Evaluation and Implementation of an Evidence-Based Loaned Surgical Instrumentation Management Program Utilizing the Plan, Do, Study, Act Cycle
Abstract
Background or Problem/Issue: Fort Belvoir Community Hospital's (FBCH) goal is to provide Ready Reliable Care (RRC). Ready Reliable Care outcomes are quality, safety, and continuous process improvement. Currently, the loaned surgical instrumentation (LSI) program does not evaluate quality issue identification in the practice of loaned surgical instrumentation management (LSIM). Fort Belvoir Community Hospital processes approximately five LSI sets per day, averaging 500 sets per quarter. Last year there were 12 occurrences of bioburden reported at FBCH. Surgical instruments contaminated with bioburden places the patient at risk for debilitating surgical site infections. Clinical Question or Purpose: Does an evidence-based LSIM program evaluation, compared to current practice, achieve FBCHs goal of providing RRC? Project Design: The Plan, Do, Study, Act Cycle was the overarching framework for this project. Additional frameworks such as the Audit Quality Loop and CDC Program Evaluation were utilized to carry out several audit iterations. Patient centered care, leadership commitment, culture of safety, and continuous process improvement are all pivotal to the Defense Health Agency's (DHA) goal of RRC. These domains of change serve as the outcomes for this quality improvement project. Results: Within the organization four iterations of audit and feedback cycles were completed. Compliance was measured using an evidence-based audit checklist containing 59 elements to evaluate the LSIM program. Loaned surgical instrumentation management performance increased 17% with the implementation of 11 improvements for practice, from 80% to 97%.Further system/process evaluations resulted in an additional 24 initiatives that improved LSIM compliance. These improvements impacted the operating room and sterile processing department in addition to other areas within the organization to include logistics, post anesthesia care unit, anesthesia department, and hospital bed management.
Document Details
- Document Type
- Technical Report
- Publication Date
- May 02, 2023
- Accession Number
- AD1212202
Entities
People
- Gaston Baza
- Jesse M. Hatrmann
Organizations
- Uniformed Services University of the Health Sciences