Revealing complex interdependencies in surgical instrument reprocessing using SEIPS 101 tools

Abstract

Sterile Processing Departments (SPDs) must clean, maintain, store, and organize surgical instruments which are then delivered to Operating Rooms (ORs) using a Courier Network, with regular coordination occurring across departmental boundaries. To represent these relationships, we utilized the Systems Engineering Initiative for Patient Safety (SEIPS) 101 Toolkit, which helps model how health-related outcomes are affected by healthcare work systems. Through observations and interviews which built on prior work system analyses, we developed a SEIPS 101 journey map, PETT scan, and tasks matrices to represent the instrument reprocessing work system, revealing complex interdependencies between the people, tools, and tasks occurring within it. The SPD, OR and Courier teams are found to have overlapping responsibilities and a clear co-dependence, with critical implications for the successful functioning of the whole hospital system.

1. Introduction

The work of a hospital’s Sterile Processing Department (SPD) may be more complex than is apparent to outside stakeholders. On the surface, the work looks straightforward and linear: surgical instruments must be retrieved after use in Operating Rooms (ORs) or other procedural areas, then cleaned, maintained, sterilized, stored, prepared, and delivered when needed for the next procedure. Recent efforts (Alfred et al., 2019, 2020, 2021) have revealed some of this complexity by taking a systems perspective rather than focusing only on individual performance. However, this work did not consider further increases in complexity as remote or off-site instrument reprocessing has become more common at many institutions. These provide the necessary infrastructure to handle high surgical volumes, but in doing so may create new challenges. Keeping pace with these changes and sustaining our understanding of this complex work system by identifying interactions and interdependencies is even more critical for maintaining the quality, safety, and efficiency of surgical care.

Less apparent within our prior work was how performance within the SPD could also be influenced by work in the OR and through delivery and retrieval supply chain mechanisms, here described as the Courier Network. Ensuring that the thousands of tools and devices needed for surgeries each day are delivered to the right OR at the right time involves regular coordination across the SPD, ORs, and the Courier Network. The Systems Engineering Initiative for Patient Safety (SEIPS) (Carayon et al., 2006; Holden et al., 2013) has become the de-facto systems engineering framework within patient safety which describes how tasks, tools, technologies, work environments and the organization interact to create successes and failures. The SEIPS 101 toolkit (Holden and Carayon, 2021; Carayon et al., 2020), consists of seven tools which represent different features of the healthcare system from the SEIPS perspective. By utilizing SEIPS framework to understand the surgical work system, we aimed to assist healthcare teams and decision-makers in improving the efficiency of healthcare delivery and ultimately benefiting the patients they care for.

2. Methods

To establish an overview of the surgical tray reprocessing work system, which includes the SPD, OR, and Courier Network, our team (GS, JW, MR, SH, CJ, KC, KT) conducted observation sessions and interviews with professionals at multiple levels of the healthcare organization to take the wider work system into account. We then constructed three system representations that utilized the SEIPS 101 framework: a PETT Scan for the whole organization; a Journey Map for a surgical instrument tray as it moves through the SPD process to the OR and then back to the SPD via the hospital Courier Network; and a series of tasks matrices for work directly related to the preparation, use, and delivery of surgical trays in the SPD (Assembly), OR (Procedures), and Courier Network (Delivery) work environments.

2.1. Setting

This study was conducted at an academic hospital system in the Southeastern United States comprised of 8 hospitals with 2500 beds and 63 operating rooms (ORs) where approximately 37,500 surgeries are performed annually in 16 specialty groups. The system was supported by two on-campus SPDs and one offsite Consolidated Service Center (CSC), with a Courier Network handling supplies and logistics between all locations and delivering trays of surgical instruments throughout the system. At the time of this study, the hospital system was in the process of integrating the CSC into daily operations, providing an opportunity to investigate how introducing an off-site sterilization location may impact system-wide departmental coordination.

2.2. Data collection

Data for this study were collected through extensive background work (Alfred et al., 2019, 2020, 2021) as well as a series of direct observations of work as done throughout the instrument reprocessing system by multiple researchers, totaling over 300 h. Tasks performed in the workplace were observed for the SPD, OR, and Courier teams and tasks directly related to the preparation, usage, and transportation of surgical instrument trays were focused on for inclusion in the three tasks matrices with an aim to illustrate parts of the system directly related to surgical trays. Observations of the Sterile Processing Department (150 h), the Operating Room (100 h), and the Courier Network (50 h) were analyzed by multiple researchers (GS, KC, CJ, MR) and organized using the SEIPS framework. A series of formal and informal semi-structured interviews (35 participants ages 25–60, 30 h, average length 1 h) were also conducted in several work environments (hospital offices, conference rooms, operating rooms, instrument processing areas, phone calls, virtual meetings) with a variety of healthcare team members throughout the organization including SPD team members (Managers, Educators, Supervisors, Travelers, Technicians), OR team members (Surgeons, Educators, Nurses, Scrub Technicians) and Courier team members (Managers, Coordinators, Supervisors, Drivers). Interviews questions were pilot tested, audio recorded, transcribed via software, manually finalized, and supplemented with field notes from observations. The interviews were designed to elicit stories about daily challenges in the work environment, identify system stressors and adaptations, and understand individual perspectives about and within the work system, and initial pilot testing helped us to develop language which engaged hospital staff. Once initial versions of the SEIPS tools were created, follow-up observations and interviews were conducted to verify the validity of the tools. Interview participants were encountered naturally during the study and were introduced to its main goals but were otherwise uninitiated to systems thinking. No outside participants were present during interviews, and no participants dropped out of the study. All study authors (both male and female with BS, MS, PhD credentials) participated in the interviews and none had direct workplace roles or relationships to the participants, though all had a natural bias toward systems thinking due to their backgrounds in human factors and systems engineering. A collection of formal and informal interview methods (ad-hoc, scripted questionnaires, and conversational meetings geared toward proactive systems safety (Jefferies, et al., 2022)), were utilized.

