Caring Wisely FY 2023 Project Contest

A Sustainable Solution to Reduce Surgical Supply Waste – A Preference Card Optimization Tool

Primary Author: Seema Gandhi
Proposal Status: 



Seema Gandhi, MD






Surgical instruments and supplies are a significant source of an operating room’s cost and carbon footprint, yet usage varies widely among surgeons performing similar procedures. Surgical Preference cards are used to communicate a surgeon’s preferred supplies and instruments to the nursing staff prior to a case, allowing for intentional selection of supplies most likely to be used while, in theory, decreasing the waste of unused items. However, cards are often outdated and awareness among surgeons of the associated cost and environmental impact of their supply use is lacking. This is largely because there is currently no streamlined approach for surgeons to directly request changes or compare their supply use and procedure cost to their colleagues. We aim to design an accessible digital platform by which surgeons can quickly understand the cost and carbon impact of their instruments and submit change requests, as needed. We have built a prototype that allows surgeons to visualize the key sustainability and cost metrics in their preference card, compare their supply and instrument use to colleagues, and send an automatically generated email to the preference card manager with requested changes. We have consulted with multiple surgeons and perioperative leaders and iteratively improved the design of the prototype with their feedback. Through the Caring Wisely grant, we aim to transition our prototype into a production-ready module that can be ultimately integrated into the EPIC system-wide rollout for surgical waste and cost reduction.



Departments of Anesthesia and Perioperative Care

Department of General Surgery

Perioperative Informatic Lead

Perioperative Nursing Leads



Surgical waste, specifically opened but unused supplies and instruments remain a challenge and opportunity for optimization. Our previous Caring Wisely work closely scrutinized the surgical supply and instrument workflow and discovered that surgeons' preference cards are not updated frequently to accurately reflect the supply and instrument needs. The preference cards are generally managed by nurses, who incline to overprepare, which leads to unused supplies and instruments that get wasted or had to be returned for restocking. In addition, because surgeons trained at different institutions and had various levels of cost awareness, there are notable variabilities in their supply and instrument used for common procedures. As such, some surgeons have a significantly higher cost per case and carbon footprint compared to their peers despite the equivalent quality of care provided.


Currently, there is no streamlined approach to understanding how a surgeon’s instrument and supply usage compares to their colleagues, or for submitting change requests on their cards. While the functionality is being built into EPIC, the workflow is too cumbersome for surgeons for it to be effectively utilized. The current state of preference card management involves nurses marking preference card changes on pen and paper based on their observations and sending them to a preference card manager. As a result, changes take a long time, are difficult to track, and leave surgeons feeling like they are not getting the right supplies or having appropriate control over the process.



-Allow surgeons to easily access their preference cards, compare their supply usage to their peers, and directly request changes

-Increase surgeon engagement and cost awareness

-Reduce supply overage and returned supplies/instruments

-Reduce cost per case


We have prototyped a digital platform for preference card management to increase efficacy and reduce unused/wasted supplies. This platform provides feedback to surgeons on their cost per case along with other sustainability metrics and how they compare to their peers. Furthermore, it allows surgeons to submit supply and instrument changes directly to the service line manager. Overwhelming evidence has demonstrated that providing surgeons with cost feedback and leveraging peer competition leads to cost reduction per case. Moreover, standardization of supplies and instruments among the surgeons performing similar procedures will increase efficiency, thus further decreasing cost. The changes requested by surgeons will be routed to their service line manager to be reviewed before official changes are made. This dual attestation process ensures that both parties have verified the change request before execution. Our innovative platform will also include sustainability metrics such as carbon footprint per case and water usage from instrument use to increase surgeons’ awareness of the environmental impacts of their operations.

In the future, we aim to pair an incentive structure with this tool to promote periodic preference card reviews, which will be significantly simplified by our platform compared to the existing method.


Following a successful pilot, we aim to integrate this module into EPIC to be a permanent module that can be used for all surgical specialties. This module can also be expanded with more advanced capabilities, such as integration with a supply chain database that recommends clinical-equivalent but more cost-effective alternatives to surgeons during the preference card review.



We hope to demonstrate a measurable reduction in supply cost by 20% over a six-month period in selected service lines, which is consistent with prior operating room scorecard interventions in literature.



Our previous Caring Wisely experience has indicated that a one-off preference card audit is not likely to yield sustainable results. We believe that an accessible, EPIC-integrated preference card optimization module, paired with an incentive structure and the dual attestation verified by both surgeons and nursing staff, will enable sustained changes. This will make the preference cards more effective at decreasing waste and the cost of unused supplies in perpetuity.



The $50,000 budget will go into the following: 

-Server cost to support the digital platform during the pilot period

-Developer cost to help transition from prototype to production-ready system with advanced capabilities, such as the ability to recommend cost-effective alternatives.

-EPIC Analyst time support for integrating this module into EPIC interface