If surgical services represents the engine that drives revenue in a hospital, then supply processing and distribution (SPD), also commonly referred to as central service (CS), represents the motor oil that keeps it going.

As is the case with an automobile, neglecting the motor oil can hinder performance and even damage that engine. However, when it comes to evaluating the professional relationship between the operating room (OR) and CS, such logic has yet to sink in as a universal truth. Who suffers? Well, the OR, CS, the bottom line, and unfortunately, the patient. In short? Everyone.

But that shouldn’t come as a surprise. In many hospitals and healthcare facilities the relationship between the OR and CS can be characterized as politely aloof or strained at best. These facilities attribute their deep-seeded attitudes to a history of lackluster performance. The OR may trace it to poor and unacceptable service by CS; meanwhile, CS may trace it to ignorance of their operations and unrealistic expectations by the OR. And ne’er the twain shall meet.

Some hospitals, on the other hand, simply have made it work, cultivating a symbiotic relationship spearheaded by the long-suffering efforts of the department managers. Not surprisingly, one of those managers tends to have both OR and CS experience in their background.

"Many don’t understand what we do," said Edward Baker, CRCST, sterile processing manager, Banner Thunderbird Medical Center, Glendale, AZ. "They don’t realize the importance of what we do. We are the backbone of this facility."

Don Gordon, CRCST, FEL, network director of central service at North Bronx (NY) Healthcare Network, applies a naval military analogy to characterize the partnership between OR and CS. "The OR is a lot like an aircraft carrier, and CS is a lot like the destroyers circling the carrier to protect and defend it from attack," he said.

"CS and OR are not or should not be enemies," said Ray Taurasi, director of professional services at Case Medical Inc. and a key operative in Case Medical’s new consulting services arm, Ridgefield, NJ. "When such an environment exists the patients become the POWs and their care and welfare can be adversely affected.

Hot potato

If you’re trying to find the root cause behind the tension, perhaps you could start by locating CS’ perch on the facility’s organizational chart. Overlook the fact that specific CS duties and functions, as well as what the department actually is called, may differ by facility.

Typically, CS tends to report to one of two departments – either surgical services or materials management, each with their own supporters and detractors of the decision. Frequently, you’ll hear of CS reporting directly to nursing. Nancy Chobin, R.N., AAS, CSPDT, CSPDS, CSPDM, CSIT, SPD educator/consultant, Saint Barnabas Healthcare System, Lebanon, NJ, noted that she’s heard of a number of CS departments actually reporting to infection control, dietary and even pharmacy but she admitted that those represent more of the exception than the rule.

"Does the reporting mechanism matter?" Chobin asked. "It should not but sometimes it does." While she favors CS reporting to materials management because "it permits a system of checks and balances," she admits that many CS departments that report to surgical services or to nursing function very well.

Barbara Trattler, R.N., MPA, CNOR, CNA, director of orthopedic services at Atlantic Health System, Montclair, NJ, agreed with Chobin’s secondary assessment. "I believe with the OR director responsible for both departments the expectation for performance standards, communication parameters and meeting organizational goals and objectives can be clearly defined," she said. "The director’s goal should be to establish cohesiveness as a surgical service."

Indeed, Chobin acknowledges that when CS reports to materials management then the department may not be performing as well as it should. "Nursing feels that materials management does not understand the needs of the OR and therefore negatively impacts on the OR," she said. "When this happens, confrontations can occur, which are counterproductive and unfortunately can lead to the ‘Hatfields vs. McCoys’ syndrome. It is very difficult to rebuild relationships once they are broken."

Gordon doesn’t buy the argument that a CS department reporting to anybody but the OR is out-of-touch with the OR. In fact, he believes CS has "an opportunity to be more ‘independent,’ especially in decisions regarding such conflicts of interest as flash sterilization," he said. "The OR is our main customer. In order for me to do my job correctly I have to serve my customer, regardless of who I report to."