2.3. Model development

A team of embedded human factors and systems engineering experts utilized the observation and interview findings to construct three SEIPS tools based on SEIPS 101 templates (Holden and Carayon, 2021), which were specifically adapted for the scope of this study. Over the course of one year, the team met regularly to report and discuss findings before deciding which versions of the tools would best represent the findings. Professionals from the SPD, OR and Courier teams including department heads, administrators, managers, supervisors, technicians, clinical professionals, and others were consulted for feedback about the tools to assist with the development process. Preliminary versions of the tools were deployed as part of the interview materials for verification by 3 senior staff (one manager from each department.)

2.4. PETT scan

The PETT (People, Environment, Tools, and Tasks) Scan (Table 1) is a tool designed for system-wide application which attempts to describe the whole work system in a straightforward way. In it, the people, environments, tools, and tasks that exist in the system and the barriers and facilitators which interact with them are readily identified. In this case, barriers are aspects of the work system which get in the way of the delivery of surgical care and/or increase the risks to patients or healthcare team members, and facilitators are system aspects which assist efficient and effective delivery of care and decrease risks. A PETT scan may be helpful to decision makers in charge of a healthcare system by providing a profile of factors to consider when planning or implementing workplace interventions designed to improve quality of care. Potential changes or interventions can be evaluated to consider their effects before they are implemented, and interactions between barriers and facilitators can be utilized to create a pattern library for improved management.

Table 1.

A SEIPS 101 PETT scan of the surgical instrument reprocessing work system showing SEIPS factors such as people, environments, tasks, tools, and selected interactions between the factors across the healthcare organization.

PETT Scan (Whole System)
SEIPS Factors	Barriers	Facilitators
People: SPD Team OR Team Courier Team	Time Pressure/Scheduling Surgical Demands Workload Limitations Budget Constraints High Turnover Rates High Skill Requisites	Staff Training/Work Experience Meetings/Focus Groups Staffing Optimization Research Participation Job Satisfaction Connection To Purpose (Patient Care)
Environment: Physical	Multiple Campuses & Hospitals Multiple SPDs Offsite Central SPD/Supply Road/Traffic Conditions	Campus Proximities SPD/OR Proximities Localized Research Team Sky Bridges Between Buildings
Environment: Socio-organizational	Workplace Culture Issues Miscommunication/Lack of Coordination Reporting Structures Event Reporting Systems Introducing New Tools/Software Language Barriers Differences in Localized Terminology (Instruments, etc.) Differences in Professional Training Loss of Individual/Departmental Knowledge Pickup/Dropoff Schedule Surgical Schedule/Adjustments (Routine or Add-On Cases) Organizational Mistrust	Positive Workplace Culture Teaching Hospitals Trained/Educated Team Members Centralized/Standardized Software Standardized/Adaptable Workflows Team Experience Maintaining Individual/Departmental Knowledge Pickup/Dropoff Schedule Surgical Schedule/Adjustments (Routine or Add-On Cases) Adaptive/Anticipatory Behaviors Organizational Risk Management Dedicated Vehicle Fleet
Environment: External	Demand for Surgeries Availability of Supplies Availability of Staff Funding/Economic Factors Legal Factors State or Federal Government Regulations Software Updates Weather Conditions	Demand for Surgeries Charitable Donations Community Outreach Funding/Economic Factors
Tools	Usability/Usage Familiarity Staff Legal Concerns Reliability (Equipment or Data) Email or Call Not Received Inaccurate Count Sheet, Pick Sheet or Preference Card Illegible Handwriting (Documents, Notes) System Library Errors Reliance on Scanning Compliance (Barcodes) Reliance on Voluntary Reporting (Incident Reports)	Real-Time Data/Scheduling Ability to Locate Trays/Case Carts Direct Conversations (Phone, Video, Face-to-Face) Cart/Tray/Instrument Tracking Organizational Knowledge Transfer/Preservation Organizational Coordination Instructions For Use (IFUs) Surgical Needs List
Tasks	Trays Sent/Received in Non-Ideal Condition Lost, Broken or Missing Instruments Contamination/Sterilization Issues Time Requirements Inventory Size/Limitations/Hoarding Scanning Compliance/Errors Issues finding trays or carts Lack of individual instrument tracking Instrument Similarities	Trays Sent/Received in Ideal Condition Instruments/Trays Organized Correctly Replacement/Disposable Instruments Available Timely Instrument Repair Advance Notice of Needs (All Teams) Available Storage Space Informative Signage Accurate/Updated/Accessible Needs List
Interaction between people, environment, tools, tasks	Negative interactions between departments (organizational environments, people) may reduce trust (organizational environments, people) leading to decreased communication effectiveness (tasks) High workload (environments) may result in non-ideal staff roles (organizational environment) which affects work quality (tasks) and/or may lead to case delays (tasks) which affects the organization (organizational environments), healthcare teams (people) and ultimately the patients they care for (people) Lack of awareness about instrument inventory (organizational environments, tools) when scheduling surgical cases (organizational environments, tasks) can lead to an inability to prepare for scheduled cases (organizational environments, tasks) which can challenge care teams (people, tasks) to adapt to production pressure (organizational environment) and ultimately affect patient wellbeing (people)	Positive interactions between departments (organizational environments) facilitates trust (organizational environments) leading to increased communication effectiveness (tasks) Team members (people) with increased understanding of challenges faced by other teams in other departments (organizational environments, tasks) may facilitate improved coordination between departments (tasks) and connection to purpose for patient outcomes (people) Awareness of system-wide interactions throughout the work system (organizational environment) by decision-makers (people) can facilitate improved decision making (organizational environments, tools, tasks) which may positively impact care teams and patients (people)

