What belongs in your procedure packs and what's just taking up space and costing you money? The short answer: Items that are used 90 percent of the time belong in your packs. But how do you get to that magic number? And — as your case mix, your surgeons and their preferences change — how do you stay there once you get there? That answer's a little trickier, so we surveyed your colleagues to find out what's worked for them.

As you'll see in this article, for packs to fulfill their promise of improving case efficiency and cost effectiveness, you must monitor their usage and usefulness on a regular basis — be it at audits at monthly staff meetings or periodic reviews based on surgeon requests. That's one point on which almost all 101 respondents to a recent Outpatient Surgery Magazine reader survey could agree.

When to review procedure packs?
How often do you review and update your procedure packs? The frequency varies: annually (37.6 percent), quarterly (23.8 percent) and monthly (4 percent), according to our survey. Others say they review packs on an "as-needed" or "ongoing" basis — usually when surgeons or staff request a change.

Some of you stick to a strict policy of regular audits. Perhaps you target a different specialty each quarter for procedure-pack reviews. Or maybe you review packs frequently on initial use, but once you have them exactly how you want them, you "only review if [there's a] price increase or physician request for change," says Linda Phillips, RN, administrator of Southgate Surgery Center in Southgate, Mich.

Physician preference appears to be a strong driver of what gets included in packs and what gets eliminated, but the rest of the surgical team also plays a vital role in determining packs' contents. Many of you rely on surgical techs, scrubs and circulating RNs to track usage and waste. Greg Easom, BSN, clinical director of the Surgery Center of Idaho in Meridian, Idaho, has the circulator log unused items during every case and present the data during the center's monthly reviews of procedure packs. "It's amazing how fast items accumulate that are not being used," he says. The logged items "are presented to physicians for justification to continue keeping them in the pack."

Hancock Surgery Center in Lenoir, N.C., employs a similar technique. Director Anne Gragg, RN, BSHM, CNOR, RNFA, finds that "changing custom packs can be done more readily if the RN and scrub handle the process. The surgeon seems more willing to let go if the scrub tech tells him ???we never use this.'"

Supply vendors can also help you right-size your packs. Edward J. Tennant, CASC, administrator of DeAnza Surgery Center in Riverside, Calif., who says he "leans heavily" on his surgical techs to keep tabs on supply usage, also asks "the representative for the company manufacturing our [procedure] packs to make regular stops at the facility to check on physician and staff satisfaction with overall and individual item quality and appropriateness." The procedure pack vendor for Rex Healthcare in Raleigh, N.C., "has a nurse consultant who comes into the OR and observes what is being used and not used," says Lynda Drye, director of resources for surgical services.

When's a pack just right?
Is there a magic formula to determine which items should stay in a pack and which should go? The conventional wisdom says an item must be used 90 percent of the time in order for it to be a worthwhile addition to your procedure packs, but survey responses indicate some of you adhere to a stricter standard (a few said utilization must be 100 percent) and some are more lenient ("If they are not used by 75 percent of the surgeons using the pack, they are deleted"). Lori Fecht, director of perioperative services at Blessing Hospital in Quincy, Ill., adds cost to the equation: "Item needs to be utilized >95% of the time; item needs to be <$20." Many respondents did not offer a scientific formula or ironclad figure, but suggested other insights into the right-sizing process. Two common threads:

• Avoid customization. Many of you share the philosophy of Bevie Swanson, RN, BSN, CNOR, director of nursing at North Platte Surgery Center in North Platte, Neb.: "Only items that are used for every case, regardless of the physician doing the case, are included," she says. "If everyone does not use the item, it is not included in the pack but is thrown in separately." When determining what will be included in procedure packs, identify common items that all surgeons use for that specialty or procedure and leave out those that fit just one surgeon's preference, say respondents. "Standardize one procedure pack for as many physicians as possible," says Mr. Tennant. "Avoid creating a pack for each one."

Joyce Danels, RN, CNOR, director of surgery at Twin Rivers Regional Medical Center in Kennett, Mo., determines common items by going over surgeon preference cards with her staff and including only those items that are used by all surgeons in a specialty. "We tried at one time to include everything for every surgeon and that was a disaster," she recalls. "The packs were too big and cumbersome." Kris Williams, RN, director of nursing at Hastings Surgery Center in Hastings, Neb., says using basic packs and then adding extra supplies to accommodate surgeon preference "still makes it easy to turn over the room quickly and eliminate the chance of contamination" — two perks of using packs.

• Compare costs. In addition to usage, many of you cite cost as a determining factor as to what will be included in your packs. "We do a cost comparison with and without each item in the packs. Does it save us money to include additional items in the packs?" says George Tway, CRT, administrator of Galileo Surgery Center in San Luis Obispo, Calif.

Brenda Perry, RN, ophthalmology coordinator at Stony Point Surgery Center in Richmond, Va., says she conducts a cost analysis on items that aren't being used by every surgeon, "to see if it is more cost effective to remove it from the packs and open individual items for specific surgeons." She cites price increases as the biggest challenge she faces in managing procedure packs, but it's a challenge her facility has met head-on. "Over the last year, we have looked at our packs and adjusted various ones about three times trying to be more cost effective, and each time we have saved a considerable amount of money for our ASC."

When presented with a price increase on any item in her facility's procedure packs, Ms. Phillips re-evaluates the necessity of the item to see if there's "a less costly alternative." She then goes back to the vendor to renegotiate.

Several of you recommended shopping around and seeking competitive bids to get the best deal on your procedure packs. "Have suppliers compete for pack business," recommends a California-based ASC administrator. "You would be surprised how you can reduce prices." Many of you aren't afraid to play hardball, either. "I only allow sales reps to submit a bid if they can come in under a set price," says the director of an Indiana-based ASC.

Most endangered items?
Everyone seems to agree that the items that shouldn't be occupying space in your procedure packs are the ones that are regularly going unused and being discarded. When we asked readers which items they'd deleted from their procedure packs over the past year, the answers were all over the map (see survey results on page 76), but there were some common threads.

Many of you have recently removed sharps, including needles (21.3 percent), blades (19.1 percent) and syringes (14.9 percent). Dressings were also relatively high on the list, with 18.1 percent of you striking them from your packs in the past year. Other items that readers said they keep out of their packs include those that tend to vary from surgeon to surgeon (gloves and gowns, for example) and procedure to procedure (drapes and sutures, for example). And 21.3 percent of you haven't removed any items in the past 12 months.

Challenges and rewards
When we asked readers to choose the biggest challenge they face in managing procedure packs, the two answers that tied for No. 1 were finding adequate storage space for the packs and dealing with price increases. Both responses highlight the importance of regular monitoring to ensure your packs are as lean and cost efficient as possible. "Encourage your staff to keep looking for items that are wasted with each pack and having them make suggestions for ways to streamline your cases," says Ms. Perry. "Having your staff involved in helping to cut costs is a big plus."