After my previous blog post, in which I shared an article that was published in the Journal of Healthcare Contracting that highlighted the work that my team and I did in regards to the optimization of preference cards as a ticket to savings, I had a few individuals contact me and ask,
“We have hold items that prevent against material from being opened in advance. Do you agree with hold items and why is this not enough to prevent against material waste?”
While in theory I agree with hold items, having hold items are a great process and practice, however, this effort is simply not enough. In addition, hold items may actually be negatively impacting your system in multiple ways, including the bottom line. If preference cards are not optimized prior to labeling surgical items as “hold items,” and the process is not done with the correct due diligence and data to drive the process, there may be many unnecessary and unwanted results from this process.
For those unfamiliar with the term, hold items are items that are on the Physician Preference Card, and are picked by Central Sterile and placed on the case cart. These items go through the same issuing and picking process as regular items or non-hold items that are identified for a surgical procedure. Items that are identified as “hold items” for a respective individual case or procedure are typically only handled differently after the case cart is issued to the room (hold items may be placed on a different level or bin in the case cart) prior to the material being opened in advance of a case. Being marked as hold means that these items are not to be opened or taken out of their packaging until they are requested by a physician during, or just immediately before the procedure from beginning. A visual control or color coding process may also be implanted instead of hold items, to identify items that are issued to a case, but are not to be opened in advance of the case.
Hold items are a good practice as they can mitigate material waste and can prevent against material possibly being unintentionally opened in advance. These marked items are typically seldom used throughout the respective case, or may rarely be used for this respective procedure. They are often items that can come in multiple sizes and only one size will be used; however, the size is patient specific and will have to be determined by the physician immediately before the case begins.
Getting back to the question, again, while it is a good practice and process to identify items as hold items this simply is not enough and will not allow your system to achieve a great financial savings. As I previously mentioned, hold items may actually be increasing your overall costs. A main issue with only marking hold items and hoping that this will provide savings, is that marking hold items does not optimize preference cards, which is what leads to many inefficiencies.
The real ticket to savings comes from the optimization process of the preference cards. Not having optimized cards or optimized hold items will increase the amount of overall transactions in issuing items and will increase the overall amount of returns. The re-stocking of these returned items is a non-value added activity, and causes unnecessary waste. Having more items than necessary being issued to the case initially increases the amount of time it takes to pick and select the material to build the case cart. This increases not only the time per case metric, but financially impacts labor costs, as a higher amount of resources are needed to pick the amount of “unnecessary” material requested.
Once the case cart is issued with excessive material, regardless of hold-items or not, a non-optimized preference card will cause excessive sorting and unnecessary time spent by clinical resources searching for the desired product either in their initial setup or during a procedure. This process of having to sift through products, not only makes it very difficult on clinical resources to find the correct product, but also can increase the overall time of the procedure, having many negative impacts, including scheduling and increasing turn-around times, as well as many other clinical and personal ramifications that may emerge due to this delay.
Inefficient issuing of materials also increases the likelihood of the product being damaged, due to excessive handling. Once the case is complete and the item is not used, the item then has to be returned to Central Sterile and re-stocked on the shelf. This re-stocking process causes increased overall touch points and additional non-value added handling, eliminating any type of efficient process that may have been implemented.
There are also additional costs incurred in the re-sterilization and re-processing in order to restock this item. Not only does the sterile integrity of the product become questionable, there are large financial costs involved in this inefficient process, increasing labor and utility costs as well as material spend.
Depending upon the current processes in place, the inventory system and replenishment methodology used by the system, there is a strong likelihood that this inefficient preference card is adding to your overall inventory amount held. As reordering counts are usually performed throughout the day, the returned items, whether hold or non-hold, can cause inaccuracies in these counts causing excessive inventory levels to be held.
Inefficient preference cards also cause problems in being able to identify an accurate cost per procedure. It is common to see excess inventory held and inventory inaccuracies correlated to items with that are commonly identified as hold items. So again, while hold items are a great process to prevent items from being unnecessarily opened in advanced, and not used, there are many adverse effects if the hold items and preference cards are not optimized prior to identifying hold items.