Compiling factors for a system-wide PETT scan involved careful consideration of current and previous findings as well as a system-wide scope with an aim to assist decision-makers with the development of future workplace interventions. As workplace observations and interviews were conducted, factors were organized according to the categories established in the SEIPS 101 template and were classified as barriers or facilitators based on the team’s expertise regarding how they may impact the system. Throughout the data collection process, a multitude of interactions were observed between the people, environments, tools and tasks throughout the system, and a full list of interactions or potential interactions would yield many possibilities. Guided by prior research (Alfred et al., 2019, 2020, 2021), we focused on interactions which illustrate the potential for large-scale management decisions or future interventions to impact the system at multiple levels of the organization. Themes which came up often at all levels included the importance of good interdepartmental relationships, the effects of high workload and production pressure, financial concerns, disconnects between departments or with leadership during decision making, staffing issues, and the prioritization of patient wellbeing. Due to its system-wide scope, the PETT scan did not account for all barriers and facilitators in every individual work environment and was instead intended to provide an overview of the work system to assist decision making and stimulate additional study.

2.5. Journey map

The SEIPS Journey Map (Fig. 1) is designed to show a process over time and the relevant factors which chronologically affect that process, thereby illustrating dynamic interactions between them in a practical way (Holden and Carayon, 2021). Here, the Journey Map depicts a surgical tray as it passes through the instrument reprocessing work system and the people and tasks which directly affect its journey through that system. Arrows show the flow through the tray utilization cycle as the tray is brought down to the SPD after being used for a surgical case, is cleaned and prepared for its next use, and is delivered to the OR to be used again. Columns represent the process stages of the tray’s journey and show the different responsibilities across multiple teams of individuals at each step which contribute to its successful use and re-use. Due to the complexity of multidimensional factors affecting the hospital work system, accounting for all the people, tools, tasks, and environments in one map would not be practical. Therefore, we chose to highlight the people and tasks within each department at each process step to clearly illustrate departmental interdependence throughout the usage and reprocessing process specifically.

Figure 1.

A SEIPS 101 Journey Map showing the usage and reprocessing steps of a surgical instrument tray through the reprocessing work system. Process phases are identified at the top and SEIPS factors in the leftmost column. Involvement of different team members during multiple process phases is represented by boxes which extend across those phases. Team members who are collectively involved across process phases are grouped together; all teams are shown to have roles which span multiple phases. Differences in team organization between departments are readily apparent, as the Courier Team has a collective structure across all process phases while the SPD and OR exhibit more specialization within individual phases and groups of phases. It should be noted that while the OR Team has responsibilities such as regularly performing procedures and turning over rooms for cases across the full length of this process, we did not choose to fully represent that here.

The research team began by creating a journey map for the steps of tray reprocessing in the SPD and OR only. As observation sessions progressed however, it became clear that the OR and Courier Network shared responsibilities which constituted additional steps in tray usage and reprocessing, particularly as off-site reprocessing and storage was increasingly implemented at the institution. These responsibilities were added to the map as additional steps, and a system-wide map was constructed using relevant SEIPS factors (people, tools, tasks, environments). To reduce complexity in the map and to show ongoing system-wide coordination, we focused on the people and tasks involved in keeping the work system functional to illustrate the departmental interdependence that had been observed. The map was verified by returning to the work environment and utilized during interviews with workplace-embedded experts in all three departments to confirm its validity.

2.6. Tasks matrix

The Tasks Matrices (Tables 2–4) list key tasks within three chosen areas of interest in the stages of the tray usage and delivery process, illustrating who performs the tasks along with why, how, how often, and when they perform them. Task Matrices can demonstrate the actual complexity of a task or series of tasks by showing the directly observed experiences of the teams assigned to perform them in greater detail.

Table 2.

A SEIPS 101 Tasks Matrix showing the tasks and people involved in the Assembly stage of tray reprocessing in the SPD. IFU: Instructions for Use provided by manufacturer.

