- Appendix Book -

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Appendix Book

-E.J. Voogd

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- Appendix Book –

This Appendix Book is created as a supplement to the core text of the master thesis. This document contains declaring theories, extra reasoning, used documents during the data collection phase, rough data (figures and tables), photo’s and different other used and declaring documents. This Appendix Book is structured on the base of the structure – and references of the core text. The references are visible as Appendix Book ?.

This Appendix Book contains the following documents (between brackets we have mentioned the page number of the core text):

I Market situation and Internal situation (p.17)

II The new DBC case-mix system (p.18)

III Cost price calculation (p.19)

IV Four stages of the transition period (p.24)

V Health Care Providers’ Supply Chain (p.32)

VI Outsourcing and Environment Management (p.34)

VII Record list used during the materials preparation time study (p.60)

VIII Used task list card during MDWS technique (p.61)

IX Out of OK study form (p.62)

X Questionnaire Surgical Assistants (p.67)

XI Time schedule for transports between SPD and Operations Center (p.79)

XII Causes of the emergency appeals of the four quarters of 2008 (p.89)

XIII Comments by not specified reasons of emergency appeals non stock items (p.89)

XIV Overview of the found 117 emergency appeals for non stock items (p.91)

XV Overview of the 29 found emergency appeals for stock items (p.91)

XVI Overview of the emergency appeals reusable items for 2007, 2008 and 2009 (p.92)

XVII General description of a Surgical Assistant (p.95)

XVIII Total overview of the general health, UBS and JDI of Surgical Assistants (p.101)

XIX Different elements of the Job Descriptive Index (work items) (p.102)

XX Paper registration forms of special non stock items (p.115)

XXI Appeal of a medical resource Form (p.119)

XXII Integrated logistical service centers at Deventer Hospital and MCL (p.134)

XXIII Connection between planning, preparation protocols and inventory level (p.147)

XXIV Vacancies of Surgical Assistants at Dutch Hospitals (p.148)

XXV Sterility of the operations center (p.150)

XXVI Salary scales of hospitals in The Netherlands (p.152)

XXVII Used picking list at the Martini Hospital Groningen (p.152)

XXVIII Used Picking list at the Medical Center Leeuwarden (p.152)

XXIX Layout of the integrated logistical service center of the MHG (p.152)

XXX Content of two procedure trays of the Martini Hospital Groningen (p.152)

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I. Market Situation and Internal Situation Theory

The market situation consists of elements like customer needs, market positioning, competitor’s actions and environmental changes. Based on the market situation, companies will develop, adjust or change their corporate strategy. Within the corporate strategy, each business unit will need to compile its own business strategy. This will set out its individual mission, objectives and strategy about how it intends to compete in its markets. Similarly, within the business each function will need to consider what part it should play in contributing to the strategic and/or competitive objectives of the business by developing a functional strategy which guides its actions within the business [Barney, 1986].

This top-down perspective provides an orthodox view of how functional strategies are put together. In reality, however, the relationship between the different levels in the strategy hierarchy is more complex. This hierarchical view does not represents the way strategies are always formulated. When a department is developing or reviewing its strategy, it will also take into account the internal circumstances. Businesses, when reviewing their strategies, will consult the individual functions within the business about their constraints and capabilities. Further, they may also incorporate the ideas that come from each function’s day-to-day experience. Functional strategies thus also involve elements of a bottom-up view [Bourne et al, 2003]. Instead of thinking in terms of hierarchy of strategies, it thus is better to think in terms of heterarchies of strategies [Hedlund, 1986]. Faced with the turbulent environment that confronts a typical organization today, it is better to view corporate, business and functional strategies not only as a top-down hierarchy with very separate roles and responsibilities, but as an interdependent network or heterarchy with a fundamental challenge, for all the different levels of strategy, of continuous adaptation and renewal [Chakravarthy, 1996].

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which an organization performs, with its corporate and business strategy. The disaggregation of businesses into their component activities in Porter’s value chain heightens the importance of functions and functional strategies to competitive success [Porter, 1996].

Functional strategies include marketing strategies, new product development strategies, human resource strategies, financial strategies, legal strategies, information technology management strategies and operational strategies. The emphasis is on short and medium term plans and the strategies are limited to the domain of each department’s functional responsibility [Chakravarthy and Henderson, 2007].

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II. The new DBC case-mix system

In the DBC case-mix system, a separation is made between DBCs with fixed prices (list A) and with negotiable prices (list B). For DBCs on list A, fixed tariffs apply to all hospitals and include two distinct components: a reimbursement of hospital costs and a honorarium for medical specialists. In the existing situation, reimbursement of list A DBCs only deals as a mode to transfer money from health insurers to hospitals and medical specialists. Like in the preceding hospital reimbursement system, the allowable budget of hospitals and medical specialists for list A concerned health care services is still based on a limited number of budget parameters

[Borhuis et al, 2003]:

• The hospital’s adherent population

• The type of facilities present

• The number of beds

• Production parameters (number of bed days, outpatient visits, etc.)

