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Central Services by Julie E. Williamson Surgeons aren’t exactly shy about communicating their demands and vocalizing their concerns in the operating room. But when it comes to the functionality, quality and usability of surgical instrumentation, such complaints are certainly justified. A malfunctioning instrument poses problems on numerous fronts. Not only can it prevent a surgeon from performing the procedure properly – and, as a result, place the patient at unnecessary risk — it can also result in costly delays or cancellations of surgical cases. Beyond that, a severely damaged device often requires total replacement, which can drive a hospital’s costs up further.
While one would assume that hospitals would be doing everything possible to minimize the risks and complications related to surgical instrumentation, and maximize their investments, that isn’t always the case. In fact, malfunctioning, misaligned and poorly maintained instruments remain one of surgeons’ biggest complaints, sources told Healthcare Purchasing News. "It’s an enormous and costly problem that still isn’t being addressed properly by many facilities," said David Cabral, director of new business for Five Star Surgical Inc., New Bedford, MA. He noted that inferior scissors, sticking rongeurs and laparoscopic instruments with debris in the shafts are commonly reported complaints. "It’s a shame because proper care and maintenance of the instruments can mean a lot less expense, stress and headaches down the road," Cabral continued.
Indeed. According to figures from Cardinal Health, investing just $1 in preventive maintenance services on the front end will prevent $2 being spent in repairs on the back end. That expense will be far more if the device needs to be replaced entirely, added Alex Vrancich, general manager of Spectrum Surgical Instruments Corp., Stow, OH. "Many facilities are
still waiting for an Partners in education Although repairs are, of course, a hearty revenue source for service organizations, many instrument manufacturers and third party repair companies are becoming increasingly committed to teaching customers how to avoid or at least minimize those costly fixes. "Normal wear and tear is going to happen, but many of the larger problems can be prevented with education," said Scott Kabanek, vice president of equipment sales and service for Instrument Specialists Inc., Boerne, TX. "If a repair company or OEM isn’t willing to provide hands-on education and training, my suggestion is to go elsewhere." According to Vrancich, the goal is to build long lasting partnerships that are based on trust. "Education has and always will be a big part of what we do. We believe it’s imperative that everyone who handles instrumentation understand how the instruments should be cared for. They should also understand why an instrument needs service and what led to the problem." He stressed that ongoing training is critical, particularly because of high staff turnover in sterile processing departments and the continuously evolving technology that makes instrument management more challenging. Mobile Instrument Service & Repair Inc., Bellefontaine, OH, also subscribes to an educationally-focused approach. The company’s technicians routinely train hospital personnel regarding proper care and handling of instruments, and Mobile Instrument also offers continuing education self-study guides for the O.R. staff. Interdepartmental education appears to be the best approach. As Gregg Agoston, sales manager, Protection 1 Services, Karl Storz Endoscopy-America Inc., Culver City, CA, explained, many technicians who are handling the equipment in the SPD haven’t had exposure in the O.R. to see how the equipment is actually being used. "Having the knowledge about that equipment and understanding how vital it is to the success of the procedure is a critical first step." Another important area of education, he said, is teaching SPDs the value of allowing technicians to become instrumentation specialists, as opposed to generalists who may, to the detriment of the instrument and patient, perform the same level of care and handling on a wide range of devices. That’s not to say that SPDs are solely responsible. Agoston added that there are instances where instruments aren’t properly tagged in the O.R. for repairs or service, or where surgical staff mishandle and subsequently damage the instruments before they entered the processing department. "Each department plays an important role in the proper care, handling and inspection of instruments." Technological challenges Repair vendors agreed that certain instruments, in particular, are causing the greatest headaches in the SPD and O.R., and wreaking havoc on hospitals’ budgets. Laparoscopic instruments, for example, are getting smaller, narrower and more delicate, and are making it increasingly difficult to properly disassemble, clean, disinfect and dry. What’s more, because they are so delicate, they simply cannot withstand being dropped or inappropriately transported and stored. "Surgeons’ satisfaction
in the performance of these instruments is frequently very low,
resulting in short life expectancy and an extremely high repair or
replacement cost ratio," explained Chris Sullivan, marketing director
for Cardinal Health’s OnSite "Microscopic cracks in the instrument insulation may not be visible, but can cause risks of patient burns. Biofilm and debris can also build up inside the instrument shaft creating potential safe havens for microorganism growth and risk of life-threatening infections." Cardinal Health’s OnSite Services offers an array of education services ranging from on location customer inservices to continuing education unit videos and study guides. Wall chart material and sterilization container services are also available.