SEIPS Tasks Matrix for a Surgical Instrument Tray (SPD Assembly)
Task	People	Goals of Task	Frequency	How Performed	When Performed
Retrieve Trays from Washer	Technician SPD Team	Free up Decontamination washer for next batch of trays, organize incoming trays	High – Multiple Times Daily	Trays removed from washer cart, placed on designated cart or shelf	As soon as Decon washer cycle completes
Determine Tray Priority	Supervisor Technician	Ensure needs list criteria are met, optimize work of technicians according to case schedule		Check needs list, apply quick turnaround label, place on priority cart. Check for quick turnaround designation or label	Immediately after retrieval, before starting assembly
Assign Tray to Technician	Supervisor Shift Lead	Optimize/prioritize staff workload		Place on technician’s cart and/or bring to workstation	ASAP after priority determined
Scan Tray to Workstation	Technician	Track tray movement, verify tray contents		Bar code scanner for workstation computer	When assembly begins
Remove Instruments	Technician	Prepare instruments for inspection		Instruments organized at workstation outside tray	After tray is scanned
Inspect for Bioburden	Technician	Ensure bioburden is not present on instruments or trays before sterilization		Instruments and tray opened, examined with magnifier, blown out with air compressor. Possibly returned to Decontamination	During instrument inspection
Inspect Functionality	Technician	Ensure all instruments are functioning correctly		Follow inspection protocol specified by computer database, management and/or staff knowledge, skills, and abilities	During instrument inspection
Verify Tray is Complete	Technician Supervisor	Ensure all required instruments are present		Tray recipe in computer database and/or pick sheet, signed by supervisor once verified	During instrument inspection
Note Tray Discrepancies	Technician	Ensure any extra, missing or broken instruments accounted for on count sheet and tray label before it is sent to the OR		Set aside extra instruments for storage, broken instruments for repair, and replace missing instruments. Note on count sheet if tray is sent with missing instruments and/or substitutions	During instrument inspection
Communicate Discrepancies	Supervisor Coordinator	Verify whether tray can still be used for procedure if missing or substituting an instrument		Call OR coordinator or other individual to check whether procedure can still proceed	During instrument inspection or before closing and locking box
Instrument Lookup	Supervisor Technician	Identify instruments by name and appearance, identify potential substitutions		Look up instrument with software, use database and IFUs	During instrument inspection
Find Instruments	Supervisor Technician Coordinator	Physically find replacement instruments for those which are missing or broken		Search storage area (wall pegboard, rotomat or other trays) for replacement instruments	During instrument inspection
Return Instruments to Tray	Technician	Ensure tray contains all required instruments		Placed in tray one at a time using software list and/or pick sheet	During instrument inspection
Roll Up Instruments	Technician	Prevent damage to sensitive instruments during storage/transit		Rolled together in approved peel pouch and placed in tray	During instrument inspection
Place Count Sheet in Tray	Technician	Ensure OR team receives a count sheet with the tray		Printed from workstation computer, folded and placed in waterproof envelope, placed in tray	After instrument inspection
Sanitize Tray Container	Technician	Ensure no bioburden or foreign objects/debris present		Visual inspection, air compressor, alcohol wipe per IFU	Before tray is placed in container
Add Integrators	Technician	Ensure tray is sterilized correctly		2 chemical integrators placed in opposite corners of tray	Before tray is placed in container
Place Tray in Container	Technician	Ensure tray is protected during rest of process		Lift tray by handles, place in lower half of container	After sanitizing container
Install Filters	Technician	Prevent contamination, condensation after sterilization		New packaged filters placed in retention plates and clicked in	After sanitizing container
Close, Lock and Tag Tray	Technician	Prevent tampering, facilitate re-use if not used for case		Chemical indicator lock placed on container, labels printed from computer and looped around container handles	After tray is placed in container
Add Corner Protectors	Technician	Reduce likelihood of tray wrap holes		Blow out protectors with air compressor, place on tray	Before wrapping tray
Wrap Tray	Technician	Prepare tray for sterilization step, ensure sterility		Wrap tray completely, tape wrap to hold it in place and place barcode label on wrap. Tape cannot overlap	Before sending to Sterilization
Add Protective Belts	Technician	Reduce likelihood of tray wrap holes		Wrap soft protective belts around outside tray wrap	Immediately after wrapping
Send to Sterilization	Technician	Complete Assembly process, assemble next tray		Container placed on sterilization cart	After assembly is completed
Add Tip Protectors	Technician	Guard against sharps injuries		Add to certain sharp instruments upon request	During assembly

Table 4.

A SEIPS 101 Tasks Matrix showing the tasks and people involved in the transport of surgical trays and carts between the OR and SPD.