The level of production is discussed with insurers, and the result is an input into the calculation of the hospital budget. If the total amount of DBC reimbursements exceeds or remains below the allowable budget, differences are compensated by a closing tariff in the next year. If the expenses of the hospital transcend the allowable costs, the deficit is for account of the hospital. This even is true when the overspending is due to a higher volume of production. It is expected that in the near future, the allowable budget will be rescinded and the hospital’s and medical specialists’ compensation will eventually depend on DBC reimbursement.

In that situation, health care expenditures will be guided by agreements between health insurers and medical centers about the maximum numbers of DBCs to be compensated each year. This means that a higher production may lead to higher costs without additional reimbursement, while a lower production than agreed upon will directly result in lower benefits for the hospital

[Oostenbrink and Rutten, 2006].

Health care services performed for list B DBCs are not part of the allowable budget. Deficiencies or earnings on list B DBCs are the responsibility of the hospital. Inequality of actual profits of list B DBCs and costs of the medical center are not compensated by a closing tariff. Also the prices of list B DBCs are not fixed, but are the outcome of negotiations between hospitals and health insurers. Insurers may exert different DBC prices for different hospitals. Simultaneously, hospitals may negotiate distinct prices for the same DBCs with different insurers [Oostenbrink and Rutten, 2006].

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III. Cost price calculation

To be able to calculate the unit costs, a general product-costing model was developed. It is possible to see that a distinction is made between intermediate and final products. The final products are the DBCs.

The costs of the cost centres (hospital departments) are separated in direct costs and allocated costs. Direct costs are costs made by the cost centres and allocated costs are costs made by departments that are not providing patient care (support cost centres; overheads). The costs of these support cost centres are assigned to final cost centres using direct allocation. This means that the costs of support cost centres are assigned to the final cost centres using a weighting methodology based on various allocation bases as area (m²), number of full time equivalents, etc.

In the current controlling of hospitals, internal departments are thus often treated as cost centers

[Atkinson et al, 2004]. Real cost-price calculation is only applied on a very limited scale. In the

Product-costing model used by the hospitals to calculate the unit cost of intermediate products and DBCs (source: Oostenbrink & Rutten, 2006)

COST CENTERS are responsibility centers in which employees control costs but do not control revenues or investment level. Organizations evaluate the performance of cost center employees by comparing the center’s actual costs with target or standard cost levels for the amount and type of work done

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IV. Four stages of the transition period

On first hand it is possible to say that it is rather strange that health care organizations, which are mainly regarded as service firms [Jelovac and Macho-Stadler, 2002], not earlier considered the use and application of operations management concepts from the production environment. When they, for example, would had walked into an automobile factory in the fifties or the sixties, they would already had observed it in action. It however took a long time before services were considered as different from goods. Until the seventies, literature mentioned no differences. This more or less explains the slow transition from operations management concepts to the service environment and ultimately to the hospital environment. It is possible to subdivide the period from the seventies until today in four stages [Johnston, 2005][Johnston, 2005].

Stage one

Before 1980, business academics were primarily concerned with the production, marketing, and management of physical goods. This while by 1955, the service sector already accounted for just over 50 per cent of the gross domestic product in developed countries, overtaking the product-based sectors. Yet it took another 20 years before the Operations Management academics of that day started to apply their knowledge and skills to service operations [Parker, 1973].

Operations Management in 1970 was known as Production Management. It had developed out of an even more focused view of operations, Factory Management. Factory management was the name given to the search for efficiency in the post-industrial revolution period based upon Taylor’s philosophy of scientific management [Horn, 1978]. Production management was concerned with applying techniques like production planning and control, capacity management and materials management in production settings [D’Netto and Sohal, 1999]. Since 1970 there were the first recognitions of some kind of service operations [Johnston, 1972].

Service Operations was essentially considered as “operations research applied to service settings”

[Chase, 1996]. The major breakthrough came in 1976 with the publication of the article “Match supply and demand in service industries” in the Harvard Business Review, followed two years later by the textbook Management of Service Operations containing what is now regarded as classic cases and issues [Sasser, 1976].

In essence, this first stage was the “crawling out” stage and was characterised by the notification of the existence of services. The nature of academic work was primarily descriptive and focused on the difference between goods and services.

Stage two

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Stage three

The third stage in the development of Service Management has been characterised by the multidisciplinary nature of the service research. Different functional disciplines came together. Marketing, Operations and HRM, in particular, brought together their different strengths and perspectives to issues of common concern. This period, from around 1985 to 1995, was the time of Service Management. A subject whose strength lies in its multidisciplinary nature and approaches.

Stage four

It looks like service firms now finally have entered the fourth stage concerned with the application of the tools and frameworks to improve service processes. This fourth stage is characterised by a “return to the roots”, a realisation that they might have lost, or unknowingly ignored, the strength of their core disciplines in the developing of service management. Organizations in all service industries, including hospitals, therefore develop new strategies to respond to environmental factors and competitive challenges [Goldstein et al, 2002]. They namely can no longer afford it to see themselves as operational different than other businesses

[Kumar et al, 2008].