Inadequate processing equipment may also pose a challenge in the proper management of laparoscopic instruments. "These long tubes with the actuation mechanisms inside are of close tolerance, which can prohibit ease of flushing," noted Cabral. "The new technologies in the marketplace have nicely addressed this problem, but not all facilities have purchased these high pressure flushers, ultrasonic cleaners or other dedicated systems." Many facilities have also failed to either address their shortage of instrumentation sets or properly keep track of the ones they do have available – a problem that places more strain on the instruments that are in rotation and makes them more susceptible to damage. "It’s the old 80/20 rule, where roughly 20 percent of instruments are used for 80 percent of procedures," explained Vrancich. "If we wore the same pair of shoes every day, they’re going to wear out quickly. Imagine what’s happening with that one scope that’s being used over and over again." Fortunately, vendor-provided education appears to be paying off. Vrancich said facilities are beginning to realize that repairs and maintenance are a necessary part of instrumentation ownership, and that repair budgets simply can’t be cut. He’s also seen more hospitals respond by increasing inventory and committing to routine preventive maintenance for frequently used instruments. Melville, NY-based Olympus America Inc. has also seen significant improvements in its customers’ own commitment to education and repair prevention within their facilities. "Olympus recognizes its role in helping customers identify areas for cost reduction. We see this particularly within the area of cleaning, disinfection and sterilization," noted Olympus vice president of Endoscopy Services, Eddie Garces. Olympus delivers a range of educational opportunities, including formal Olympus University courses, which offer continuing education units; VIP visits to service centers to learn about inspection and repair processes; and a new set of videos that emphasize proper reprocessing protocols. Olympus also has a dedicated team of Endoscopy Support Specialists whose job is work onsite with customers to increase efficiencies and reduce repairs.
The financial pay-off can be substantial. ISI’s Kabanek said one three-hospital health system cut its endoscopy repair bill from nearly $415,000 to just $125,000 in one year. Another facility was able to cut its fluid-related repairs from $140,000 annually to approximately $30,000. As yet another example, one Texas-based health system slashed its annual repair bill from half a million dollars to under $160,000. Kabanek credited much of that success to dedicated training, including at least quarterly inservices. Stepped-up services If the associated savings weren’t enough incentive for facilities to board the preventive maintenance bandwagon, healthcare organizations may be pleased to learn that instrument repair vendors are expanding their service offerings to give customers even more bang for their buck. That includes more skilled technicians and faster instrument turnaround times. Through its Protection 1 comprehensive repair services program, KARL STORZ provides Field Service Technicians, to the majority of its customers around the country. Each FST is factory-trained and carries a wide range of inventory parts to accommodate common repairs on location. Although the KARL STORZ FST can process repairs and replacements immediately, their true value is in the emphasis on education, damage avoidance, and preventive maintenance of KARL STORZ instrument trays and equipment. Through their on site PM Service, equipment lasts longer, is of higher quality and breaks less frequently. KARL STORZ has also developed the customizable Comprehensive Asset Management program that offers facilities enhanced assistance with the acquisition, management and maintenance of Karl Storz instrumentation and video equipment. CAM is for customers with adequate staffing to manage their instrument sets, but who would like to capture all costs for equipment, repairs and replacements in a single monthly bill. CAM offers repair and replacement of KARL STORZ reusable instruments and video equipment for a fixed monthly fee; scheduled visits from FSEs in covered markets; and staff training on the proper inspection, care and handling of KARL STORZ equipment. "We also offer CAM On-Site for customers who prefer to have a KARL STORZ technician manage their instruments and video equipment in house," Agoston explained. Olympus has also expanded its service offerings, including broadening its service network to 19 service centers that are strategically placed throughout the U.S. A set of enhancements to Olympus’ 24x7 web service portal, which includes automatic generation of shipping labels and greater visibility to repair histories, has also been added. "Olympus’ comprehensive software and new service portal enables efficient tracking and expediting of endoscope repairs," noted Garces. Beyond that, Olympus recently developed and introduced several new repairs, including minors and majors for the new EVIS Exera II 180 technology platform. The vendor also sets specific targets for turnaround times for the completion of all levels of repair. "Our motto is ‘In today, out tomorrow,’ which means in most cases Olympus can bring the equipment back to its original factory specifications within 24 hours," Garces said, adding that to further meet the needs of its customers, Olympus’ national sales center is open six days a week and operating on two shifts, beginning at 5:00 AM PST. Cardinal Health’s OnSite Services recently added to its service capabilities a repair-exchange program for critical cases where surgeons can’t be without