurses Association of Canada
Why implementing a traceability system?
Streamlining and improving the process in new building
7
“Past is experience, present is experiment, future is expectation”
8
PAST
Scanning single instruments
Incomplete
instrument tagging
Corrupted database
Hardware malfunctions
No formal process
PRESENT
Scanning instrument trays
Complete crate
tagging
Updated database
New hardware
Designed process flow
FUTURE
RFID technology
RFID tagging and antenna installation
Integration with ERP
system
Design process flow
Traceability system is important for…
Keeping records of disinfection cycles
Reducing mistakes in assembling
9
Linking patients with instruments
Locating medical instrument at time
Perform What-if Analysis Measure, simulate and analyze
(prospective) alternatives Model the future processes
TO-BE Analysis
FEEDBACK
Model the current processes (traceability of
equipment)
AS-IS Analysis
Select one scenario, manage transition (pilot project )
and monitor performance
Implementation &
measurement
- Objectives - Stakeholders - Inputs/outputs - Control - Information systems
- Performance monitoring frameworks
- KPIs - Stakeholders/Roles - Information systems
Understand the current hospital’s business
processes
- Simulation Tools (Arena)
- Business process tools (Visio; Aris/Software AG)
Data gathering
Using different options - Manual data capture - 1D and 2D bar codes (item level) - RFID technologies (item level) - Hybrid options (RFID + bar code)
Analytical approach
• Data collection: Onsite observations, interviewing employees, reviewing reports
• Methodology: – Developing different scenarios on
traceability system – Mapping business process (MS Visio) – Simulating the scenarios (Arena®) – Evaluating and comparing
performance of different scenarios
11
As-Is process flow between OR & CSD
12
What is scanned?
13
1 2 3
4
(4) Reusable resistant 1D barcode on the outside of crates: scanned at the CSD.
(1) Preparation crates (2) one time use 2D barcode label on the set/crate or (3) on the blue wrapped sets: scanned at the OR before surgery.
To-Be process flow between OR & CSD Traceability Throughout the Case Cart Preparation Process – High Level Mapping
OR-
Ster
ile C
ore
OR-
Gen
eral
M
anag
emen
tCS
D-So
iled
Case
Ca
rt Z
one
CSD-
Clea
n Zo
neCS
D-St
erile
Zon
eCS
D-St
orag
e Zo
neM
ater
ial M
anag
emen
t an
d Pu
rcha
sing
OR-
Ope
ratin
g Th
eatr
eCS
D-So
iled
Zone
Legend
Determine the surgery list for next
day
Get a case cart
Pick items from carousel and shelves
Transport case cart to OR-sterile core via clean elevators
Take the cart inside operating theatre
Surgery starts
Pick rest of items from Sterile Core
Surgery ends
Nurse put Soiled items In case cart and leave it in Soiled Holding Zone
OR attendant transport case cart to CSD via
soiled elevator
Empty the case cart
Wash the soiled case card in
washing machines
Decontaminate and wash the
intruments
Park the soiled
case cart
Case carts are ready to be used
Assemble the instrument
sets
Sterilize instrument
sets
Restock carousel
and shelves
Instruments are ready to
be used
Opera
Carousel System
Order based on the purchasing
demands
Receive ordered
items
Record and de-box items
Restock carousel
and shelves
Items ready to be used
ERP system: Logibec
Restock the sterile core
storage
Items are ready to be
used
Park the case cart near the
operating theatre
Items should be stored in
CSD?
Transport items to CSD
Transport items to sterile core
NO
Preparing
case cart
Operating
Theatre and
Sterile Core
Reprocessing
of soiled
instruments
Material
Managem
ent
Once a surgery list is planned, A
preparation list request Is
transferred to CSD (about) 24hrs in
advance; at 9pm of the day before surgery by the
latest
The preparation of case carts starts during the night shift (10pm-6am). When the night shift employees arrive, the CSD supervisor provides the printed preparation list.
