Perioperative Enterprise:
Re-Designing Ambulatory Surgery
Center Supplies Replenishment
Presenter: David Bivens
Team Members
Materials: Lisa McMillian, Lauren Smoke, Patrice Jordan,
Brodrick Thompson, Mary Murray
Supply Chain: Jim Ishikawa
IT: Wade Altman, Craig Owen, Keith Shook, Irvin Serra
Institution
The University of Texas MD Anderson Cancer Center
So What Kind of Project is This?
• Focus: OR Supplies Management
• Involves:
– Physical setup of supplies storage
– Path Supplies take to arrive in the OR
– Supplies ordering process
Geographical Proximity of the Main
and Ambulatory ORs
Main OR &
Supplies Storage
Ambulatory Surgery
Center & Supplies
Overview of Baseline Condition
• 2 Locations Performing Surgical Functions
– Main OR
• Supporting 29 OR Rooms plus the Ambulatory Surgery
Center
– Ambulatory Surgery Center (ASC)
• 6 OR Rooms
• 1 stock location
– Supplier Ordering and Receiving in Main Only
• Automated, receipts daily
– Ambulatory Surgery Center orders from Main OR
Stock
• Manual ordering requisitions to Main OR daily
Geographical Proximity of the Main
and Ambulatory ORs
Main OR &
Supplies Storage
Ambulatory Surgery
Center & Supplies
Catalyst For Starting the Project
• Why did we start this project?
– Logical 2nd Step of a project that separated the two
electronic stock locations in our OR Management
Software
– Large quantities being returned to Main OR
Stockroom
– Some Items getting close to expiration
– Backup staff from Main stockroom struggling with
workflow demands unique to the ASC
Baseline Conditions:
ASC Workflow
• Only Generalized Work Processes
• No Standard Way to Perform a Task
– What is the effect?
• Inconsistent service to the Operating Rooms
• No documentation for consistent training
• No “Best Method” from a quality and performance
standpoint
• No clearly defined pars
– Result: Too Much and Too Little
• $’s tied up, expired material, lots of expediting
Baseline VSM
Suppliers
Email to Main
Warehouse &
Finance
Lawson
I
1 hrs
Main
Whse
Receipt
I
12 hrs
2
Pick for ASC
Re-Supply
3
I
2 hrs
C/T=60min
Delivery
to ASC
1
I
ASC Whse
Receipt
8 hrs
1
C/T=180min
C/T=60min
C/T=40min
Re-Supply
Order
Generation &
IDT
1
Processing
1
C/T=85min
I
4 hrs
Pick for
ASC Sched.
Cases
3
C/T=75min
Non Value Added
Lead Time (waiting)
720 min
120 min
480 min
26 Hrs
240 min
Processing Lead
Time (activity)
40 min
60 min
60 min
180 min
85 min
7.1 Hrs
Total Lead Time
33.1 Hrs
Baseline Data
• Inventory Level
– Total Inventory on hand $ 322,500
– This equates to a days on hand of….
>30 days = 620 SKUs,
>60 days = 546 SKUs,
>90 days = 504 SKUs
... out of 1210 total items
– In Terms of Dollars
$ > 10 days = $186,830
$ >15 days = $118,979
$ >20 days = $51,128
• The Opportunity?
– Set a goal of 30% reduction in On-Hand Inventory
Aim Statement
“To reduce the amount of supplies transferred
from the main POE materials center to the
ASC materials location by 50% by August 31,
2011”
Secondary Aim
“To reduce the inventory on hand in the ASC
materials location by 30% by August 31,2011
through improved par management”
ASC Ishikawa Exercise
Personnel
Physical Space
Item used once,
never again
Can’t find item
when needed
Items not
logically
organized
Space
crowded with
supplies
Item in wrong
location
In wrong qty
Not
enough
Nothing to help
determine how
many to order
Too much
Item stocked
and seldom
or never
used
Main uses
handheld, ACB
doesn’t
Nothing to show
what’s already
been ordered
Tools
Staff perform
tasks differently
Staff Training
Communication
with main
Scheduling
AddOns
Non-typical
procedure
Pars not set for the
majority of items
Have to ask Main
what to order
Excessive
searching
Multiple items in
same bin or
location
Methods
Not always as
timely as
necessary
Sub-Optimal ASC
Supply Management
Re-Ordering is
completely manual
No Standard
Work Processes
Locations not in
Picis OR Manager
so can’t “look-up”
where item is in
storage area
ASC Ishikawa Exercise
Physical Space
Can’t find
item when
needed
Items not
logically
organized
Item used once,
never again
In wrong qty
Nothing to help
determine how
many to order
Too much
Main uses
handheld, ACB
doesn’t
Communication
with main
Scheduling
Item stocked
and seldom
or never
used
Nothing to show
what’s already
been ordered
Tools
Staff Training
Space
crowded with
supplies
Item in wrong
location
Not
enough
Personnel
Staff perform
tasks
differently
AddOns
Non-typical
procedure
Pars not set for
the majority of
items
Have to ask Main
what to order
Excessive
searching
Multiple items
in same bin or
location
Methods
Not always as
timely as
necessary
Sub-Optimal ASC
Supply Management
Re-Ordering is
completely manual
No Standard
Work Processes
Locations not in
Picis OR Manager
so can’t “look-up”
where item is in
storage area
VSM Idea Sheet
Suppliers
Email to Main
Warehouse &
Finance
Lawson
I
1 hrs
Main
Whse
Receipt
2
C/T=40min
I
12 hrs
Pick for ASC
Re-Supply
3
Delivery
to ASC
I
2 hrs
1
Double Handling
of ASC
C/T=60min
Supplies
I
ASC Whse
Receipt
8 hrs
1
C/T=180min
C/T=60min
Re-Supply
Order
Generation &
IDT
1
Processing
Manual
Re-Ordering
-can we use
barcode
scanner?