SEIPS Tasks Matrix for Delivery of a Surgical Instrument Tray (Courier Network)
Task	People	Goals of Task	Frequency	How Performed	When Performed
Bring Case Cart to Dock	Driver Coordinator	Bring case carts to vehicle for delivery	High - Multiple Times Daily	Navigate hallways, elevators, warehouses and/or other environments to retrieve the cart and bring it to the docking area	Constantly: routinely or when requested
Load Vehicle at Dock	Driver Coordinator	Place carts, trays or other items in vehicle for delivery		Vehicle is pulled into loading dock, dock ramps/machinery utilized, carts strapped down	At each stop routinely or as requested
Transport Cargo	Driver Coordinator	Transport items from pickup to dropoff locations		Vehicle is driven between locations and navigated throughout hospital network, through traffic or other potential obstacles	Constantly: routinely or when requested
Unload Vehicle at Dock	Driver Coordinator	Remove carts, trays or other items from vehicle for delivery		Vehicle is pulled into loading dock, dock ramps/machinery utilized, carts unstrapped	At each stop routinely or as requested
Mark Order Progress/Completion	Driver Coordinator	Ensure other teams are aware that items were picked up or dropped off		Use mobile phone app to mark orders as “in progress” or “complete”	Immediately after pickup or drop-off
Ensure Cart Receipt	Driver Coordinator	Ensure location team receives/is aware of the cart		Communicate with location team via phone, doorbell, or in person	Each time a cart is delivered
Bring Cart from Dock to Destination	Driver OR Liaison	Deliver case cart to requested location		Navigate hallways, elevators, and other environments to bring the cart from the docking area to its final destination (SPD, OR, etc.)	Constantly: routinely or when requested
Scan Cart Pickup/Delivery	Driver Supervisor OR Liaison	Show cart location in delivery network, communicate pickup status with OR and SPD teams		Mobile phone or barcode scanner at location	Immediately after pickup or drop-off process
Coordinate With/Among Drivers	Manager Coordinator Supervisor Driver	Communicate needs and adjustments to delivery system/schedule		Logistical software, GPS, schedule planning and/or mobile phone apps or calls	Constantly: throughout the day
Move Supplies/Equipment (Non-SPD)	Manager Supervisor Driver	Move requested non-SPD supplies to destination		Boxed supplies on pallets moved in vehicles, moved through rest of work environment on pallet trucks	Constantly: routinely or when requested
Refuel Vehicles	Driver Supervisor	Ensure vehicles remain functional, avoid running out of fuel		Vehicles are taken to specific gas stations which carry the proper fuel. A supervisor or coordinator must authorize the fuel purchase.	As needed
Manage Traffic	Manager Supervisor Driver	Optimize delivery efficiency, optimize driver utilization, reduce/prevent slowdowns		Coordinate loading dock pickup/drop off times, Coordinate driver schedules and routes	Constantly: throughout the day
Schedule Driver	Manager Supervisor	Ensure adequate staffing, optimize delivery efficiency and driver utilization		Logistical software, schedule planning	Daily
Place Driver	Manager Supervisor	Select best driver starting point and route, optimize delivery efficiency and driver utilization	Moderate - At least daily	Logistical software, schedule planning	In advance, at start of day, or throughout the day
Sterilize Vehicles (Ultraviolet or Manual)	Driver Supervisor	Prepare vehicle cargo areas for clean pickups, reduce contamination risk		Standard UV procedure provided by management or by hand using specialized cleaning implements and chemicals if UV unavailable	At least once daily
Maintain/Repair Vehicles	Driver Supervisor	Ensure vehicles remain functional/repaired as needed, avoid safety hazards	Low - weekly or monthly	Vehicles are rotated out as they are cleaned or sent for maintenance. Vehicles which need towing are picked up by local businesses.	According to established maintenance schedule

Observations of the SPD, OR, and Courier Network work environments allowed the research team to familiarize themselves with the people and tasks in different parts of the tray reprocessing work system and describe how different tasks were performed. Researchers recorded tray-related tasks throughout the workday for different individuals through means such as watching trays go through the cleaning, sterilization, and storge processes in the SPD, observing usage and treatment throughout multiple surgical cases in the OR, riding along with drivers on courier delivery routes, and attending management-level quality meetings. Once a list of team members and tasks was assembled into matrices, the matrices were brought back into the work environment and verified against additional rounds of observations. Each matrix was then brought to individuals embedded in the workplace at different levels of the organization for final confirmation.

3. Results

3.1. PETT scan findings

A total of 48 barriers and 43 facilitators related to delivering trays for surgical care were identified in the physical environment (4 barriers, 4 facilitators), socio-organizational environment (12 barriers, 12 facilitators), and external environment (8 barriers, 4 facilitators) for all involved teams at all levels of the organization. Some factors, such as the demand for surgeries, surgical schedule, and pick up/drop off schedule, were found to be both barriers and facilitators to successful organizational function under different circumstances.

Organizational barriers included time pressure, workload limitations, surgical demands, budget constraints, staffing issues, and the need for highly skilled team members. Physical barriers included the presence of multiple campuses, hospitals, and SPDs in the healthcare network, offsite central supply and instrument processing, and road and traffic conditions.

Organizational facilitators included team training and work experience, meetings or focus groups, initiatives to optimize staffing levels and improve job satisfaction, active participation in research, and connection to purpose for individual team members through attempts to help teams experience the work environments of other teams across departments. Physical facilitators included proximities between on-campus hospitals and SPDs, sky bridges between on-campus buildings, and the localized, integrated presence of management and the research team in the SPD, OR, and Courier work environments.

Multiple interactions were found involving the people (team members and patients), environments (physical and organizational), tools (instruments and software), and tasks (case scheduling, coordination, instrument reprocessing) throughout the organization and within multiple departments (Table 1). Six system-wide interactions which illustrate the interdependent nature of the work system and how cascades of disruptive events might occur within it were identified. These included positive or negative interdepartmental relationships affecting coordination effectiveness, high workloads leading to non-ideal staff roles, awareness between departments affecting the efficiency of case scheduling and preparation, and general awareness of system-wide interactions affecting organizational decision making. Mistrust between different parts of the organization was also identified as a major theme within rework. Surgical teams concerned about missing instruments in the OR might order extra trays to create redundancy, increasing production pressure across the rest of the system.