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V. Health Care Providers’ Supply Chain

The supply chain of a prototype health care provider is mainly characterized by its complexity. This results on the one hand from the multitude of different supplies used by the institutions and the multiple distribution channels through which they flow. These supplies may come directly from the manufacturer or transit through a distributor. On the other hand, the complexity resides as well with the healthcare providers themselves, which are not the end consumers. Hospitals must deploy their own logistic network for delivering supplies to the patient care units and, ultimately, to the users (doctors), or point of care. As a result, a major characteristic of the healthcare sector supply chain is the simultaneous presence of two chains: one external and the other internal [Richard-Rover et al, 2002].

As already mentioned, the pressures on hospital supply chains are changing. In the past, a hospital that managed its purchasing costs well could operate efficiently. Today, the cost of materials management can exceed 35 percent of a hospital’s operating budget, with nearly 20-25 percent attributable to supply costs alone.

The hospital supply chain has insufficient linkages to clinical systems, revenue cycle, IT, and clinical operations. The supply chain often is viewed as a ‘back dock’ support service that

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VI. Outsourcing and Environment Management

Outsourcing

As already mentioned, outsourcing is an approach that can be an outgrowth of supply chain reengineering. Outsourcing means looking upstream and downstream in the supply chain of which the organization is part of, and cutting of some traditional processes of the organization. Activities and tasks that are outsourced should be those that external organizations can do more efficiently because of lower costs, greater scale or better performance. This should be activities and tasks that do not add to the core qualities users and demanders consider important.

The supply and cleaning, decontamination and sterilization of materials and instruments to the surgery departments can be regarded as a non core activity of a hospital and thus as a process that is suitable for outsourcing. Possible mentioned benefits are the availability of more qualified employees, greater flexibility, higher quality, lower costs, higher liquidity and solvability and a higher shareholder value [Jiang et al, 2006]. Because of the main disadvantages (loosing of knowledge, dependence on external organizations and negative consequences of not having the right materials and instruments), the University Medical Center Groningen has decided to not (yet) consider the outsourcing of supply chain processes. Instead, they consider the establishment of a shared service center with some other hospitals in the northern part of The Netherlands. In this way they try to generate the same advantages as with outsourcing, but with less disadvantages. Because outsourcing is not really an option for the UMCG, this subject will not further be discussed during this research.

Environment Management

There is a growing recognition that the environmental consequences of business strategies need to be considered during decision making. These environmental consequences include all the links from the manufacturing of raw materials to the end-user, including production, transport and disposal. Environment management is seen as one of the seven challenges European companies will face in this millennium. In the past years, the environment namely has increasingly come into focus. Many companies have started to carry out life cycle analyses of their products and processes in order to reduce adverse environmental impact on the total supply chain [Skjoett-Larsen, 2000].

Also for hospitals it is important to reduce the environmental impacts of their total supply chain. As with other industries, the main impact is due to the transport of materials and instruments and the waste of these materials and instruments. This waste can be the consequence of usage (throwing away disposables) or the expiration of the perishable date.

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VII. Record list used during the materials preparation time study

Nr Totale Tijd

Aantal Magazijnen

Aantal Producten

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VIII. Used task list card during MDWS technique

Specialisme: Thorax Chirurgie Functie: Omloop

Datum meting: Starttijd meting: Eindtijd meting:

BINNEN EEN OK:

Time Out uitvoeren en begeleiden

Klaarzetten instrumentarium / Klaarmaken OK voor operatie

Administratie

Aangeven benodigdheden aan instrumenterende Wachten (op werk)

Opruimen OK na afloop van een operatie Overige werkzaamheden binnen een OK

BUITEN EEN OK

Logistieke werkzaamheden buiten een OK (z.o.z.) Overige werkzaamheden buiten een OK

Aantal keer uit OK:

Mogelijke logistieke werkzaamheden:

• Bestellen van instrumentensets, disposables, etc.

• Klaarzetten van instrumentensets, disposables, etc.

• Opruimen van instrumentensets, disposables, etc.

• Zoeken van instrumentensets, disposables, etc.

• Administratief logistieke werkzaamheden (invullen van aanvraagformulieren, leensetformulieren, etc.)

• Overige werkzaamheden rondom de voor operaties benodigde Materialen en instrumenten

Wilt u bij elke meting een nieuw kaartje gebruiken? Nieuwe kaartjes (en piepers) zijn op te halen bij Judith de Priester (W1.104)

Ingevulde kaartjes en gebruikte piepers kunt u na de meting inleveren bij Judith de Priester (W1.104)

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IX. Out of OK study form

Nr Soort en duur Operatie Aantal keer uit OK Reden verlaten OK (op volgorde van verlaten)

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X. Questionnaire Surgical Assistants

1.

Wij willen graag weten hoe gezond u zich voelt en welke klachten u de afgelopen 6 maanden hebt gehad. Wilt u daarom alle onderstaande vragen beantwoorden door bij iedere vraag het antwoord dat het meest op u van toepassing is omcirkelen. Denk erom dat het bij deze vragen uitsluitend gaat om de klachten van dit moment of

van de afgelopen 6 maanden en dus niet om klachten die u in het verleden ooit hebt gehad.