1
C/T=85min
I
4 hrs
Pick for
ASC Sched.
Cases
Manual
IDT Process
3
C/T=75min
Non Value Added
Lead Time (waiting)
720 min
120 min
480 min
26 Hrs
240 min
Processing Lead
Time (activity)
40 min
60 min
60 min
180 min
85 min
7.1 Hrs
Total Lead Time
33.1 Hrs
VSM: Future State Plan
Suppliers
Utilize Barcode scanner
for ordering JIT items
Email to Main
Warehouse &
Finance
Lawson
I
1 hrs
Main
Whse
Receipt
I
12 hrs
2
Pick for ASC
Re-Supply
3
I
2 hrs
C/T=60min
Delivery
to ASC
1
I
ASC Whse
Receipt
8 hrs
1
C/T=180min
C/T=60min
C/T=40min
Re-Supply
Order
Generation &
IDT
1
Processing
1
C/T=85min
I
4 hrs
Pick for
ASC Sched.
Cases
3
C/T=75min
Non Value Added
Lead Time (waiting)
720 min
120 min
480 min
26 Hrs
240 min
Processing Lead
Time (activity)
40 min
60 min
60 min
180 min
85 min
7.1 Hrs
Total Lead Time
33.1 Hrs
Project Timeline
2010
Milestone
Baseline Phy. Inventory
Project Initiation
Testing
PAR Analysis & Decisions
Phy. Inventory Setup
Begin Ordering from ASC
Begin deliveries
JIT Barcode ordering
Post Implementation Phy. Inv.
2011
Mar. ---> Jul. Aug. Sep. Oct. Nov. Dec. Jan. Feb. Mar. ---> Aug.
PAR Analysis
• Based on a combination of actual usage
documented in the OR Case Record and staff
review for validation.
• PAR calculations:
– If JIT: PAR = (Avg. Day) + (Highest Day)
– Non-JIT: PAR = (5) x (Avg. Day)
Both were rounded up to next Order Unit, either
each, box or case
Sample of PAR Analysis
Cat #
8881-220100
DYNJ05132
31142527
1808060
26006M-D/10
7541
006775-901
1600
138659
FCS9
1706060
29410
Desc.
QOH
12 mo.
Usage
(ORMgr)
NEEDLE Spinal 22g x 3 1/2"
77
ACE Wrap 6" Sterile
34
ENDO Fog Prevention Dr. Fog
10
POWER PORT isp M.R.I. 8Fr Chronoflex Single
15Lumen
CABLE HI-FI W/8MM PLUG 300CM
13
COVERLET 4 x 8
50
ACMI Dolphin Collection Kit
24
Catheter Plug
30
CAUTERY PENCIL FOOT CONTROL 10ft.
43
HARMONIC FOCUS Shears Curved,Torque/Grip
30 9mm
PORT Power isp 6Fr
10
SHEET Laparotomy Disposable
20
31
14
46
70
61
235
116
186
267
196
463
1022
Highest
Avg/ Day's Usage Days on
Day
(in OU's)
Hand
0.12
0.06
0.18
0.28
0.24
0.94
0.46
0.74
1.06
0.78
1.84
4.07
2.0
0.2
0.1
2.0
0.4
7.0
1.0
6.0
0.2
0.8
5.0
0.6
623
610
55
54
53
53
52
40
40
38
5
5
New Stockroom Setup
Barcode Scanning Replenishment
• No more scrolling through each item or typing items and
quantities
• Just scan locations needing re-supply and type in quantity
remaining
Job Guidance Sheet: New Process
• Posted in the
Work Area
• Training Aid
• As-Needed Quick
Reference
Data Over Time:
Revisiting the Aim Statement
“To reduce the amount of supplies transferred
from the main POE materials center to the
ASC materials location by 50% by August 31,
2011”
So, using QI Analyst software an Individuals and
Moving Range chart was created to monitor
the progress.