3.2. Journey map findings

The preparation, usage, and delivery of a surgical tray was found to be an intricate process taking place in a highly complex organizational work environment and affected by a wide variety of individuals and factors. Ten total phases were identified in the journey of a surgical instrument tray with five taking place in the SPD, three taking place in the OR, and two taking place in the Courier Network. Several shared and overlapping responsibilities, such as coordination between individuals and departments, were identified across the organization and throughout the tray preparation, usage, and delivery process. While some responsibilities such as performing a surgical procedure, driving a truck, or assembling a tray were not directly shared across departments, all still involved communication and coordination between departments. Continuous communication to facilitate fluid coordination was found to occur across every stage of the process for the system to function, and all three teams from all three departments share the ultimate responsibility of getting the right tray with the right instruments to the right patient at the right time. Trade-offs, adaptations, and work-arounds were found to occur throughout all phases of the journey to keep the system functioning and served as an integral part of its functioning to avoid system failures. Major themes included switching job roles (supervisors working as technicians or couriers, managers acting as truck drivers), communication breakdowns (missed phone calls, phones going out, missed or incorrect tray bar code scans, information not reaching the correct individuals), and tray defect resolution (finding alternate trays for procedures, sourcing instruments from non-ideal trays, ordering extra trays). All points in the tray journey had the potential for the tray to move back one or more steps in the process if an issue occurred (Fig. 1).

3.3. Tasks matrix findings

A total of 60 tray-related tasks were identified for the three chosen work environments of interest, with 25 tasks identified in the Assembly stage of the SPD, 19 tasks identified in the OR, and 16 tasks identified in the Courier Network. Most tasks were found to have a high frequency across all three work environments, occurring multiple times daily. Tasks which did not have a high frequency still occurred on at least a daily to monthly basis. Several tasks in all departments were found to involve or potentially involve multiple individuals within the same department, and others involved team members from more than one department, often simultaneously. Team members were observed switching roles within and between departments as needed to adapt to daily challenges in their work environments and maintain organizational flexibility to facilitate the continued functioning of the work system.

Tasks for the Assembly stage in the SPD included prioritizing trays as they arrived from decontamination, assigning trays to technicians, scanning the trays to assembly workstations, inspecting trays and instruments for bioburden, checking instrument functionality, verifying that all necessary instruments were present, looking up instruments which needed to be replaced in a computer database and physically retrieving them from the inventory, verifying instrument substitutions, addition of filters and sterile integrators, printing count sheets, wrapping trays, locking and tagging the trays for sterilization, and many others (Table 2). Tray-related tasks for the OR included scanning the trays to the OR, loading and unloading trays from carts, setting up the sterile field, performing instrument counts before, during, and after surgical procedures, breaking down the sterile field, stringing and spraying instruments to prepare them for decontamination in the SPD, coordinating emergent needs for additional trays or instruments before or during the procedure with the SPD, and assigning tray destinations to used or unused trays after the procedure (Table 3). Courier tasks included coordinating and optimizing delivery routes and schedules, assigning drivers to routes and schedules, loading and unloading carts and trays at loading docks, refueling and maintaining vehicles, scanning tray and cart destinations, adapting to routine and “STAT” (priority) requests, and maintaining constant coordination with the OR and SPD teams (Table 4).

Table 3.

A SEIPS 101 Tasks Matrix showing the tasks and people involved in the use of surgical instruments in the OR.

SEIPS Tasks Matrix for a Surgical Instrument Tray (OR)
Task	People	Goals of Task	Frequency	How Performed	When Performed
Receive/Scan Case Carts	Circulating Nurse Scrub Tech OR Liaison	Obtain case carts with trays needed for case, prepare for case, track cart movement	High - Multiple Times Daily	Move carts to OR or OR Storage area for later retrieval, scan carts with barcode scanner at nurse workstation in OR	When case carts are received
Scan Trays to OR	Circulating Nurse Scrub Tech	Track tray movement, verify tray arrival, update needs list for SPD		Use barcode scanner at nurse workstation in OR	Before or during procedure
Verify Tray and Tray Wrap Integrity	Scrub Tech Circulating Nurse	Ensure tray/instrument sterility		Check if lock is intact, check tray wrap for holes, check that sterile indicators are present and changed color	Before or during procedure
Verify Tray Contents	Scrub Tech Circulating Nurse	Ensure correct instrumentation is present		Check count sheet in tray, ensure sheet matches tray contents, ensure chemical integrators changed color	Before or during procedure
Set Up Sterile Field	Scrub Tech Scrub Nurse	Set up and drape table, prepare and organize instruments for procedure		Varies by procedure, team and specialty	Before procedure
Perform Instrument Count 1	Scrub Tech Circulating Nurse Scrub Nurse	Ensure all instruments are accounted for		Varies by procedure, team and specialty	Before procedure, during/after closing, before returning to SPD
Perform Time-Out	Surgical Team	Plan for procedure, verify who is present		Verify patient identity, surgical plan, and surgical team	Immediately before procedure
Perform Surgical Procedure	Surgical Team	Complete procedure safely and effectively		Varies by procedure, team and specialty	When patient and team are ready
Perform Intraoperative/Continual Point of Use	Scrub Tech Scrub Nurse	Prevent bioburden buildup, facilitate cleaning, keep track of instruments used, ensure patient safety		Separate dirty/clean instruments, soak used instruments	Immediately after use and continuously during surgery
Perform Instrument Count 2	Scrub Tech Circulating Nurse Scrub Nurse	Ensure all instruments are accounted for, ensure patient safety		Varies by procedure, team and specialty	Immediately after use/after surgery
Tear Down Sterile Field	Scrub Tech Circulating Nurse	Turn over OR, prepare for next case		Varies by procedure, team and specialty	Immediately after surgery
Return Instruments to Trays	Scrub Tech Scrub Nurse	Organize instruments to send to SPD		Return instruments to trays as count is performed, tag broken/rapid turnover instruments	Immediately after use and during count
String Instruments (If Applicable)	Scrub Tech Scrub Nurse	Prevent bioburden buildup, facilitate cleaning		Instruments with open handles placed on stringer in open position, stringer closed	Immediately after surgery
Spray Instruments	Scrub Tech Circulating Nurse	Prevent bioburden buildup, facilitate cleaning		Instruments sprayed with enzymatic spray bottle	Immediately after surgery
Return Trays to Containers	Scrub Tech Circulating Nurse	Facilitate safe return of trays to SPD		Trays placed back in original cases using visual labels	Immediately after surgery, after count
Place Trays in Designated Carts	Scrub Tech Circulating Nurse	Determine use of cart(s) and/or request more. Facilitate return of trays to SPD or Storage, reduce system strain		Used trays placed in designated Decontamination cart, unused trays placed in designated Return to Storage cart	When cart use is determined, instruments are returned to trays, and all trays are accounted for
Scan Tray Destinations	Scrub Tech Circulating Nurse	Establish destinations, track tray location		Scan unused Barcode scanner at nurse workstation in OR	As soon as cart use is determined
Send Carts to Destinations	Scrub Tech OR Liaison	Return cart and trays to Decontamination or to Sterile storage (SPD or OR)		Cart sent down hallway and/or elevator to Decontamination or Sterile Storage (SPD or OR)	Immediately after scanning trays
Request Additional Trays	Circulating Nurse Coordinator OR Liaison	Satisfy real-time needs of the case		Call to request additional trays from OR or SPD storage	When current or upcoming needs are identified

