PONE-D-21-17028Standardization of laparoscopic trays using an inventory optimization model to produce immediate cost savings and efficiency gainsPLOS ONE

Dear Dr. Toor,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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We look forward to receiving your revised manuscript.

Kind regards,

Federico Ferrari

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This article has standard language and clear thinking.This study mainly demostrated that Standardization of three laparoscopic surgical trays (GS, GY, GO) into a single SL tray resulted in 261 significant cost savings and increased satisfaction at our institution. I have 2 suggestions for this study. First,the statistical method is not very clear in this article.The statisical method using in every test should be clearly described.Next,The actual clinical application effect in different regions needs to be further analyzed by increasing the number of samples and adopting multi-center method.

Reviewer #2: This scientific paper is vell written and informed. The content of study is very interesting and useful for surgeons, RNs ann MDRs. I congratualte the author for their successful research which will play a very important role for cost control in operating room. There are some grammatical and typing errors in this manuscript.

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: kai Zhang

Reviewer #2: Yes: Tuerhongjiang Tuxun

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PONE-D-21-17028R1Standardization of laparoscopic trays using an inventory optimization model to produce immediate cost savings and efficiency gainsPLOS ONE

Dear Dr. Toor,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 20 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Kush Raj Lohani, Master of Surgery

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: (No Response)

Reviewer #3: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: (No Response)

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

Reviewer #3: Thank you for inviting me to review this paper.

The manuscript reports a study that aimed to produce cost and efficiency gains by standardizing the contents of laparoscopic surgery instrument trays. Research and improvement in the delivery of sterile processing services is an important and often overlooked component of surgical safety and efficiency. While there have been a small number of similar studies this can be a useful addition to that literature.

It seems that there have been prior reviews, so it’s unfortunate, and probably frustrating for the authors, that I have a range of new comments; however, while challenging, I feel they are important and would substantially enhance the paper.

Overall, the focus on mathematical approaches belies some of the nuanced complexities of sterile processing. There are also quite a few areas where more clarification or precision is warranted (e.g. survey response rates; costs ‘per year’ or other). I also don’t feel that the operational consequences have been fully thought through. There is no discussion of how the trays were changed and the new “standard” was introduced into practice.

Looking at the tables detailing the changes, one original tray has more instruments than the final one. Does this mean that the new tray was missing critical instruments for certain procedures, or simply the older tray had legacy instruments that weren’t used (in which case this isn’t just about standardization but also optimization)? Similarly, another original tray has exactly the same number of instruments as the new tray – are these the same or are there differences? Definitely missing here is the consideration – at least a discussion point - not just of the numbers of instruments in a tray, but also the types and uses of instruments.

I think it’s really valuable work, but can’t help thinking it’s ignored many of the real-world implications that may make this appear to be more straightforward that in actually is. Addressing the wider context of the work system in the Introduction and Discussion would make this a much stronger and more relevant paper.

INTRO

The first sentence of a paper or abstract is important. Consider qualifying why surgical inventories can be a “source of inefficiency” with some reasons why and / or some effect. Of course, they can also be a source of efficiency.

The introduction is very short. There is space to expand on the learning from prior work. I’d like to see more on the reasons why there are “limitations preventing practical application.” You could also discuss a little more the methods and results of the other prior studies, especially as you haven’t addressed this in your own work. An extra sentence or 3 would be valuable for establishing how your study builds on this prior work.

The introduction doesn’t really go into the challenges or trade-offs of standardization. Including surgeon preferences, generic vs specific uses, or the trade-off between having a range of instruments to cover a broader set of preferences/procedures, which may lead to more instruments in a tray vs specialist trays with less instruments. It might not need that, but I think a little more nuanced thought about the challenges of “standardization” and what it really means would be helpful. Of course, standardization can lead to standardized inefficiency.

In moving on to the methods, I would also like to see more discussion of the background of the “Newsvendor” problem, and the modelling methods chosen. Most readers will be unfamiliar with these. This could be in the intro or methods, but I would suggest the former as that is naturually more discursive.

METHODS

How were procurement & reprocessing costs discovered?

What did the “clinical review” of the SL tray involve? How many clinicians? What did they review? Were any operational trials (ie. A clinical review might not reveal missing instruments for all procedures & all surgeons).

How might this affect scheduling? If you have different procedure-specific trays, simultaneous surgeries would not be an issue. However, instead with “one size fits all” trays you presumably need more of them, or carefully schedule procedures and reprocessing to allow appropriate sharing?