Baker, who began his medical career in 1970 as a surgical technologist and spent the last 10 years in CS for various facilities, prefers an OR reporting line for his department, which actually reports to materials management. "CS can work under materials management so long as materials management understands the concept of what your department does and why it does what it does," he said. "Roughly 80 percent to 90 percent of CS business is with the OR. I’ve found over the years that materials management doesn’t always fully grasp the technology used in the OR and CS. Standards and technology have progressed a lot since my early days."

Baker joined Banner Thunderbird two years ago. Part of the six-hospital Banner system, Baker’s department is one of three reporting to materials management. The other three hospital CS departments report to the OR and they’re investigating whether to make that the standard at all six. "We feel that the logistics side isn’t aware of what we’re trying to achieve and that hurts our relationship with the OR," he indicated. Baker admitted that when he signed on as department manager the relationship between sterile processing and surgical services had been damaged for a number of years. "SPD once stood for ‘stupid people downstairs,’" he added, "but we’ve since made tremendous progress toward improving that relationship."

Still, reporting to materials management serves as something of a speed bump. "They don’t fully understand the concept of bacteria and microorganisms on packages," Baker noted. Case in point: Sans a segregated sterile core, Baker’s crew shares a storeroom with materials management. "We’re in scrubs, caps and shoe covers and they come in their street clothes," he noted. "They open boxes that have been on planes, trains and trucks and have collected dust. They don’t understand how bacteria and microorganisms in that dust can affect the sterility of the products we send to the OR in kits and trays. We try to explain nosocomial infections and infection control basics to them but they just don’t get it and they don’t understand how that affects the patient."

But Gordon cautions not to expect smoother sailing if CS reports to the OR. "If CS reports to the OR I believe certain problems could arise unless the OR director is very objective and very knowledgeable about how CS operates and its sterilization safeguards," he said. Points of contention center around such controversies as flash sterilization, tray turnaround times and loaner instrument management.

"Frequently, it comes down to the relationship between the OR director and the CS director," he noted. "Chances are that if their relationship is good, problems are often avoided and, for the most part, the departments operate harmoniously."

Such is the case at North Bronx where Gordon enjoys a successful professional relationship with Bill McDonagh, network associate director of nursing for perioperative services. A former CS manager, McDonagh has worked at North Bronx for the last five years, and has worked with Gordon before, too. "Don and I are both goal-oriented," he said. "We have joint meetings. We carefully plan together what we’re going to do to provide better service to the OR. Our orientation is the same. The patient is the center of everything we do. If I have an idea for CS that will help them achieve better results then Don is receptive to hearing it and vice versa. The latest project we’re working on is looking to eliminate the need for flash sterilization in the OR. It’s important to have the ability to sit down and discuss ideas in a non-confrontational and non-threatening way with one another. It gives us both a compass. We have locked arms and pled cases to administration. We do it together because we have well-defined goals."

Gordon agreed. "Bill and I decided early on that once trays reach my department it’s up to me to take it through to the terminal sterilization process before they go back to the OR, unless he or his designee tells us otherwise," he said. "We have a detailed process here that involves various checkpoints along the way to assure that each and every instrument is being processed correctly – cleaned thoroughly and sterilized."

Daily communication, regular and frequent meetings and pairing up staff members from either department for educational purposes further cements the partnership. McDonagh even dedicates space in his perioperative newsletter for CS topics. And when a surgical tech no longer could work in the OR directly, McDonagh reassigned her to be the OR liaison educating the CS staff on instruments and tray assembly.

"We had low staff satisfaction and CS was always a way out," McDonagh said. "Don’s staff works very hard and it’s easy for us to use them as a scapegoat for complaints, but I refuse to do that. My staff has to look me in the eye when we have a problem and explain what went wrong. I try to work with Don to shore things up. When we started working together we threw everything out, except the baby, with the bathwater."

They solved a loaner tray tracking problem by having CS affix orange stickers to the trays and ordering them at least 48 hours in advance when possible.

"The biggest obstacle to this is past history," McDonagh said. "You have to get beyond it. We’ve made tremendous strides in getting rid of that past history. We’ve identified satisfiers for CS and OR. I’ve worked in systems where CS was not empowered to make decisions and not respected. That affects instruments, fill rates, completion rates. That’s not the case here. As a result, my staff has gained confidence in CS."