1. Bent u de laatste tijd door zorgen veel slaap tekort gekomen?

1. Helemaal niet

2. Niet meer dan gewoonlijk

3. Wat meer dan gewoonlijk

4. Veel meer dan gewoonlijk

2. Hebt u de laatste tijd het gevoel gehad dat u voortdurend onder druk stond?

1. Helemaal niet

3. Hebt u zich de laatste tijd kunnen concentreren op uw bezigheden?

1. Beter dan gewoonlijk

2. Net zo goed als gewoonlijk

3. Slechter dan gewoonlijk

4. Veel slechter dan gewoonlijk

4. Hebt u de laatste tijd het gevoel gehad zinvol bezig te zijn?

1. Zinvoller dan gewoonlijk

2. Net zo zinvol als gewoonlijk

3. Minder zinvol dan gewoonlijk

4. Veel minder zinvol dan gewoonlijk

5. Voelde u zich de laatste tijd in staat om beslissingen (over dingen) te nemen?

1. Beter in staat dan gewoonlijk

2. Net zo goed in staat als gewoonlijk

3. Wat minder goed in staat dan gewoonlijk

4. Veel minder goed in staat dan gewoonlijk

6. Hebt u de laatste tijd het gevoel gehad dat u uw moeilijkheden niet de baas kon?

1. Nee, had dat gevoel helemaal niet

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7. Hebt u zich de laatste tijd alles bij elkaar redelijk gelukkig gevoeld?

1. Gelukkiger dan gewoonlijk

2. Even gelukkig als gewoonlijk

3. Minder gelukkig dan gewoonlijk

4. Veel minder gelukkig dan gewoonlijk

8. Hebt u de laatste tijd plezier kunnen beleven aan uw gewone, dagelijkse bezigheden?

1. Meer dan gewoonlijk

2. Even veel als gewoonlijk

3. Wat minder dan gewoonlijk

4. Veel minder dan gewoonlijk

9. Hebt u zich de laatste tijd ongelukkig en neerslachtig gevoeld?

1. Helemaal niet

10. Bent u de laatste tijd het vertrouwen in uzelf kwijtgeraakt?

1. Helemaal niet

11. Hebt u zich de laatste tijd als een waardeloos iemand beschouwd?

1. Helemaal niet

4. Veel minder goed in staat dan gewoonlijk

12. Bent u de laatste tijd in staat geweest uw problemen onder ogen te zien?

1. Beter dan gewoonlijk

2. Net zo goed als gewoonlijk

3. Minder goed in staat dan gewoonlijk

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2.

De volgende uitspraken hebben betrekking op hoe u uw werk beleeft en hoe u zich daarbij voelt.

Wilt u aangeven hoe vaak iedere uitspraak op u van toepassing is door steeds het best passende cijfer (van 0 tot 6) te omcirkelen?

Nooit Spora-disch

Een paar keer per jaar of minder Af en toe Eens per maand of minder Regel-matig Een paar keer per maand Dikwijls Eens per week Zeer dikwijls Een paar keer per week Altijd Dagelijks

1. Ik voel me mentaal uitgeput

door mijn werk. 0 1 2 3 4 5 6 2. Ik twijfel aan het nut van mijn

werk. 0 1 2 3 4 5 6 3. Een hele dag werken vormt

een zware belasting voor mij.

0 1 2 3 4 5 6

4. Ik weet de problemen in mijn werk goed op te lossen. nn

0 1 2 3 4 5 6

5. Ik voel me "opgebrand" door

mijn werk. nnnnnnnnnnnn 0 1 2 3 4 5 6

6. Ik heb het gevoel dat ik met mijn werk een positieve bijdrage lever aan het functioneren van de organisatie.

0 1 2 3 4 5 6

7. Ik merk dat ik teveel afstand heb gekregen van mijn werk.

0 1 2 3 4 5 6

8. Ik ben niet meer zo enthousiast als

vroeger over mijn werk.

0 1 2 3 4 5 6

9. Ik vind dat ik mijn werk goed doe.

0 1 2 3 4 5 6

10. Als ik op mijn werk iets afrond vrolijkt me dat op. nnnnn

0 1 2 3 4 5 6

11. Aan het einde van een werk dag voel ik me leeg.

0 1 2 3 4 5 6

12. Ik heb in deze baan veel waardevolle dingen bereikt.

0 1 2 3 4 5 6

13. Ik voel me vermoeid als ik

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14. Ik ben cynischer geworden over de effecten van mijn werk.

0 1 2 3 4 5 6

15. Op mijn werk blaak ik van zelfvertrouwen. nnnnnnnnnn

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3.

Wilt u bij ieder aspect aangeven of het van toepassing is? Is het wel van toepassing, omcirkel dan ja;

Is het niet van toepassing, omcirkel dan nee; Weet u het niet, of twijfelt u, omcirkel dan ?.