OROR
CSDCSD
MMMM
A,B
Responsible from OR (nurse, team leader…)
Sterilization department employee
Responsible from material mgt (store keeper, employee…)
Purchasing demand
CSD: Central Sterilization Department
OR: Operating Room
ORMS: OR Management System
Flow of information In ERP
Beginning/end of a process
Employee/system interaction
Transport of items or case cart
Operation
Decision
Links between high level processes and detailed level processes
Links between different sections
of detailed level processes
Print & attach preparation list to each case cart
Scan the cart/s (barcode on the preparation list)
Instrumental
Scan the case cart and
instrument sets
Opera/Instrumental
Scan the instrument trays and the case cart
Instrumental
Scan the tray for opening the
assembly recipe
Instrumental
Generate production label & attach to the set
Scan the production label (recording which sterilization machine)
Instrumental
Record itemsCSDCSD
CSDCSD
CSDCSD
OROR OROR
OROR
OROR OROR
MMMM
CSDCSD
CSDCSD
CSDCSD
CSDCSD
CSDCSD
CSDCSD
MMMMMMMM
Yes
Process flow scenarios
• Scenario 1: traceability with barcoding and case cart
• Scenario 2: traceability with RFID
15
Reprocessing of instruments at CSD
Traceability at tray level
Scenario 1: Barcode and case cart
16
Reprocessing of Soiled Instruments in CSD
Ass
embl
y Zo
ne
Dec
onta
min
atio
n-W
ash
Zon
eSt
erili
zati
on
Zone
OR
-Op
era
tin
g T
he
atr
e
Scenario1: Barcoding and Case Cart System
Soak the soiled
instruments
Disassemble & brush soiled instruments
Put in crate/wrap
instrument set
Steam sterilization
possible?
Sterilize items by steam
Leave sterile items to cool
Take out sets from cart and to the
decontamination
Washable with ultrasonic machine?
Use ulterasonic
Use mechanical
washer
Take clean instruments to assembly table
Check and sort instruments
Assemble the set
Include filter paper & chemical
indicator
Sterilize items by STRAD
Sets are ready to be sent to storage zone
Yes
No
Scan the barcode on
crates
Employee log in to the
system
Scan trays for opening the
assembly recipe
Instrumental Instrumental
Generate production label and attach to set
Scan production label (record
sterilization info)
Scan and record the
sterilized set
No Instrumental Instrumental
Instrumental
Take the cart inside the
operating thetreSurgery
Scan barcode on the instrument
sets
Put soiled instruments in crates and cart
Transport to CSD via elevators
Count instruments and check within
system
Leave instruments to
cool down
Verify with checklist
Yes
Transport to sterilization zone
Scenario 2: RFID technology
17
Reprocessing of Soiled Instruments in CSD
Ass
embl
y Zo
ne
Dec
onta
min
atio
n-W
ash
Zon
eSt
erili
zati
on
Zone
OR
-Op
era
tin
g T
he
atr
e
Scenario2: RFID Technology
Soak the soiled
instruments
Disassemble & brush soiled instruments
Put in crate/wrap
instrument set
Steam sterilization
possible?
Sterilize items by steam
Leave sterile items to cool
Take out sets from cart and to the
decontamination
Washable with ultrasonic machine?
Use ulterasonic
Use mechanical
washer
Take clean instruments to assembly table
Check and sort instruments
Assemble the set
Include filter paper & chemical
indicator
Sterilize items by STRAD
Sets are ready to be sent to storage zone
No
Read the RFID tag on crates
Employee log in to the
system
Read crate’s RFID tag for opening the
assembly recipe
Read crate’s RFID tag (record
sterilization info)
Read crate’s RFID tag to record the
sterilized set
No
Take the cart inside the
operating thetreSurgery
Put soiled instruments in crates and cart
Transport to CSD via elevators
Leave instruments to
cool down
Yes
Transport to sterilization zone
Read RFID tag on instrument sets
Verify with checklist
Yes
Simulation with ARENA
• Arena Discrete Event Simulation Software
– Enables modeling and simulation of business processes
– Designed for analyzing the impact of changes involving significant and complex redesigns associated with (logistics) processes
18
Imitate
Application
https://www.arenasimulation.com/
Simulation with ARENA
19 Arena User’s Guide
Building the simulations
Barcode simulation
20
oper at ing t heat r eTake t he car t inside
inst r um ent set sScan bar code on
Sur ger ycr at es and car tinst r um ent s in
Put soiled
t o decont am inat ionf r om car t and t ake
Take out set s
cr at eScan bar code on
Soak br ushDisassem ble_ T r u e
F a ls e
machine
Wash wit h ult r asonic
Use ult r asonic
washUse m echanical
t o cool downLeave inst r um ent s
t o assem bly t ableTake inst r um ent s
r ecipeopenning assem bly
and scan f orLog in t o syst em
sor t inst r um ent sCheck_assem ble_
Assem ble t he setpaper
indicat or and f ilt erI nclude chem ical
wr apPut set in cr at e or
and at t ache t o setpr oduct ion lablel
G ener at e
st er ilizat ion zoneTr anspor t t o
lableScan pr oduct ion T r u e
F a ls e
possible?
