Standardization of medical-surgical products across hospitals and health systems can have significant benefits in cost savings, employee satisfaction, and the quality of patient care. North Shore Long Island Jewish Health System is now well into the process of standardizing products in many areas using multidisciplinary value analysis teams, and the work is paying off on many fronts.
North Shore-Long Island Jewish Health System is the nation’s third-largest, non-profit, secular healthcare system, and covers a service area of 5.2 million people in Long Island, Queens and Staten Island, New York. With 37,000 employees—10,000 of them nurses—and a $4 billion annual operating budget, the mere size of the system presents both considerable challenges and huge opportunities in standardizing product use.
Top leadership decided to make product standardization through the office of procurement a high priority in the system’s strategic plan. The focus was on examining how the different sites ordered products in order to determine how to standardize them, while keeping patient safety the highest priority.
Jump-starting the process
During our initial attempts as the medical-surgical value analysis team (M/S VAT) to standardize products across the health system, we failed to make any headway. We were gathering all of the information and trying to communicate it back to the sites, but we weren’t making sufficient progress. We stopped to look at the process and structure that was in place and found there was none.
We began by creating a process that detailed how medical-surgical products would come to the M/S VAT committee for review and ultimately for system-wide standardization. We first needed to identify the members of the committee and our mission. Once these were established, we collaborated and developed an algorithm that defined the process to follow for systemwide product standardization based on the following guiding principles:
- Patient safety is the first priority.
- Quality of products would be a greater factor in product standardization than cost savings.
- Our largest stakeholders, nursing, would lead the selection process for clinical products.
- The educational needs of the staff needed to be addressed to ensure all clinicians understand and are competent in using the newly standardized products.
- Site accountability needed to be established to ensure the changes would be sustained.
Please click the PDF icon above to view the VAT Process
The first category of products the M/S VAT analysis teams decided to address was amenities. Thought this may not seem a critical area, we have managed to save about $200,000 through standardization. This first effort became a difficult, but valuable, learning process. We needed to standardize more than 20 products, but there were hundreds of variations among the 15 sites. Many of them were using different shampoos, toothpastes, razors, lotions and other items. One critical example that had application to not only cost but also patient safety was mouthwash. Since the health system has both psychiatric and pediatric patients, we did not want mouthwash that contained alcohol.
Moving forward with the team
The transformational changes that occurred because of the work of the M/S VAT were the result of a highly collaborative effort. Being able to answer the question, “Who are the stakeholders?” allowed us to determine who needed to be around the table to perform the analysis and make the critical decisions. Identifying team members was not as simple as it might seem. Various products used in hospital systems have varying stakeholder mixes. Sometimes the process of choosing team members evolves as the team does its work, so the process has become open-ended.
With our amenities initiative, most of the potential stakeholders were the nurses because they were the ones who frequently used amenities for patients. They were also the most suited to ensuring that the products we standardized would work at every site — at the patient’s bedside.
About four months into the process, however, we realized that the materials managers needed to join the team. These managers, for the most part, had been operating in their silos within the organization, focusing on procurement at their own sites rather than taking a systemwide view of the procurement process and structure. They ordered products, so had knowledge of inventory levels that might present challenges such as high-cost items that are misused or overused.
Our goal was to formalize structure, facilitate the incremental process changes, review products, standardize them for all sites and implement cost-saving initiatives. This goal was encased in the philosophy that patients come first, and we started every standardization initiative with this in mind.
At first we met every two weeks. During this time team members started to communicate among each other and began to learn about the different challenges at each site. All team members were encouraged to be courageous in their messages and were cautioned that change would cause some team members both at the M/S VAT and at the site to be uncomfortable, which is a normal part of the active process of change. The meetings now occur monthly.
With new discoveries, the team evolves
As we broadened our efforts beyond amenities, we found that our sites were using 14 different kinds of suture removal kits. We had representatives from each of the sites bring in the kits so that we could come to consensus as a team on which was the best product, based on the guiding principles we had established. We also brought in infection control representatives so they could weigh in with their knowledge of best practices with alcohol and povidone-iodine preps, which were part of some of the existing kits.