instruments, such as bi-polar or Kleppinger forceps. "We also added the capability of diamond dusting for micro- and cardiovascular needle holders," noted Sullivan. "We also upgraded reporting capabilities for our instrument tracking software and now offer full repair capabilities for rigid and flexible endoscopes, power tools, video equipment and dozens of other surgical equipment accessories." Third party repair companies are also building on their services. Mobile Instrument has recently begun offering laser engraving for instruments, complete small diameter flexible scope repair, and Acuson transesophegeal probes for ultrasound equipment. Spectrum Surgical offers a new reporting and tracking system that shows customers where their repair and PM dollars are being spent, and also recently added the SpectraScan – a digital mapping system than digitally magnifies photos of repairs. "Not only does it allow technicians to see things that aren’t visible to the technicians in the hospital, the photos are terrific for education," Vrancich said. ISI prides itself on speedy turnaround times, with same-day to one-day service on minor repairs, one- to two-day turnaround time for minor flexible scope repairs, two- to three-day turnaround on intermediate repairs, and three- to five-day turnaround on major overhauls. Added Kabanek, "We offer a terrific loaner program, which includes the latest models, so our customers don’t have to do without while they wait for their instrument to be repaired." Five Star Surgical
offers 24- to 48-hour turnaround once instruments are received at its
facility. The firm repairs and restores all handheld instruments, rigid
scopes, "We realize that many facilities do not have an excess of spare instruments and must rely on a reputable repair vendor who can get their instruments out promptly," he continued. "We strongly feel that the customer should be working on their O.R. schedule, not the schedule of their repair vendor." Don’t short-change quality While competitive pricing and rapid turnaround times are understandably important to healthcare organizations, those factors should never trump quality. Like virtually every other service sector, there are good, reputable companies and those that put profits before quality service. For that reason, instrument manufacturers have become increasingly vocal about the value of true OEM service. As Olympus points out, the effectiveness of a surgical instrument repair program is often linked to root issues beyond the repair of the instrument itself. "Facilities that ignore instrument management disciplines or select repair providers solely on price frequently are disappointed in the quality of their instrument sets and in the quality of their repair and replacement expenditures." Agoston encourages customers to take a closer look at the instruments going out for service and being returned by the repair company, and to evaluate more closely what’s being billed. "I encourage customers to stay and watch what’s being done and see how long it actually takes to do an instrument. There are some very reputable guys out there, but there are some repair technicians who claim they can do an entire set of instruments in a very unrealistic time frame," he said. ISI’s Kabanek said he’d be the first to admit that not all third party repair companies are created equal – a fact that has made OEMs justified in their complaints, at least to a degree. "There are cheap parts available and quality parts available, and there are some purely profit-based firms that will use the cheaper versions that they know are inferior," he explained. "But there are also high quality, reputable companies that are fully capable of performing quality repairs and maintenance at a substantial savings. We don’t use anything unless it is an OEM part or an OEM equivalent, and if those parts aren’t available, we’ll be honest with the customer and tell them it needs to be sent to the OEM." Kabanek warned customers against companies that claim they can produce parts that exceed the original. "If they claim that, don’t believe it," he said, stressing that if a company’s part were to exceed the original, that would mean the OEM’s original design had been changed. Cabral expanded upon that point, explaining that the instrument repair function is a process that should be no different from the actual manufacture of that product, and result in an instrument that performs as new and originally intended, and is as safe as new. Cabral added that if he had a choice, he would recommend more stringent regulations on the instrument repair industry to help level the playing field and promote more widespread quality. "This way, we could meet and exceed set standards to ensure proper servicing, correct utilization and the utmost in patient safety." Mick Reed, president of Mobile Instrument, underscored the importance of partnering only with established repair companies with long-term track records in the industry. Reed stressed that some independent providers have the expertise to complete more sophisticated repairs, while others with minimal capabilities will tag the item "non-repairable" simply because they are ill-equipped or incapable. Asking specific questions, such as the qualifications and years on the job of the technician performing the repair and whether the company works on stainless steel, is also key, he said.An inexperienced technician can damage $30,000 to $50,000 worth of instruments before the department supervisors realize the inefficiencies and poor quality," Reed warned. "You do not want your major investment in instruments and equipment to become training aids for an inexperienced company and new technician." HPN
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