WERK 1. Fascinerend ja ? nee 2. Routinematig ja ? nee 3. Bevredigend ja ? nee 4. Saai ja ? nee 5. Goed ja ? nee 6. Creatief ja ? nee 7. Respectabel ja ? nee 8. Vervelend ja ? nee 9. Plezierig ja ? nee 10. Zinvol ja ? nee 11. Vermoeiend ja ? nee 12. Gezond ja ? nee 13. Uitdagend ja ? nee 14. Eenvoudig ja ? nee 15. Frustrerend ja ? nee 16. Simpel ja ? nee

17. Komt geen eind aan ja ? nee

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4.

Wilt u aangeven in hoeverre onderstaande werkaspecten invloed hebben op uw welbevinden,

werkbeleving of plezier in het werk?

• Vindt u dat dat het betreffende aspect een negatieve invloed heeft, omcircel dan 1, 2 of 3.

• Heeft het aspect geen invloed, omcircel dan 4.

• Vindt u dat dat het betreffende aspect een positieve invloed heeft, omcircel dan 5, 6 of 7.

zeer negatief negatief ietwat negatief geen invloed ietwat positief positief zeer positief 1. Lichamelijke belasting 1 2 3 4 5 6 7 2. Emotionele belasting

(persoonlijk geraakt worden door dingen die u meemaakt in uw werk) 1 2 3 4 5 6 7 3. Werktempo en werkhoeveelheid 1 2 3 4 5 6 7 4. Afwisseling in werkzaamheden 1 2 3 4 5 6 7

5. Onduidelijkheden over taak (verantwoordelijkheden, verwachtingen)

1 2 3 4 5 6 7

6. Taakinhoud, aard van werkzaamheden

1 2 3 4 5 6 7

7. Samenwerking met andere afdelingen/groepen.

1 2 3 4 5 6 7

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5.

Tenslotte, nog enkele taakinhoudelijk georiënteerde vragen. Geef bij elke vraag uw mening door een cijfer op de reeks van 1 tot 10 te omcirkelen. 1 staat voor heel erg negatief, 10 staat voor heel erg positief.

De volgende vragen, vragen u naar uw mening over logistieke werkzaamheden. Met logistieke werkzaamheden wordt het bestellen, klaarzetten en zoeken van medische instrumenten en materialen bedoeld (buiten de OK) Hieronder vallen tevens administratieve werkzaamheden die logistiek georiënteerd zijn..

1. Wat is uw mening ten aanzien van logistieke werkzaamheden als Operatie Assistent. In hoeverre vindt u dit onderdeel van uw functie?

1 2 3 4 5 6 7 8 9 10

2. Hoeveel plezier heeft u in het uitvoeren van logistieke werkzaamheden als Operatie Assistent?

1 2 3 4 5 6 7 8 9 10

3. Hoe vindt u dat de huidige logistiek op het Operatiecentrum is geregeld?

1 2 3 4 5 6 7 8 9 10

4. In hoeverre vindt u het klaarzetten van materialen en instrumenten voor een operatie een taak van een Operatie Assistent?

1 2 3 4 5 6 7 8 9 10

5. In hoeverre bent u het eens met de stelling dat logistieke taken uitgevoerd zouden moeten worden door logistieke medewerkers?

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6.

Wilt u tot slot onderstaande vragen beantwoorden?

1. Geslacht: 1. man (doorstrepen wat niet van toepassing is)

2. vrouw 2. Leeftijd: ……….

3. Hoeveel uur per week werkt u? ... uur per week

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XI. Time Schedule for transports between SPD and Operations Center

Picking up Transport time Delivery Comments

7:00 7:15 7:30 Housekeeping will take care that carts are downstairs at 07:15

10:30 10:45 11:00 11:30 11:45 12:00 13:00 13:15 13:30 13:30 13:45 14:00 14:30 14:45 15:00 15:30 15:45 16:00 16:30 16:45 17:00 17:30 17:45 18:00 18:30 18:45 19:00 19:30 19:45 20:00 21:00 21:15 21:30

Weekend and holidays

7:00 7:15 7:30

13:00 13:15 13:30

14:15 14:30 14:45

Picking up Transport time Delivery Comments

7:00 7:15 7:30 SPD will take care that carts are downstairs at 07:00

7:30 7:45 8:00 10:30 10:45 11:00 11:30 11:45 12:00 13:30 13:45 14:00 14:30 14:45 15:00 15:30 15:45 16:00 16:30 16:45 17:00 18:30 18:45 19:00 19:30 19:45 20:00 21:00 21:15 22:30 22:30 22:45 23:00

Weekend and holidays

7:00 7:15 7:30

13:00 13:15 13:30

14:15 14:30 14:45

Developed time schedule of transport between SPD and the operations center

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XII. Causes of the emergency appeals of the four quarters of 2008

Table 1, 2, 3 and 4 show the causes of the emergency appeals of the four quarters of 2008. All four tables show that the greatest cause of an emergency appeal is a late request by an appealing department. This means that a department indicates at a too late moment that a certain disposable instrument is necessary for a surgery or a series of surgeries. The table further shows that also an irregular usage of products results in a high amount of emergency appeals.

