Team CS captures ‘heart and soul’ of Virginia Mason
By Rick Dana Barlow

Cutting costs and streamlining operations while maintaining high quality performance outcomes are lucrative bottom-line exercises for any central service/sterile processing and distribution (CS/SPD) department, no matter how large or small the department or the facility.

But developing and implementing a strategic plan that positions departmental activities into context within the entire organization and cultivating a healthy sense of self-worth based on the group’s contributions to patient care are priceless.

The central services department at Seattle-based Virginia Mason Medical Center, an integrated delivery network (IDN) in the Pacific Northwest, understands all of this extremely well and for the last few years has put it into effective practice with hard work, simple solutions, sweat equity and industrial examples. Surprisingly missing from the department’s signature of success? High-technology assistance.

These impressive efforts and resulting achievements are what earned Virginia Mason’s central services department the vaunted designation of Healthcare Purchasing News’ 2004 CS/SPD Department of the Year.

Providing sterile processing and supply distribution services to a 336-bed hospital and two clinic pavilions containing physician offices and outpatient services; and supply distribution services to nine satellite clinics containing physician offices, outpatient services, ambulatory surgery centers and other support services, and a facility for patients living with AIDS, Virginia Mason’s self-titled "Team CS" makes its presence known throughout the IDN in words and deeds.

"We’re pretty ambitious as a CS department," said Cheryl Reagan, R.N., director of central services. She helped spearhead the adaptation of Virginia Mason’s strategic plan to CS activities to promote departmental activities, support administration and align their direction with top management. "We use our plan to show us as the heart and soul of the organization. No one can do their work, which is providing quality patient care, without us. Everything they touch they get from us so we have to get it right. It’s a lot of responsibility. But we see ourselves as the core of the hospital. We are the beating heart."

A "triangle" guides Virginia Mason’s CS through decisions and daily work. Perched at the top is the patient. Capping the triangle is the department’s vision, mission and values. The pillars of CS’ strategic plan "focus on recruiting and retaining the best staff, pursuing the highest quality products, insisting on extraordinary service and promoting a culture of innovation. Various work groups and tools to achieve these goals form the foundation of the plan. Team CS regards none of this as management hooey.

"We find it to be a good road map for us," said William Anderson, Virginia Mason’s manager of distribution. "It keeps us focused on our daily activities to provide our caregivers what they need when they need it."

Reagan’s central services team comprises two main subgroups: CS sterile processing and linen under Andrew Baylor, manager; and distribution under Anderson. "Our staff is really proud of working together to get the job done for our customers," Reagan said. "Andrew and Bill work hard to encourage teamwork."

Their efforts seem to make available employment slots a hot commodity. "Within the last four years or so whenever we have openings in our department there’s a real clamor to get in with us," Anderson said. He attributes part of the attraction to the scope of their responsibilities. "My crew touches between $10 million and $12 million in [just-in-time] stock and another $8 million in non-stock items," he noted. "They virtually touch everything that comes into the system and that’s intriguing to people."

Asian industrial examples
Rather than turn to healthcare consultants and distributors for direction on just-in-time (JIT) supply management, Virginia Mason as an organization and its CS team, looked to Japan – specifically the "lean thinking" philosophy pioneered by Taiichi Ohno and permeating the production assembly line at Toyota.

The IDN modified the Toyota Production System for healthcare operations and renamed it the Virginia Mason Production System, which CS adapted for its own improvement. The department targeted productivity, walking distances, parts traveled distance, safety, work-in-progress, inventory and physical space and devoted special emphasis on the value stream, which represents a conceptual "map" of a process, and to the definition of standard work.

"The whole idea behind lean thinking is getting rid of waste by working on processes and refining them," Reagan said.

Virginia Mason remains so staunchly committed to lean thinking that the organization has dispatched teams of top executives to Japan on several management-intensive 14-day trips during the last few years to learn first hand the specifics from such companies as Toyota and Hitachi. These aren’t leisurely junkets, Reagan assured, but serious business ventures that have led to top- and bottom-line improvements. Unlike the popular Six Sigma management philosophy, which tackles large processes, lean thinking looks at smaller processes, she said, enabling them to identify and ultimately drive out waste.