Baker took a more direct approach. During the organization’s twice-yearly leadership retreats that involve senior administration and department heads Baker simply introduced himself to senior administrators and explained what his department does. That led to his taking the hospital CEO and finance director on separate tours of the sterile processing operation, which opened their eyes, he said.

Recognizing the lack of a panacea, Taurasi advocates strong objective leadership and management, as well as a balance of power between directors that can promote harmony between the departments. "When two very strong, competent, qualified and knowledgeable directors for the OR and CPD report to the same [vice president] then that balance obviates much of the politics and turf issues that can obstruct progress," he said. "In some respects it helps to de-emphasize a lot of the tension between the two departments so that they can balance their needs and provide a joint front, particularly when it involves budgetary and resource issues."

That’s how it works at the two-hospital North Bronx (NY) Healthcare Network. Gordon, representing CS, and McDonagh, representing the OR, both report to the vice president of patient care services, a division of hospital administration.

"Senior administrators are responsible to select competent professionals to manage CPD and OR departments." Taurasi said. "It is essential that these individuals have a solid background in management coupled with the appropriate clinical and technical expertise. They must also have keen human relations and conceptual skills. It is essential that senior administrators then support these managers and hold them accountable."

But the bottom line should be management 101, according to Taurasi: Just put competent and knowledgeable people with a basic understanding of clinical and administrative issues in place to do their jobs and don’t fight them.

Defining partnership

Aside from thumbing through Webster’s Dictionary, most people generally comprehend the concept of a partnership. "A partnership occurs when people work together in harmony to accomplish similar or mutual goals that benefit both," Gordon said. "The OR and CS working together have similar goals with the bottom line being able to utilize instrumentation that is sterile and safe for patient care."

Unfortunately, many facilities don’t live up to Webster’s definition of close cooperation and shared responsibilities, according to Chobin. "SPD is not usually recognized as a partner in the patient care team," she said. "Often, because of their educational preparation (the profession of SPD is learned on-the-job instead of in a vocational setting as with nurses), SPD personnel are not considered team members. Often, SPD employees will be screamed at by OR personnel, degraded ‘which idiot did this?’ (sometimes directly in front of the surgeons!) or made to feel insignificant. OR personnel are quick to tell SPD when they made a mistake but rarely does the OR call SPD and say, ‘job well done!’ Many of the issues focus on communications, and this can make or break the partnership. Yet, the OR cannot survive without the services of SPD!"

Both departments need to understand what each other does, according to Baker. Without that basic understanding from the start a rocky road looms ahead. "They may not understand how long it takes to do what we do. It’s my job to help them understand," he said. "My staff understands what to do in the OR and vice versa. My staff has cross-trained in the OR to understand how a room opens up, what happens and why. Doctors and nurses show them. We also show doctors and nurses what happens when their instruments come to us. It’s part of the orientation process. It’s not you up there and us down here. We work together. Our No. 1 concern is the patient. We have to be cohesive. To me, that’s what partnership is all about. There’s no bickering or fighting but a mutual respect for each other."

Said Baker: "We need to make sure we give them the educational tools in order for them to give us the tools that we need."

Communicating daily, meeting weekly, aligning goals and strategies and jointly planning and implementing projects centered on patient safety represent the key tactics to forge and nurture partnerships.

"A great deal of interdependancy exist between CPD and the OR affecting the operations of both units jointly. They should identify goals and put together an action plan to achieve those goals," Taurasi said. "The expectation is that the two departments will partner and make it work. Walls will be broken down and lines of combat will be erased. That doesn’t mean there won’t be disagreements. Disagreements can be healthy; it depends on how they are managed and responded to. Some of the best decisions and resolutions are reached by differing ideas. The key point is that once a decision is made both managers should cohesively move forward."

Partnership challengers

Topping the list of potential impediments to effective partnerships between the OR and CS is communication, experts agreed.