4. Discussion

Through a series of observations and interviews which built on our prior work system analyses, we developed a SEIPS 101 journey map, PETT (People, Environments, Tools, and Tasks) scan, and tasks matrices, aiming to describe the system and the complex interactions between people, tools, and tasks occurring within it. Themes which arose repeatedly during observations and interviews included breakdowns in interdepartmental or leadership awareness, organizational mistrust, role-switching, scheduling challenges, and universally high workload and production pressure further support this idea. Organizational, physical, and external barriers and facilitators to successful system function were also identified across the organization. Tasks within each phase of reprocessing were found to affect or be affected by other tasks across the organization, with many tasks shared between multiple individuals in multiple departments. Our findings demonstrate value in understanding the complex interactions across the organization, emphasize the importance of moving beyond individual blame in instances of failure, suggest interventions that might yield sustainable performance improvements, and illustrate both advantages and limitations of the SEIPS 101 approach.

The PETT scan illustrated a multitude of interactions between factors such as scheduling, staffing, quality assurance, and the delivery of care as it is coordinated across departments. The Journey Map helped to illustrate the hospital work system at each stage of the tray utilization process and how multiple departments interconnect to affect one another throughout the journey. Some tasks, such as scanning trays as they move through the system to track their location, are performed by all three teams and directly affect coordination and efficiency. The tasks which all teams perform require multiple steps, sophisticated equipment, and involve multiple individuals in each department. Tasks which are left out or done incorrectly can present a high risk to patient safety and may also have system-wide implications for organizational wellbeing.

Tasks performed in different departments may affect one another at multiple steps of the tray preparation, usage, and delivery processes, even though the departments involved are traditionally thought of as separate. Breakdowns in coordination with the OR and Courier Network can raise an already substantial workload and production pressure, potentially leading to increased risks to team members and patients. When trays or instruments arrive with issues and cannot be used, surgical cases can be delayed, leading to scheduling problems that can cause great difficulty for patients and providers. The surgical team in the OR must communicate emergent needs, perform quality assurance tasks such as verifying tray contents and tray wrap integrity, conduct surgical counts, and help maintain instruments through point-of-use practices such as soaking, stringing, and spraying. Failure to properly string and spray instruments can substantially increase the difficulty of reprocessing the trays in the SPD, making it harder for the SPD to maintain efficient production to support the OR. The Courier team carries out both routine and urgent deliveries while adapting to changes in surgical schedules, driver assignments, and road conditions, with lower-frequency tasks such as maintaining and refueling vehicles also necessary for success. Tasks are coordinated through a variety of methods including phone calls, texts, emails, virtual and in-person meetings, daily huddles, physical documentation, apps or software, electronic databases, and various reporting structures. Case scheduling directly affects the workload in the SPD, and tray reprocessing cycle times in the SPD likewise affect case scheduling.

While each department has a different set of team members with a unique chain of command, all must work together as seamlessly as possible. Of particular note is the role of the OR Liaison, who must coordinate between the SPD, OR, and Courier Network as they constantly adapt to help all other teams resolve emerging problems. This requires team members with experience in all the SPD tray reprocessing steps who can identify, forecast, and prepare solutions for issues before they arise. When the system is under significant strain, team members may have overlapping duties or may fill in for one another in various roles to complete tasks, resulting in changes to system function. For example, an SPD Technician described serving as an OR Liaison to help find trays when the usual liaison in his department was not available, and an SPD Supervisor was observed delivering a tray to the OR when unable to wait for a courier. It is this adaptive capacity within the system that can reduce opportunities for failure. An off-site storage and reprocessing center increases departmental interdependence, increases required coordination, amplifies the complexity of existing systemic problems, and may require additional adaptations by team members to maintain a functional system.