Might using “mean” demand not immediately disadvantage periods of demand above the mean? Ie. During peak times, trays might not be available if calculations are only done on “means”. I think you allude to this later, but a little more about it in the methods could be useful.

Did you study or explore the types and uses of instruments in each tray? How did you know it was acceptable to remove some and not others? Are any of your team actively involved in sterile processing, or did you conduct any site vists?

How did you make the changes? Did you do this over time or change all the trays over to the standardized ones in one go? How did you ensure that no critical instruments were missing? Some sense or narrative of how you did this would be very informative.

Where and how were timed observations of instrument reprocessing made? Did this time include decontamination, and assembly? In assembly, did you study the time taken for inspection, functional checking and missing instrument retrieval (as well as ensuring all instruments are present)?

Mean instruments per tray of 17 seems relatively low compared to some trays. Do you think this has implications for generalization of your methods/findings to other trays?

Are the calculated reprocessing costs yearly, monthly, or per procedure? Time scale would be precise here.

RESULTS

How can the GS tray have more instruments than the standardized tray? Does this mean that there were redundant instruments in the GS tray, or that 7 extra instruments were needed for any GS procedure? That would make the cost saving calculations misleading. What was the overlap in instruments between the “old” and “new” versions (i.e. which stayed the same, were added, or removed?). Maybe that’s all too much, but the numbers don’t tell us anything about how the new tray differed. That’s really important.

Presumably the “standardized” trays basically used the same instruments – so the 15 in GO wer the same 15 in SLT….so aren’t GO and SLT the same tray? If not, presumable in the SLT tray there were instruments that were needed in the GO cases (so important instruments were missing from the SLT); or that some of the instruments in the GO trays were never used (which means this is less about standardization and more about just removing unused instruments).

There was a lot of dissatisfaction with the customized trays with RNs and MDRs. Why was this?

How long after the standardization process was the survey delivered? How was it delivered (onoine,paper etc)? How many people was it sent to vs completed it (% response rate?).

I could not see any data on the reprocessing times for each instrument (as per the method).

DISCUSSION

The mathematical focus of this paper ignores many of the operational nuances that may be found in this type of approach.

“Financial benefits….well documented” – this is a very broad brush. In fact, it’s well documented that the wrong sort of standardization can lead to inefficiencies. Furthermore, standardization and patient-centered care are often in opposition.

How do you think your approach would fare with other types of trays e.g. general surgery? These trays often have >100 instruments. What about the trade-offs with

How many surgeries required extra instruments (or “peel packs?”)?

One challenge with standard trays is that surgeons who trained differently have different preferences. Did you find that this suited some surgeons more than others; that they all used similar approaches; or that the particular procedures you worked on required a standard set of instruments, with little personal or procedural variation?

The cost calculations are well discussed but I think this misses a lot of nuanced implications / discussion points.

Did you calculate the “lifespan” of the instruments? Presumably if they are being turned over faster, they will need to be replaced sooner?

Again, please state over what time period the “savings” (line 220) refer to,

Some trays have rarely used instruments that nevertheless are important to have at the right time. How/are you sure that you didn’t remove instruments like this?

How did the implementation of the new trays happen? Making change in organizations is complex, especially with surgeons who are used to doing this a certain way. Did this present challenges?

Overall, the conclusion should consider not just the mathematical calculations, but the safety, quality, and operational implications for this work. Can this approach be used on all trays or only a subset? Are the authors planning more studies in other specialties or procedures or trays?

As I’ve said, there’s no consideration (as far as I can tell) for the implications in tray assembly, routine maintenance, or replacement of instruments.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Tuerhongjiang Tuxun

Reviewer #3: No

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Attachments

Attachment

Submitted filename: comments.docx

Standardization of laparoscopic trays using an inventory optimization model to produce immediate cost savings and efficiency gains

PONE-D-21-17028R2

Dear Dr. Toor,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Kush Raj Lohani, Master of Surgery

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

"Suggestions - kindly use the full forms in conclusion for - IOM, GS, GY and GO."

I want to congratulate authors on their vision and hard work on this often overlooked topic. I am confident that this manuscript will get a proper recognition in the Surgical field. Readers will get the sense of necessity on proper planning of their instrument trays for enhancing OR efficiency and lowering the avoidable expenses.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: This paper is now well written and informative. All the concerns have been well answered and the manuscript was well revised.

Reviewer #3: Thank you for addressing the critique. This is much improved and now an excellent paper that I hope get a good audience.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: Yes: Tuerhongjiang Tuxun

Reviewer #3: No

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