"If we have effective communications, we can solve all the other issues," Chobin said. "The No. 2 issue is proper training and education for the SPD staff. Most operational issues stem from poor or inadequate training, often dictated by short staffing in SPD. The OR and SPD need to partner to present issues to administration to identify key issues and resources needed to resolve them to benefit both departments." Gordon added, "If everything is out in the open you can work together to solve any problems."

McDonagh, however, focused on quality assurance as an integral component supporting a healthy partnership between the two departments. "We need to know that what’s in a tray is what we need to do a case, and that those instruments are processed effectively," he said. In the past doctors routinely complained to nurses about incomplete trays so they agreed to empower CS to assume more control over instrument trays, handling some on consignment. Problem solved.

"From my point of view, we’re their No. 1 customer," McDonagh said. "Most No. 1 customers expect immediate gratification. We are an integral part of the hospital but we know our place. They’re integral to patient care, too, and not just a provider of service. They are the vanguard of infection control. In many ways we end up supporting their lead in terms of infection control." Their new building now includes dedicated clean and dirty elevators that run exclusively between the OR and CS.

"Most staff in operating rooms view CS as a support or service department for the OR," Trattler noted. "Because the OR staff do not know the functions of a CS department they view this department as a department that should meet the needs of the OR first and foremost. CS departments try very hard to meet this challenge by the OR but face tremendous barriers to do so."

Those barriers are often built on the OR’s general lack of respect and appreciation for CS, according to Taurasi, and that attitude impacts CS performance. In essence, the people become invisible as the service is detached from the human element, he added.

"The OR also doesn’t realize the complexities of the CS techs’ job," Taurasi continued. "Most OR nurses and surgical techs are so specialized or focused on one service or specialty, while the CS tech must be knowledgeable about all instrumentation for all specialties. It involves a broad learning curve with heavy expectations, growing responsibilities and increased stress. When I see the complexity of instrumentation that CS techs are working with now, coupled with keeping track of all the delicate and intricate parts and the economic pressures to care for these expensive devices I realize that one little mistake can result in an infection or otherwise harm or even cause death of a patient. The OR needs to understand the amount of time it takes to do what needs to be done the right way. There are no shortcuts to proper sterile processing procedures. Likewise CPD must understand and appreciate the role of OR clinicians and the associated work stress and pressure in the OR environment. The OR must be able to trust CPD and feel confident that CPD will be responsive to all their needs consistently and on a timely basis."

The three Cs

The secret formula for successful partnerships between OR and CS involves what Chobin and Trattler call the three Cs: Collaboration, communication and cooperation.

"Both Nancy and I believe that the only way for the OR and CS to work effectively is by direct and open communication, a sincere willingness to cooperate and to develop effective collaboration strategies to bring the departments together in the organization," Trattler said.

Chobin explained further. "To survive, we must work together to enhance patient care," she said. "The two departments have a great impact on each other and without collaboration, patient care and surgeon satisfaction can suffer. Communication is the key to effective relationships. Just like in marriage, good communication is essential. Weekly meetings where issues can be addressed in a non-threatening manner can help to create trust and a dialog to keep the lines of communication open.

"Sometimes we have to compromise," she continued. "Sometimes we have to withdraw a request because the timing is not correct. With proper communications and collaboration, we learn how each other’s department functions, which leads to cooperation." One example is when the OR recognizes that CS is short-staffed for a day and sends some of the surgical techs to SPD to help out.

A fourth C may be just as important: Certification. Experts agree that it can only raise the bar of the individual as well as the profession as a whole.

"People in the OR are certified and licensed so why not CS?" McDonagh said. "Every day we go in there to do a great job and we can’t do the job we do without CS."

Certainly mandatory certification gives CS managers more ammunition to heighten recognition and attract and hire the type of individuals needed to improve and maintain quality, according to Taurasi. "CS needs to recognize that education and credentials are an investment in one’s self. Knowledge and education are valuable assets. Once you have them they cannot be taken away. In time certification may affect compensation, but it should not be the primary impetus to one’s self-development."

Said Baker: "We’re working with highly sophisticated and costly technology that we have to know how to disassemble and assemble, clean and sterilize. We’re no longer those dishwashers in the basement." HPN

• CS will solve all of our problems.

CS of OR