Considering interactions between and among healthcare teams as they prepare, use, and deliver surgical trays may aid development of potential workplace interventions for quality improvement in the hospital. Evidence from studies in high-reliability organizations (Weick and Sutcliffe, 2007) suggests that safety may be enhanced if decision-makers recognize the systemic factors affecting their organization. Optimizing daily operations and planning for future challenges in healthcare would benefit from an understanding of the complexity of the work systems involved in surgical care and their relationships with one another. Situations where team members must adapt or switch roles to complete a task may not be accounted for by traditional management approaches which are limited by departmental lines or inflexible organizational structures. While task complexity and departmental interdependence between the SPD, OR and Courier Network are well known among healthcare workers, they are not often clearly represented in an accessible and informative way for decision makers working toward quality improvement. Understanding task complexity, departmental interdependence, and the systemic impact of both on organizational management and safety may be useful when attempting to improve healthcare systems through changes in policy, budget, staffing, standardization, workflows, or management strategy. Organizational decisions about workplace policy and patient safety that do not sufficiently take these factors into account may have unforeseen effects for patients, healthcare teams, and the healthcare organization (Dekker, 2011, 2014).

SEIPS provided a framework to consider a system scoping that is broader than the SPD and OR alone, and to represent it in an accessible way with a low technical barrier for its use. To reliably construct effective SEIPS tools we suggest that embedded background research, time spent in the work environment, and verification steps with team members immersed in the work environment are important for meaningful results. These steps, amplified by SEIPS’s guidance to view the system from multiple perspectives, were useful for helping to move beyond individual performance to explore tasks, technologies, workspace, and organization. However, its lack of explicit guidance and relevant systems patterns to support identifying other important aspects of the system, including boundaries, trade-offs, and the interplay among agents (Woods et al., 2010), made it more difficult to see this system through those lenses. Other systems perspectives that are not explicitly supported by SEIPS are how work is distributed (Hutchins, 1995; Woods, 2003; Smith et al., 2007), emergence (Patterson et al., 2010; Wilson, 2014), coupling and cascades (Woods and Hollnagel, 2006; Bradshaw et al., 2013; Saurin and Werle, 2017), time-dependent patterns (Grant et al., 2018; Woods et al., 2021), systems pressures (Cook and Rasmussen, 2005; Woods et al., 2010), and local adaptations (Koopman and Hoffman, 2003; Nemeth et al., 2008; Amalberti, 2013; Woods et al., 2013). Although SEIPS-supported research efforts have produced insights relative to some of these, including emergent aspects of systems (Werner et al., 2017), these are rare and are idiosyncratic to specific research teams. Our observations and analysis also would have benefited from a more robust set of systems patterns focused on these additional perspectives. For example, using SEIPS to map the trade-offs and adaptations that are required to respond to varying pressures within work systems might facilitate the identification of other vital interactions.

5. Limitations and future research

This study was conducted at a single institution and is therefore limited by institutionally unique socio-organizational characteristics. Surgical instrument trays discussed here do not account for all tray types in the system as scopes, electronic instruments, and robotic instruments were excluded. Due to the systemically fluid nature of shared workplace roles in healthcare environments and the highly variable needs of different surgical procedures, team members and tasks listed in the tools are not intended to be complete or exhaustive but are included to demonstrate the variety of individuals and tasks involved within the chosen scope of the use and reprocessing of surgical trays. Systems analysis follows neither classic quantitative nor qualitative approaches but utilizes mixed methods and relies on the expertise within the team to appropriately represent the system. Appropriate representation was confirmed using member checks with 3 select senior staff members. Systems tools are reliant on their own limitations as well as those of an observer, as all details may not have been accounted for. SEIPS is not intended to give precise recommendations for quality improvement actions, but rather to describe the system and facilitate research, management, and the development of workplace interventions. SEIPS 101 tools were applied here in a broad organizational context to help illustrate the organizational complexities associated with the delivery of surgical care, and other tools or versions of the tools could be used to represent the system differently, particularly when examining system-wide interactions in greater depth. Our investigation did not utilize the SEIPS 101 People Map, Outcomes Matrix, Interactions Diagram, Systems Story, or Task-Tools Matrix due to the scope of the study as well as time and resource limitations. It may be useful to compare the validity of the SEIPS 101 tools at other institutions.

6. Conclusions

The results presented here suggest that the preparation, delivery, and usage of surgical trays are organizationally complex processes, and that effective delivery of surgical care fundamentally depends upon organizational interdependencies to be successful. In addition, the implementation of off-site storage and reprocessing of surgical instruments results in additional changes throughout the entire process and organization. Understanding these interdependencies may be useful for improving quality of care, organizational efficiency, and patient safety. Systems tools such as SEIPS 101 might help provide a greater understanding of systemic issues which affect healthcare teams in their daily work and may assist with departmental management, organizational decision making, planning for future challenges and the eventual development of effective workplace interventions. Due to the highly interdependent nature of the healthcare work environment, successful quality improvement in the use and reprocessing of surgical instruments may benefit from interventions at multiple levels of the organization across departmental boundaries.