"Rather than a mile wide and an inch deep this is an inch wide and a mile deep," Anderson added.

Virginia Mason uses cross-functional, multidisciplinary work teams that gather for five days in Rapid Process Improvement Workshops (RPIW) to analyze procedures, processes and performance facility wide and make improvements using lean thinking as a guidepost. CS conducts its own internal improvement seminars, which has led to efficiencies in its four primary functional areas: Sterile processing, supply distribution, linen and equipment.

"These workshops represent the bread and butter of our lean thinking philosophy," said Andrew Baylor, Virginia Mason’s manager of CS sterile processing and linen.

"One of the benefits of lean thinking is that it’s made us aware of thinking outside the box and eliminating sacred cows," Anderson noted. "Before [lean thinking] it would take years to implement improvements. Now it takes a matter of days."

Agreed Reagan: "It’s a powerful way to change things very quickly."

Cleaner operations
Baylor’s group relied on lean thinking to increase sterile processing productivity and maintain quality as surgical cases grew in volume and complexity. When the staff looked at the process of set assembly, according to Baylor, they found that the highly skilled instrument technicians were frequently interrupted, lacked teamwork and often participated in tasks that required little skill or training to accomplish. As a result, Baylor’s team established a "waterspider" or "waterstrider" role to solve problems.

Typically, staff members responsible for assembling surgical sets complete their tasks in individual workstations where they remain for an entire shift. CS technicians serving as waterspiders, named for the bugs that can literally walk on water, select the next set for assembly, print a computer-generated recipe, prepare the set for assembly and perform an initial assessment for cleanliness, Baylor noted. Then an instrument technician takes over and physically assembles the set, which includes a second check for cleanliness. Once that set it complete the instrument tech moves to the next available standard table already set up for them and focuses on accurate assembly. Baylor called it a true team-based approach to set assembly.

"We’re really into mistake-proofing our processes," Reagan said. "We’re trying to catch them ahead of time before they reach the patient."

CS also used lean thinking to improve turnover rates with the operating room. CS considers turnover to be "any set that needs to be processed in less than the normal reprocessing time due to limited resources," according to Baylor. Prior to the RPIW used to examine the process OR staff were frustrated with CS’ performance and CS staff "were frustrated that the OR called too frequently, provided incomplete information and asked CS to hand-wash items even though sufficient time was available to machine wash and sterilize the items," Baylor noted.

The RPIW led to improved communication between the two departments, including process signals and written tools to prevent sub-standard reprocessing procedures.

Baylor’s team also reduced the number of instruments in minor sets by 50%, as well as the number of available sets in use to five from seven. The effort increased operating efficiencies in both the CS and OR, Baylor indicated. The team plans to address major sets next.

This year Baylor’s team also tackled the number of missing tags on surgical instrument sets. An initial audit in January identified 97 missing tags. By July, improved ordering methods and educational tools dramatically dropped that number to 17. By year’s end CS hopes to reduce that number further to less than 10.

Anderson adopted the waterspider concept within the distribution area, too. In fact, they also convinced their primary distributor, Owens & Minor Inc., to implement the concept in order to handle Virginia Mason’s low-unit-of-measure supplies, he said.

Low-tech logistics
Anderson’s team in distribution also racked up a number of operational and process efficiencies through lean thinking and without the use of costly technology.

Their secret weapon? A simple tool called a kanban (pronounced "kahnbahn"). It’s a colored card placed at a reorder point in a bundle or stack of supplies. Once the kanban is reached the card is pulled and placed in a collection bin checked by CS regularly.

"We integrated the kanban ordering system into our PAR supply areas, and it helps us identify JIT and non-stock items," Anderson said. "We would love to automate this process but we don’t have a platform to support that kind of technology."

Reagan admitted that the computer system they use is rather antiquated but that they’re not able to upgrade or replace it at this point. As a result, CS had to rely on its own creativity and ingenuity to improve processes. Anderson acknowledged that his long-term goal is to implement radio-frequency identification tags.