1 Late request/ confirmation by appealing department 128 35%

2 Shortage in the warehouses 7 2%

3 Crossed delivery period by suppliers 15 4%

4 Irregular usage of products 96 27%

5 Appeal to long at purchasing department 8 2%

6 Patient commited product 45 12%

7 Part due to emergency repair 6 2%

8 Remaining, not possible to specify 57 16%

362

380

324

Table 1, Causes of the emergency appeals of the first quarter of 2008

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362

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XVI. Overview of the emergency appeals of reusable items of 2007, 2008

and 2009

Week ΣΣΣΣ Week ΣΣΣΣ Week ΣΣΣΣ

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Wk 32 2008 15 Wk 33 2008 11 Wk 34 2008 24 Wk 35 2008 10 Wk 36 2008 34 Wk 37 2008 21 Wk 38 2008 18 Wk 39 2008 28 Wk 40 2007 36 Wk 40 2008 17 Wk 41 2007 20 Wk 41 2008 24 Wk 42 2007 20 Wk 42 2008 19 Wk 43 2007 24 Wk 43 2008 15 Wk 44 2007 44 Wk 44 2008 30 Wk 45 2007 33 Wk 45 2008 5 Wk 46 2007 28 Wk 46 2008 41 Wk 47 2007 18 Wk 47 2008 28 Wk 48 2007 28 Wk 48 2008 33 Wk 49 2007 20 Wk 49 2008 18 Wk 50 2007 30 Wk 50 2008 24 Wk 51 2007 32 Wk 51 2008 23 Wk 52 2007 11 Wk 52 2008 3 344 1140

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XVII. General description of a Surgical Assistant

Together with the surgeons, perfusionists and anesthetists, the surgical assistant is one of the present professions in an operation room. The surgical assistants provide aid in exposure, homeostasis, closure, and other intra operative technical functions that help the surgeon carry out a safe operation with optimal results for the patient. In addition to intra operative tasks, the surgical assistant also performs preoperative and postoperative tasks to better facilitate proper patient care. The surgical assistant performs these functions during the operation under the direction and supervision of the surgeon.

A surgical assistant executes three core tasks:

• Walk around (Dutch: Omloop)

o Inside (Dutch: Binnenomloop)

o Outside (Dutch: Buitenomloop)

• Instrumenting (Dutch: Instrumenterende)

• Assisting (Dutch: Assisterende)

The surgical assistant who walks round inside an operation room, stands outside the sterile field and prepares surgeries, extends the sterile surgical team extra materials and cleans up an operation room after a surgery. The surgical assistant who walks round outside an operation room brings different missing materials from the different warehouses, prepares surgical carts and helps with the cleaning up of an operation room. The instrumenting surgical assistant stands inside the sterile field and extends the necessary instruments, suture materials and disposables to the surgeon. The assisting surgical assistant presents tissues, binds sutures and assists during an operation.

The present persons in an operation room, all have a standard position around the operating table. These positions are presented in the following figure and table.

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As already mentioned in the introducing chapter of the master thesis, there are three different sectors at the operations center at the UMCG. Although these sectors comprise different specialisms, the tasks of the surgical assistants are comparable. The only and main difference is that sector 1 is working with a sector assistant as outside walk around. At the other two sectors, a surgical assistant is executing the outside walk around tasks.

Normally the day of a surgical assistant starts around 08:00 am, at the time when the first surgeries begin. Based on the kind of surgeries, the present surgeons and the present surgical assistants the four different surgical assistant tasks are distributed among the present surgical assistants. Because not every surgical assistant is capable of executing all the tasks and because surgeons have preferences for assisting and instrumenting surgical assistants, this distribution always is a complex operation. Based on the specialism, a surgical assistant can execute different tasks during a day. He or she, for example, can be instrumenting during the first surgery and assisting during the second.

1 Patient

2 Surgeon

3 Surgical Assistant (assisting)

4 Surgical Assistant (instrumenting)

5 Surgical Assistant (walk around)

6 Anaesthetist

7 Perfusionist

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XVIII. Total overview of the general health, Utrecht Burnout Scale and

Job Descriptive Index of surgical assistants

Respondent Score 0-12

Variabel minimum

Norm scores

1 = really low, 2 = low, 3 = average, 4 = high, 5 = really high

UBOS-A JDI

GHQ Exh. Dep. Pers. Work

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XIX. Different elements of the Job Descriptive Index (work items)

Job descriptive index [Work item: Fascinating]

Frequency Percent Valid Percent Cumulative Percent

Sometimes 0 0,0% 0,0%

Yes 27 93,1% 93,1% 93,1%

No 2 6,9% 6,9% 100,0%

Total 29 100,0% 100,0%

Job descriptive index [Work item: By experience]

Sometimes 3 10,3% 10,3%

Yes 12 41,4% 41,4% 51,7%

No 14 48,3% 48,3% 100,0%

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Job descriptive index [Work item: Satisfactory]

Sometimes 3 10,3% 10,3%

Yes 25 86,2% 86,2% 96,6%

No 1 3,4% 3,4% 100,0%

Total 29 100,0% 100,0%

Job descriptive index [Work item: Boring]