St eam st er ilizat ion St eam st er ilizat ion
st er ilizat ionSTRAD
st er ilized setScan and r ecor d
Leave t o cool downzone
send t o st or ageSet s ar e r eady t o
syst emcheck wit hin
inst r um ent s_Count
washer sTr anspor t t o
checklistVer if y wit h
zone
CSD_Decont aminat ion
CSD
f rom O R t o
CLean elevat or
OR-Operating Theatre
CSD-Decontamination
CSD-Assembly
CSD-Sterilization
Traceability with Barcode
ult r osonicAssign set f or
m echnical washAssign f or
st eam st er ilizat ionAssign set t o
st er ilizat ionAssign t o STRAD
O RSet s com es out of
Set s r eady t o st or e
Average time set in system
# sets ready to store
Average cost of resources
0 0 0 0
0 0 0 0
0
0
0
0
0 0 0 0 0 0 0 0 0
0
0
0 0
0
0 00
0 0
0
Nu mb er o f rep ro cessed sets
Ti me14401380132012601200114010801020960900840780720660600540480420360300240180120600
Sets 0
S C A N N E R
S C A N N E R
S C A N N E R
S C A N N E R
0.00
0.00
0.00
RFID simulation
21
t heat r einside oper at ingTake t he car t
set son inst r um entRead RFI D t ag
Sur ger ycr at es and car tinst r um ent s in
Put soiled
decont am inat iont ake t o
f r om car t andTake out set s
on cr at esRead RFI D t ag
Soakbr ush
Disassem ble_ T r u e
F a ls e
machine
Wash wit h ult rasonic
Use ult r asonic
washUse m echanical
cool downinst r um ent s t o
Leave
t o assem bly t ableTake inst r um ent s
assem bly r ecipet ag f or openningand r ead RFI D
Log in t o syst em
sor t inst r um ent sCheck_assem ble_
Assem ble t he setpaper
indicat or and f ilt erI nclude chem ical
or wr apPut set in cr at e
setand at t ache t opr oduct ion lablel
G ener at e
st er ilizat ion zoneTr anspor t t o
st er ilizat ion inf ot ag t o r ecor d
Read cr at e RFI D T r u e
F a ls e
possible?
St eam st er ilizat ion st er ilizat ionSt eam
st er ilizat ionSTRAD
st er ilized sett ag t o r ecor d
Read cr at e RFI D
downLeave t o cool
zonesend t o st or age
Set s ar e r eady t o
washer sTr anspor t t o
checklistVer if y wit h
zone
CSD_Decont aminat ion
f r om O R t o CSD
CLean elevat or
OR-Operating Theatre
CSD-Decontamination
CSD-Assembly
CSD-Sterilization
Traceability with RFID
ult r osonicAssign set f or
m echnical washAssign f or
st eam st er ilizat ionAssign set t o
st er ilizat ionAssign t o STRAD
of O RSet s com es out
st or eSet s r eady t o
Average time set in system
# sets ready to store
Average cost of resources
0 0 0 0
0 0 0 0
0
0
0
0
0 0 0 0 0 0 0 0 0
0
0
0
0
0
0 00
0
0
Nu mb er o f rep ro cessed sets
Ti me14401380132012601200114010801020960900840780720660600540480420360300240180120600
Set
s
0
S C A N N E R
S C A N N E R
S C A N N E R
S C A N N E R
0.00
0.00
0.00
Simulation results comparison
22
30 replications 24hrs each
407
14
341
375
519
16
353
387
0
100
200
300
400
500
600
All resources.busycost
System number out Set.VA time Set.Total time
RFID
Barcode
Traceability system: value proposition
23
Reduce: - Packing time - Storage level - Counting time - Set accuracy
- Free up time for medical care - Proactive alert to ensure sterile process - Reduction of retain surgical instruments
Reduce: - Instrument disappearance - Surgical cancelations - Cost of repeated surgeries - Lawsuits
Toward a smart hospital
With RFID…
– Upstream traceability
– Fast recall
– Patient safety
– Accurate statistics
– Cost neutral
24
What is management’s perception about cost of
RFID and ROI?
Thank you!
UQAM, School of business 315 Ste-Catherine est Montréal (Québec) Canada H2X 3X2
Afrooz Moatari-Kazerouni moatari_kazerouni.afrooz@courrier.uqam.ca
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