The distribution team also implemented a "grab-and-go" cart system as a way to facilitate one-piece-flow and decrease required processing. Here’s how it works. Owens & Minor, who signed with Virginia Mason back in January, picks items based on department-level orders. When Owens & Minor delivers the orders to Virginia Mason Anderson’s team moves the stock directly to the ordering department. "We’ve eliminated the stage-and-sort process here and don’t have to break bulk," Anderson noted. Owens & Minor started supporting the project in June. Virginia Mason’s previous vendor, Cardinal Health Inc., originally worked with the facility to make it happen.

CS also is trying out a consignment-like program with Owens & Minor where the distributor owns and manages the inventory until the facility actually uses it. Reagan said they’re working with a cancer unit on the clinic side with the ultimate goal of potentially rolling it out throughout the organization.

Clinical trouble shooters
While many of the process improvements implemented by Team CS certainly enhanced their relationship with their clinical department customers, another key strategy made a difference: Two registered nurses who serve as supply specialists. They help evaluate new products, concentrating on safety, effectiveness and cost savings. They provide 24-hour educational services during product implementations. They serve as the liaison between the clinicians, CS and the vendors. They work closely with materials management (which also staffs physician assistants in similar roles) and CS regarding product recalls and defective equipment. One specializes in the nursing areas; the other in the OR, cardiac catheterization laboratory and interventional radiology. Together, they represent an enterprise-wide consulting service.

"They really brought a lot of credibility to our department," Reagan said. "They make sure that the physicians and nurses always have a place to go and talk about a concern. Having two people with clinical backgrounds is important, too."

In fact, working with materials management the supply specialists helped the organization cut more than $755,000 in costs throughout 2003. One example involved changing vendors and standardizing IV start kits, which realized $55,000 in savings.

Outsourcing opportunities
Virginia Mason targeted linen and equipment as two areas where the organization could rely on external companies to assist in managing those operations internally.

Baylor oversees linen management but actual processing takes place at an offsite linen service consortium called Hospital Central Services Association. Virginia Mason owns 20% of the shared service organization, which processes more than 2 million pounds of linen annually for the facility. HCSA has enabled Virginia Mason to cut in half the amount of space needed for linen storage, even for emergencies. Baylor’s team also employs a "grab-and-go" system for linen in much the same way Anderson’s group uses it for supplies.

Seven hospitals own HCSA and eight additional facilities use the consortium for their linen service.

Virginia Mason tapped Universal Hospital Services (UHS) to provide staff to pick up, clean, charge, track, maintain and deliver pumps and durable patient care equipment to the facility. UHS owns the equipment, which Virginia Mason leases from the company. That decision enabled the facility to avoid a $1.3 million capital outlay when it upgraded to new pumps last year and this year, according to Baylor. Through UHS customer satisfaction with CS remains high throughout the organization, Baylor said. The department also facilitated online equipment ordering to save time and minimize errors.

Charity and visibility
Virginia Mason’s Team CS values its charitable contributions, too. It has collected and donated thousands of dollars to the American Heart Association and United Way. Team CS also donates outdated and surplus equipment and supplies to World Concern, which redistributes the material to needy countries.

Reagan, Anderson and Baylor all agree that these efforts reflect and reinforce their group’s commitment to patient care.

But Team CS also remains steadfastly behind accuracy and quality performance through visual signals and alerts that lead to improved standard workflow. "Simply putting a policy into place isn’t enough," Baylor noted. Team CS puts it into practice. These efforts help Virginia Mason understand the complexity of CS functions and the vital role it plays, which generates respect for a profession that sorely needs it.

"We’re so visible throughout the enterprise," Anderson said. "The staff here know that they can come to us for virtually everything. We’re proud that CS can make it happen. It has been a feather in our cap for years. Even if something doesn’t involve CS expertise directly we’ll figure out a solution."

Concurred Reagan: "We don’t pass the buck. They know we’ll answer the telephone. If we can’t solve something ourselves we’ll find out who can." HPN