Yes 1 3,4% 3,4% 10,3%

No 26 89,7% 89,7% 100,0%

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Job descriptive index [Work item: Good]

Sometimes 4 13,8% 13,8%

Yes 24 82,8% 82,8% 96,6%

No 1 3,4% 3,4% 100,0%

Total 29 100,0% 100,0%

Job descriptive index [Work item: Creative]

Sometimes 5 17,2% 17,2%

Yes 19 65,5% 65,5% 82,8%

No 5 17,2% 17,2% 100,0%

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Job descriptive index [Work item: Respectable]

Sometimes 7 24,1% 24,1%

Yes 19 65,5% 65,5% 89,7%

No 3 10,3% 10,3% 100,0%

Total 29 100,0% 100,0%

Job descriptive index [Work item: Dull]

Sometimes 6 20,7% 20,7%

Yes 0 0,0% 0,0% 20,7%

No 23 79,3% 79,3% 100,0%

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Job descriptive index [Work item: Pleasant]

Sometimes 5 17,2% 17,2%

Yes 24 82,8% 82,8% 100,0%

No 0 0,0% 0,0% 100,0%

Total 29 100,0% 100,0%

Job descriptive index [Work item: Appropriate]

Yes 28 96,6% 96,6% 100,0%

No 0 0,0% 0,0% 100,0%

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Job descriptive index [Work item: Tiring]

Sometimes 4 13,8% 13,8%

Yes 21 72,4% 72,4% 86,2%

No 4 13,8% 13,8% 100,0%

Total 29 100,0% 100,0%

Job descriptive index [Work item: Healthy]

Sometimes 12 41,4% 41,4%

Yes 4 13,8% 13,8% 55,2%

No 13 44,8% 44,8% 100,0%

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Job descriptive index [Work item: Challenging]

Sometimes 6 20,7% 20,7%

Yes 21 72,4% 72,4% 93,1%

No 2 6,9% 6,9% 100,0%

Total 29 100,0% 100,0%

Job descriptive index [Work item: Simple]

Sometimes 5 17,2% 17,2%

Yes 0 0,0% 0,0% 17,2%

No 24 82,8% 82,8% 100,0%

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Job descriptive index [Work item: Frustrating]

Sometimes 13 44,8% 44,8%

Yes 3 10,3% 10,3% 55,2%

No 13 44,8% 44,8% 100,0%

Total 29 100,0% 100,0%

Job descriptive index [Work item: Easy]

Yes 0 0,0% 0,0% 6,9%

No 27 93,1% 93,1% 100,0%

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Job descriptive index [Work item: Never ends]

Sometimes 5 17,2% 17,2%

Yes 2 6,9% 6,9% 24,1%

No 22 75,9% 75,9% 100,0%

Total 29 100,0% 100,0%

Job descriptive index [Work item: Gives a sense of competence]

Sometimes 4 13,8% 13,8%

Yes 23 79,3% 79,3% 93,1%

No 2 6,9% 6,9% 100,0%

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XXII. Integrated logistical service centers at Deventer Hospital and

Medical Center Leeuwarden

Central

Warehouse Exit autoclaves SPD Goods receipt point

external supplies

Operation Rooms

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XXV. Sterility of the operations center

The operations center is the area in a hospital where the different surgeries and connected activities are taking place. It is sometimes called the heart of the hospital. In general, the operations center is centralized in a hospital to reduce the possibility of micro organisms entering the operation room. The most important room inside the operations center is the operation room. All the remaining rooms are in support of the operation room, and they don’t have to meet all the special and strict demands. The different areas within an operations center are presented in the following table. It is also possible to distinguish the prescribed amount of sterility of the different rooms.

Inside the operation room, everything is aimed at the quickly recovering of patients. Prevention of infections is very important. Especially in case of prosthesis and implant surgeries there are great chances of infections by micro organisms. Hospitals therefore are trying to keep micro organisms out of the operation room by the creation of a pressure difference between the operation room and bounded rooms. The realization of a pressure difference is established by adding more clean air to the sterile area than removing dirty air from this sterile area. This will result in an overpressure. Between the sterile room and adjacent rooms, one or more over current lattices are placed, through which the clean air can flow to the adjacent rooms. This pressure

Area 1, Not clean Reception +

Staff Rooms +

Recovery +

Holding +

Introduction Room +

Laundry Room +

Area 2, Clean Sterile warehouses ++

Anaesthetic warehouses ++

Corridors ++

Area 3, Sterile Operation Room +++

Preparation Room (Opdekruimte) +++

Sterile warehouses (Daily stock) +++

Area 4, Operations Area Space under the plenum +++++

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9 € 2.994,00

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XXIX. Layout of the integrated logistical service center at the Martini

Hospital Groningen

Exits of autoclaves (SSD)

Surgical sets and instruments (reusables) Surgical sets and instruments (reusables)

Disposables Disposables

Disposables Procedure Trays

Workplace logistical employees

Exit Case

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XXX. Sorts of procedure trays at Martini Hospital Groningen and UMCG

