A surgery center found that efforts to streamline endocrine surgical trays led to faster tray preparation time and saved $31.62 per operation in reprocessing costs.1

The streamlining effort was based on the observation that surgical instrument trays were developed for general purposes when they could be developed for specific surgeries. By streamlining the trays for a more exact fit with each procedure, the hospital projected a $28,000 annual savings in instrument reprocessing.

One size tray does not fit all procedures, notes Brenessa Lindeman, MD, MEHP, associate program director of general surgery at the University of Alabama at Birmingham. For instance, the surgery center used 27-pound trays, carrying 98 total instruments, even though most of its procedures were smaller cases that would require far fewer instruments. “The majority of the procedures were thyroidectomy and parathyroidectomy,” Lindeman says.

The ASC’s efficiency process resulted in a reduction to 36 instruments and 10 pounds per tray. It also led to faster tray preparation, down to three minutes from eight. The major shift in preparing surgical trays began with forming a multidisciplinary team of staff, including physicians, operating room nursing staff, and team leaders, Lindeman says.

“We wanted to make sure we weren’t leaving things out from multiple perspectives,” she says. “Our surgeons identified the instruments they used most frequently in operations. It turned out there were 25 instruments that the surgeons largely agreed they used in every case. There was a subset of instruments they wanted to have available if needed and that we could use in 25% to 50% of the procedures.”

Those were the instruments that were selected for inclusion in the streamlined trays. “Instruments that only were rated as highly valued by one surgeon were made available as an additional peel pack instrument rather than always included on the tray,” Lindeman says. “We were able to dramatically decrease the number of instruments on the tray.”

The efficiency process worked like this:

Work with surgeons on their preferences. “We found that surgeons actually were able to change out some of the instruments they preferred a little less for some they preferred a little more,” Lindeman reports. “Surgeons had exactly the instruments they preferred.”

When the surgery center started to roll out the change, the operating room staff would unknowingly open the wrong tray sometimes — the one with unnecessary instruments. When this happened, surgeons often realized that they preferred the smaller, streamlined trays with instruments that met their specific preferences.

“It can’t be emphasized enough how important it was to have surgeons be part of the process of deciding what instruments they wanted available to them,” Lindeman says. “We did this with a small number of surgeons who perform these endocrine surgical procedures and utilize these trays.”

It works best to start small with surgeons who perform the same procedures before branching out to streamlining trays for additional surgery areas. “My advice to ambulatory surgery centers is to identify a relatively small group of surgeons that perform some fairly well-defined procedures, and begin there,” Lindeman offers. “Get them engaged and ensure they know they’ll have available exactly all the instruments they want.”

Use peel packs liberally. Peel pack instruments can include more than the items like forceps or towel clamps that often are dropped on the floor during surgery and need to be replaced quickly. These peel pack items can include less common instruments that were not made available that way, Lindeman says.

“Central surgical supply has made available single-instrument packages. These can be available and opened as single instruments where you don’t have to open a whole tray to get one,” she explains.

These peel pack instruments are ones that a specific surgeon requested for the tray, but other surgeons were not using it. “The one downside to these peel packs is that sterility can only be guaranteed for a limited period of time,” Lindeman cautions. “You want to make sure the instruments you make available this way actually will be utilized by the surgeons who request they are made available separately. That’s something we track, informally, and we find that surgeons are using it.”

Work through obstacles. It took time to coordinate the changes with central sterile supply, Lindeman notes. “We had to make sure we had the new sterile tray containers in smaller sizes than what we had before,” she says. “There were a few growing pains at the beginning.”

On rare occasions, there might be certain instruments that were not available in sufficient quantity, so similar items were added to the tray. “Once the stock was resupplied, new instruments were ordered and changed out in the trays as soon as they were available,” Lindeman explains.

Typically, surgeons used three to four trays a day, so the trays could be ready in advance. ASCs likely would need to make more trays available as their procedure volume is greater on a daily basis, Lindeman adds.

Maintaining smaller and streamlined trays was its own incentive to the central sterile supply staff. “One of the things they track is related to reprocessing costs; it was helpful for all stakeholders involved,” Lindeman says.

Create a culture change. “The biggest aid to changing the culture around use of these trays was to emphasize to surgeons that we wanted to create something specifically for their procedures and that this was streamlined with exactly the instruments they would want to have,” Lindeman says.

Leaders promised that there would be enough of these streamlined trays to cover all surgeries. One way they helped build trust for the new process was by making the older trays available during a trial period.

“Everyone was assured that the older, more general trays would continue to be available should the surgeon become dissatisfied with the instruments available on the smaller, streamlined tray,” Lindeman says. “Interestingly, we found that no one who was involved in this instrument selection and tray creation process went back and opened one of the older trays within the first six months of implementation.” The implementation and culture change worked as leaders hoped. “We found that our surgeons would talk about their trays with other surgeons,” Lindeman says. “Those surgeons would begin to think about how they might optimize a tray for their specific procedures as well.”


  1. Dyas AR, Lovell KM, Balentine CJ, et al. Reducing cost and improving operating room efficiency: Examination of surgical instrument processing. J Surg Res 2018;229:15-19.