IDT History Prior to Intervention
Total:
19
Rows:
All
Std Dev :79.211
CpM : N/A
CpK: N/A
Est % out SL (Cap) : N/A
Act % out SL: N/A
Dist:Normal
X-Bar298.478
:
Est Sigma:44.308
Sigma Type: N/A
MR-Bar :49.996
Supply IDT's to ASC (per case adjusted): Baseline Process
Baseline
500.0
Nov. 10’: PAR
Analysis
450.0
UCL=431.402
Mar. 10’:
Baseline Physical
Inventory
400.0
Individual Values
Process Statistics
350.0
July 09’:
First Data
Available
300.0
CL=298.478
250.0
Jan. 10’: Physical
Inventory Setup
200.0
LCL=165.554
150.0
Label:
200.0
Moving Range
Chart Point
UCL=163.314
150.0
X:
X UCL:
X CL:
X LCL:
MR:
100.0
50.0
CL=49.996
0.0
LCL=0.000
1
2
3
4
5
6
7
8
9
10
11
Point Number
12
13
14
15
16
17
18
19
Intervention Timeline
Monthly IDTs to ASC (per case adjusted): Baseline & Post Implementation
Baseline
500.0
450.0
July 09’:
First Data
Available
400.0
Individual Values
350.0
New Process
Nov. 10’: PAR
Analysis
300.0
250.0
200.0
UCL=181.477
Mar. 10’:
Baseline Physical
Inventory
150.0
100.0
CL=85.009
Jan. 10’: Physical
Inventory Setup
50.0
0.0
LCL=-11.460
-50.0
Moving Range
250.0
200.0
150.0
UCL=118.524
100.0
50.0
CL=36.284
LCL=0.000
0.0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Point Number
Intervention Timeline
Monthly IDTs to ASC (per case adjusted): Baseline & Post Implementation
Baseline
500.0
450.0
July 09’:
First Data
Available
400.0
Individual Values
350.0
New Process
Nov. 10’: PAR
Analysis
300.0
Mar.11’: Start
JIT handheld
Ordering
250.0
200.0
Mar. 10’:
Baseline Physical
Inventory
150.0
100.0
0.0
UCL=181.477
CL=85.009
Jan. 10’: Physical
Inventory Setup
50.0
-50.0
LCL=-11.460
Aug. 11’: FollowUp Physical
Inventory
250.0
Moving Range
Feb.11’:
Begin Direct
Ordering/
Receiving at
ASC
200.0
150.0
UCL=118.524
100.0
50.0
CL=36.284
LCL=0.000
0.0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
Point Number
VSM: New Current State
Suppliers
EDI to Vendor
Replenishment
Order
Lawson
Email IDT to
Finance
I
1 hrs
Re-Supply
Order
Generation &
IDT
1
Processing
1
ASC Whse
Receipt
C/T=61min
1
Lead Time Reduction of
24.8 hrs & Labor
Reduction of 3.1 Hrs per
Day
C/T=180min
I
4 hrs
Pick for
ASC Sched.
Cases
3
C/T=75min
Non Value Added
Lead Time (waiting)
720 min
120 min
480 min
4 Hrs
240 min
Processing Lead
Time (activity)
40 min
60 min
60 min
180 min
75 min
4.3 Hrs
Total Lead Time
8.3 Hrs
Results – Primary Aim
• 71.5% Reduction in transfers from Main to
ASC ($298/case to $85/case) through 8
Months of post implementation data available
– (Feb. ‘11 through Sept. ’11).
• Looking at the last 6 months to get beyond the
learning curve, transfers have reduced by
79.9%, exceeding goal by 59.7%.
– This translates to a labor savings of $47,376
annually
Chart of Total Transferred by Month
Go Live
Results – Secondary Aim
• 48% Reduction in on hand inventory.
• This is a reduction from the baseline physical
inventory of $322,534 to $169,220 recorded in
the first post implementation annual
inventory (Aug. 31, 2011).
• The goal of a 30% reduction in on-hand
inventory has been exceeded by 58%
Next Steps?
 Explore Implementing bar code scanning
replenishment in the main POE Materials
location proved out at ASC.
 Re-Allocate some of the staff hours gained by
the project to case cart picking of
instruments. This would free Sterile
Processing staff to focus on improving
instrument set turnaround time and quality.