Once we had agreed on the standardized suture removal kits we also realized that we had to involve representatives from nursing education at the system level and at all of the sites so that staff could be taught how to use the chosen kit.
In the end, our M/S VAT had representatives from nursing, materials management, infection control, nursing education, and system procurement. It took months to form the VAT team, but we learned from the experience how to form teams more efficiently at the outset of a project. Putting the team together taught us that you have to be mindful of the consequences of your actions on all of the potential stakeholders of a given product, including direct caregivers, administrative personnel and most importantly, the patient. This is why careful stakeholder analysis is critical to the success of VAT teams.
Vendors are also involved in the process in some cases. For example, with blood pressure cuffs, three vendors were invited in to present before the team. They were all asked to create a plan that included why their particular cuff should be used, the projected cost savings, and how the product design contributes to infection control. Present at the meeting were representatives from medical/surgical and critical care nursing, infection control, nursing education, system risk and biomedical engineering, anesthesia and system procurement.
The M/S VAT members and the invited team members were coached and asked to remember that our decision to standardize would include evidence-based best practice, and that a product should not be chosen based on the vendor vision, but rather on our vision, which includes patient safety and improved efficiency in our work processes.
Piloting and communicating changes
Once a product is chosen, you have to decide whether a pilot trial is needed and where it should occur. In our system, we have everything from small community hospitals to large tertiary hospitals with 800 beds. We decided that when a clinical product required a pilot, we would conduct a trial in one tertiary hospital and two community hospitals.
The hospitals now use a pilot trial evaluation form to document lessons learned during the evaluation to help other hospitals once implementation begins. The other hospitals are also given the contact information for staff at the piloting hospitals so they can communicate with them if a question arises about a product.
As we met we were able to identify we needed to establish a process to hold team members accountable to the decisions made at the M/S VAT, with members feeling comfortable with the pushback that did occur at some of the sites.
Developing an effective communication plan was another vital part of the M/S VAT process because many of the team members were staff nurses who would be going back to their nurse executives and presenting changes in products. When the M/S VAT team process started and the team was in place, we asked the team members to go back to their monthly nursing meetings at their sites and ask how their staffs wanted the information communicated.
After the plan was created, a team member from system procurement, and chairperson of the M/S VAT, visited each site and met with the local site team that consisted of the site’s VAT member, director of nursing education, materials management, and the nurse executive to review the communication plan and talk about the expectations for the value analysis team member and the M/S VAT. Once this was completed, our team members felt empowered to drive these changes and communicate them in their organizations.
Again, being courageous in their messages, understanding their roles and responsibilities, and coaching in crucial conversations was warranted. As the members’ courage grew, and they could articulate our guiding principles at the value analysis team meeting and at their site, sustainability was emerging. This process validated the fact that it was more difficult to develop the personal accountability to the process than to select the products to standardize.
Accomplishments and lessons learned
So far, amenities, suture removal kits, pillows, blood pressure cuffs, electrodes, personal protective equipment, tape slippers, incentive spirometers, post mortem shrouds and hypodermic needles have been standardized across the health system. A year into the process, M/S VAT efforts have saved about $2 million. More importantly, a tested process has been implemented to trial new products, and everyone in the system knows how the process works and what their role is in that process.
We found VATs must be formal and structured to meet the objective of substantial savings. They must revise or create a process that will generate sustainable performance and profitable outcomes.
It is challenging to manage product standardization and cost containment through a collaborative team effort. However, with incremental changes and positive communication, higher productivity is possible. Addressing this challenge requires a leader to understand the principles of change theory and the need to shift from the I paradigm to the team paradigm.
Finally, the vision for change needs to be communicated from top leadership. Once communicated from the top as a priority, leaders at each site who are in experts in driving a process forward have the support to address staff members who may be resisting change. Site leaders will be able to present these individuals with clear and convincing communication, ensuring that individuals and sites understand the reason behind an organizational imperative. It was support from the top, combined with the focus of patients first that allowed us to get over some of the initial resistance and all work together for success.
Kathryn L Lang MSN, RN, NE-BS-C-NE, was the director of nursing operations for North Shore Long Island Jewish Health System and the system’s Medical Surgical Value Analysis Team leader at the time this article was written.