Procedure Trays Martini Hospital Groningen X

1 Sectio pakket 44

2 Groot universeel pakket 57

3 Universeel pakket 31

4 Extensie pakket 29

5 TUR pakket 20

6 Abdo perineaal pakket 64

7 Perifeer vaat pakket 55

8 Aneurysma pakket 78

9 Aanvullend Endo AAA pakket 65

10 Gatlaken pakket 18

11 Hoofd & Hals pakket 57

12 Oogset pakket 25

13 KNO Oor pakket 37

14 Klein chirurgisch en gynaecologisch pakket 23

15 Handpakket 24 16 Extremiteitenpakket 32 17 Schouderpakket 37 18 Arthroscopie pakket 34 19 UKB Pakket 49 20 Kniepakket 58 21 Heuppakket 55 22 Vaginaal pakket 34

23 Neuro Rug Nek pakket 36

24 Neuro craniotomie pakket 115

25 Tulband pakket 29

Procedure Trays UMCG X

1 Sectio Tray 46

Small packets UMCG

1 U-pakket 6 2 Thorax pakket 16 3 Basis pakket 8 4 Ortho pakket 1 7 5 Klein U-pakket 5 6 Hoofd-hals pakket 7 7 Tulband pakket 8 8 Oogheelkunde pakket 14 9 Craniotomiepakket 19 10 Urologiepakket 2 11 Gynaecologiepakket 5 12 Traumapakket 6 13 Ortho pakket 2 6 14 Kinderpakket 12

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XXXVII.

Picture Wall

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Picture 3, Different (expensive) medical resources lay dispersed over the offices

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XXXVIII.

Advantages and expansion

Advantages Procedure Trays

• Preparing surgical carts for surgeries takes less time

• Clearing away replenishment stocks takes less time

• Preparing surgeries takes less time

• Decrease of the amount of stock

• More standardization of the disposable assortment

Advantages hard cut between supporting functions and core care functions / Creation of an integrated logistical service center

• Possibility to implement a closed door policy

o Less infections / disturbance of sterility of an operation room

o Surgical assistants can stay in an operation room (less waiting and danger for patients)

• Less tasks for surgical assistants

o More focus on care related tasks

o Less forced flexibility

• Higher quality, higher speed and lower costs of execution of logistical tasks

o Surgical employees are more expensive than logistical employees

o Logistical employees have got more dedication, more effort and more time. They besides that also have higher interests, higher motivation and better education to do it effective, efficiently and properly

o Preparation of materials takes a lot of time from the surgical assistants. Logistical employees also are faster than surgical assistants

o Logistical employees can transport missing materials faster to an operation room

o Less empty operation rooms

o Less hiring of temporary workers

o Less job stress and health complaints of surgical assistants

o Less labor shortages

o More care related time for surgical assistants

o Less illness and job switches of surgical assistants

o Less frequent changes of locations of materials in warehouses

o Better determination of ideal amount of stock, safety stock and replenishment amount

Advantages of implementing a digital scanning system

• Management information about the process steps where (and how long) materials currently are postponed

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sharp enough anymore and thus need maintenance

• Management information about which materials are used during a surgery

o Possibility to adjust preparation protocols

o Possibility to create/adjust procedure trays

• Possibility to weigh instrument sets to check the completeness of these sets

• Direct insight in the location and the amount of stock of a certain material (when materials are immediately required or are lost)

• Create real time inventory levels and signals when certain materials require replenishment stocks

• Create up to date picking lists of specific surgery. Since all the locations of necessary materials and preparation protocols are present in the system the system can generate picking lists for all possible surgeries

• Fast indication of locations of necessary materials. Useful in case of night shifts (when no logistical employees are present) and in case of missing instruments during a surgery

• More reliable cost price calculation during a surgery since all the used materials are individually scanned instead of using a standard add-on percentage (which never is reliable since always different materials are used)

• Advantages in case of product recalls (it is not possible to check how much of the involved material is in stock, where these materials are stocked and which patients have been in touch with the involved materials)

• Generate picking lists based on the duration of the perishable dates of materials. It also would be possible to generate picking lists of materials with passed perishable dates

• Base the height of the stock levels and the amount of safety stock on the historical usage of the products

• Automatic reordering when the stock level falls below a stated stock level

• Connect all the used materials to the patient and present employees

o Trace the present employees at a specific surgery when the used instruments or instrument sets contain damages

• High savings because of possible elimination of paper-based systems

• Reduce the amount of emergency appeals

o More overview by SPD which instruments and/or instrument sets need priority

o More overview by care related employees whether materials are present / are entering the operations center in time

• When scanning materials when they leave the warehouse, in combination with reliable reordering levels and a reliable amount of safety stock and an overview of the future planning (several days and connected to reliable preparation protocols), it is possible to automatically reorder materials (based on supermarket reorder policy)

• Base picking lists on the perishable dates of inventories

• Create picking lists of products with passed perishable dates Advantages Inventory Management System

• Determining optimal and reliable amount of safety stock and order quantity

• Determine when amount of inventory falls below reorder point

• Monitor irregular usage of products which leads to replenishment orders and adjustment of safety stock amount and order quantity

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