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Improving Surgical Services at Memorial Regional Hospital: Evidence-Based
Recommendations
The Memorial Regional Hospital was recently sampled by the Joint Commission audit,
revealing that the hospital has several room areas to improve surgical services, which are covered
by 12 operational rooms, and the hospital has a total of 350 beds. Considering this, the hospital
administrator has commissioned an in-depth study that aims to evaluate workflow, patient safety,
compliance and operational efficiency. This report focuses on the existing practices involving
scheduling of the staff, use of equipment, orientation, and safety measures to establish the critical
areas of gaps that influence surgical performance. Upon this assessment, there are five major
suggestions of areas of improvement. The evidence-based suggestions are offered, and it is
recommended to follow AORN standards, CDC guidelines on infection control, and the latest
studies with the aim of contributing to improving patient safety, workflow organization, and
increasing high perioperative care quality in all operating rooms.
Analysis of Current Practices and Areas for Improvement
1. Inefficient Surgical Instrument Tray Management
Instrument tray analysis of surgical case logs and preference cards showed that there was
a high amount of redundancy in instrument trays. Several operations included tools that were
seldom used, leading to unnecessary sterilizations and extended preparation times. According to
Van Nieuwenhuizen et al. (2024), surgical trays can be optimized by actual use, which
contributes to better efficiency and waste reduction as well as patient safety. The practice
currently existing at Memorial Regional Hospital adds to the hospital's operational expenses and
the time taken between operations.
2. Suboptimal Staff Scheduling and Operating Room Utilization
, 2
The scheduling protocols of staff showed a lack of match-ups between the staff othering
during the peak periods of surgery, which led to delays in starting the cases and longer hours of
the operation. Lim et al. (2023) revealed that using the obstetric operating room staffing model
based on the queueing theory might improve the efficiency of the operation greatly. The existing
system used in the hospital sometimes lacks the required experienced surgical technologist or
circular staff to meet demand, which negatively impacts workflow and increases the chances of
making mistakes.
3. Inadequate Orientation and Training for New Surgical Technologists
The existing orientation checklist of new employees is mostly on the administrative front,
and not much real work training is given. According to incident reports, small procedural
mistakes, miscommunication, and equipment mishandling were common with newly onboarded
technologists. Many studies demonstrate that the effective reduction of errors and patient safety
is impossible without comprehensive perioperative education, such as competency tests and
scenario-based training (Association of periOperative Registered Nurses, 2022).
4. Equipment Maintenance and Compliance Gaps
Recordkeeping for equipment maintenance indicates that the records are inconsistent, and
sometimes there are delays when it comes to preventive maintenance schedules. The result of
such lapses is a compromise between sterile processing and the probabilities of complications
during operation. The Joint Commission (2021) requires the strict following of equipment
maintenance standards that may be regular checks and timely mending of defective equipment.
The non-compliance can impact the accreditation status and compromise patient safety.
5. Inefficient Storage and Inventory Management
Improving Surgical Services at Memorial Regional Hospital: Evidence-Based
Recommendations
The Memorial Regional Hospital was recently sampled by the Joint Commission audit,
revealing that the hospital has several room areas to improve surgical services, which are covered
by 12 operational rooms, and the hospital has a total of 350 beds. Considering this, the hospital
administrator has commissioned an in-depth study that aims to evaluate workflow, patient safety,
compliance and operational efficiency. This report focuses on the existing practices involving
scheduling of the staff, use of equipment, orientation, and safety measures to establish the critical
areas of gaps that influence surgical performance. Upon this assessment, there are five major
suggestions of areas of improvement. The evidence-based suggestions are offered, and it is
recommended to follow AORN standards, CDC guidelines on infection control, and the latest
studies with the aim of contributing to improving patient safety, workflow organization, and
increasing high perioperative care quality in all operating rooms.
Analysis of Current Practices and Areas for Improvement
1. Inefficient Surgical Instrument Tray Management
Instrument tray analysis of surgical case logs and preference cards showed that there was
a high amount of redundancy in instrument trays. Several operations included tools that were
seldom used, leading to unnecessary sterilizations and extended preparation times. According to
Van Nieuwenhuizen et al. (2024), surgical trays can be optimized by actual use, which
contributes to better efficiency and waste reduction as well as patient safety. The practice
currently existing at Memorial Regional Hospital adds to the hospital's operational expenses and
the time taken between operations.
2. Suboptimal Staff Scheduling and Operating Room Utilization
, 2
The scheduling protocols of staff showed a lack of match-ups between the staff othering
during the peak periods of surgery, which led to delays in starting the cases and longer hours of
the operation. Lim et al. (2023) revealed that using the obstetric operating room staffing model
based on the queueing theory might improve the efficiency of the operation greatly. The existing
system used in the hospital sometimes lacks the required experienced surgical technologist or
circular staff to meet demand, which negatively impacts workflow and increases the chances of
making mistakes.
3. Inadequate Orientation and Training for New Surgical Technologists
The existing orientation checklist of new employees is mostly on the administrative front,
and not much real work training is given. According to incident reports, small procedural
mistakes, miscommunication, and equipment mishandling were common with newly onboarded
technologists. Many studies demonstrate that the effective reduction of errors and patient safety
is impossible without comprehensive perioperative education, such as competency tests and
scenario-based training (Association of periOperative Registered Nurses, 2022).
4. Equipment Maintenance and Compliance Gaps
Recordkeeping for equipment maintenance indicates that the records are inconsistent, and
sometimes there are delays when it comes to preventive maintenance schedules. The result of
such lapses is a compromise between sterile processing and the probabilities of complications
during operation. The Joint Commission (2021) requires the strict following of equipment
maintenance standards that may be regular checks and timely mending of defective equipment.
The non-compliance can impact the accreditation status and compromise patient safety.
5. Inefficient Storage and Inventory Management
