JOINT BASE SAN ANTONIO-FORT SAM HOUSTON, Texas —
Brooke Army Medical Center at Joint Base San Antonio-Fort Sam Houston has returned to full surgical capability after implementing a number of initiatives aimed at further improving surgical care.
BAMC is back to averaging 65 to 70 surgical cases per day. The hospital scaled back its surgical procedures by about 50 percent last spring to conduct a full-scale review of end to end processing and quality standards, said Brig. Gen. Jeffrey Johnson, BAMC commander.
“We want to be proactive, ensuring we are able to meet safety and quality requirements our patients expect and deserve,” the commander said. “We implemented a deliberate full-scale review with our patients first and foremost in mind.”
A few key indicators triggered the surgical slowdown, including a backlog in unassembled, sterilized surgical instrument sets and pre-surgery instrument sterilization concerns.
BAMC’s Sterile Processing and Distribution, or SPD, division is charged with sterilizing all instruments for in and outpatient surgeries and procedures throughout the hospital and outlying clinics. The division processes about 14,000 surgical instrument sets per month on average, according to Lt. Col. Patricia O’Neal-Mellen, SPD chief. Surgeons request anywhere from two to 26 sets per surgery depending on the complexity of the case.
SPD is an integral part of the surgical process, O’Neal-Mellen noted. “It touches every area of the hospital,” she said.
The labor-intensive process starts in the operating room, where the OR technicians are charged with ensuring instruments are kept clean throughout the surgery. After the surgery is completed, OR technicians wipe off the instruments and spray them with an enzymatic cleaner before handing them off to SPD.
Once in SPD, technicians decontaminate the instruments, run them through a washer/disinfector machine, and then dry, wrap, and send the instruments through a high temperature sterilizer, while documenting and logging all sets through an electronic tracking device. “Intense, detail-oriented” quality checks take place at every step of the way, O’Neal-Mellen said.
With each set taking up to an hour and a half to sterilize and process, SPD has a “daunting task to undertake each day,” she said. The complexity of our instruments supporting advanced surgical procedures performed at BAMC has dramatically increased adding to the importance of the SPD mission.
Starting last spring, SPD began to run up against a rising backlog tied to personnel, equipment and processing inefficiencies, explained Col. Eugene Christen, chief, Department of Operative Services. Over time, the SPD staff became challenged in meeting the increased set demand as surgeons focused on meeting patient needs and completing repetitions to ensure their readiness to deploy in support of military operations.
At the same time, OR personnel began to raise some instrument sterilization concerns discovered in their quality checks – all prior to patient use, Christen said. “Their early detection is a great tribute to our OR staff and their attention to detail.”
The sterilization concerns, coupled with the backlog, signaled an immediate need to leadership for a surgical slowdown to ensure experts had the opportunity to conduct a full review of the entire surgical services process, Christen added.
“Our aim was to ensure the absolute highest quality of surgical services every step of the way,” he said. The slowdown postponed elective surgeries to enable BAMC’s trauma and urgent care mission to remain unaffected, he added.
The review started with a close examination of SPD processes and personnel, Christen said.
“We took a close look at staffing, schedules, equipment and workflow,” he said. “While we felt confident we could get to the root of the issues, we also invited in experts from The Joint Commission and Army Medical Command headquarters for an additional, external perspective.”
As a result of the review, BAMC increased the current SPD staff by 25 percent with 24 personnel and increased the “leadership footprint,” Christen said. The division also added a fourth shift to provide an extra layer of coverage during the busiest surgical times of the day.
BAMC also instituted a number of improvements to an already intensive sterilization process to include increased quality checks, equipment additions and updates, and a closely monitored tracking system to ensure accountability for surgical sets from the OR to SPD and back again.
“We call this our ‘point of use’ policy,” Christen explained. “By knowing who has hands on each set at every point … if there’s ever an issue, we can make quick corrections to processes and quality control.”
“Point of use” refers to the cleaning the OR technician completes in the OR before SPD receives the set. Chain of custody tags are attached to each set annotating who has touched the set.
Additionally, SPD examined its configuration to enhance the workflow and worked closely with OR personnel to improve the lines of communication. “Each day we review the list of cases for the next day and start supplying case carts to ensure we’re all set for each case,” Christen said. “We work methodically and professionally to ensure a precise outcome.”
The key to this entire process was collaboration, Christen emphasized. Leaders, surgeons, OR and SPD personnel were involved at every step of the way, he said.
This was a tremendous team effort,” Christen said. “SPD touches not just the OR, but all of our clinics. It supports the entire system and we needed everyone’s input and suggestions.”
The end result was a “drastic increase to SPD’s capabilities and throughput,” Christen said.
For O’Neal-Mellen, a high point of this process was the feedback she received from a MEDCOM expert, who conducted an initial survey and provided suggestions to improve processes. BAMC invited him back for a follow-up review a few months later.
“He took a look at our improved quality processes and turned to me and said, ‘I’ve got chills,’” O’Neal-Mellen recalled. “It was tremendous validation as we move forward in our high-reliability organization journey.”
The surgical slowdown was the “absolute right thing to do” for BAMC’s military and civilian patients, Johnson noted. The teamwork, collaboration and improvements are “a testament to BAMC’s continuous commitment to safe, quality care for our patients and their families.”