Sterile processing professionals that have historically fought for respect, or even a simple pat on the back, may just find their place in the sun — if they are committed to taking the performance improvement plunge, that is.

Infusing day-to-day tasks with higher quality standards isn’t exactly a new concept in healthcare. Revenue-generating departments, such as the operating room, have been doing it for years in an attempt to improve patient care and further drive efficiencies and higher profits. Interestingly, though, non-revenue-generating functions like sterile processing and environmental services have historically been excluded from organizations’ performance improvement roadmaps, even though such quality efforts could significantly improve customer service and overall operating efficiencies, as well as maximize departmental resources and reduce the likelihood of instrument- or equipment-related complications.

"Many sterile processing departments aren’t doing any type of focused performance improvement, even though they and the facilities they serve would greatly benefit from it," said CS consultant Fred Wykoff of Salisbury, MD. He added that part of the problem is that some CS departments just don’t know where to begin. "All it takes is an understanding of what performance improvement really is, and an ongoing commitment to [the cause]."

Failing to develop a performance improvement process in CS can prove perilous for hospitals. As Mike Duckett, director of Stategic Initiatives for STERIS Corp., Mentor, OH, put it, "The goal of any business — and healthcare is a business — is to be profitable. To be profitable, you have to look at both the revenue-producing areas and the cost centers simultaneously." He noted that adding more surgical procedures to a facility that has an already saturated or non-productive sterile processing department will most likely result in a lower return than expected for the hospital. The result, he said, could create additional hardship on the SPD that could prompt higher staff turnover, increased quality problems and, ultimately, a frustrated O.R. team.

Although widespread adoption of performance improvement efforts in CS may be slow coming, more SPDs do appear to be getting the message – a move that can be at least partially attributed to performance improvement standards set forth by the Joint Commission on Accreditation of Healthcare Organizations. JCAHO’s goal is to ensure the processes are well planned and designed, that they are systematically measured and assessed, and that the improvements are implemented.

Laying the foundation

Performance improvement goes by many names, but whether facilities call it continuous quality improvement or total quality management, or another label, sources agreed that the terms are typically geared toward the same goal: improving processes to drive quality.

"People tend to get caught up in semantics, but the point is there are many variations on the theme and it makes no real difference what name is used. It all boils down to how an organization can move their energies to improve various processes, and ultimately, outcomes," explained John Whittlesey, principal of the Healthcare Management Council Inc., a Needham, MA-based healthcare benchmark-ing firm. "It’s about getting the engagement of staff and building a consensus so the department can move forward in a positive way."

STERIS’ Duckett cites the following as core components of an effective performance improvement process: a cross-functional team of all stakeholders or customers that serve or are served by the SPD; access to data, such as surgical procedure volumes, and the ability to translate this data in workload requirements; a process map to detail out potential bottlenecks and areas of waste; and the ability to translate data and process information into a technical, clinical and financial plan to allow the SPD to implement the necessary corrective actions.

When it comes to the various functions of sterile processing, it’s understandable how committing to solid performance improvement efforts can pay big dividends, both for the department itself and the hospital as a whole. After all, there’s no arguing that any efforts aimed at improving quality in decontamination and sterilization, instrument sorting, inspection, set assembly, and distribution, among other functions, is time well spent. At the same time, it’s understandable how embarking on such a performance improvement initiative can seem daunting to those who are new to the concept. Because of that challenge, SPDs would be better served by approaching the process methodically, yet specifically, and focusing on specific functions, sources told Healthcare Purchasing News.

"Breaking the process into more digestible pieces is important because if you don’t, it can be easy to become overwhelmed. Again, performance improvement is about progressively moving in the right direction, not about trying to overhaul everything at once," stressed Whittlesey.

To determine which areas to target first, sources agreed that SPDs should conduct a thorough audit of the department’s core functions. Sources agreed that these should, in the very least, cover decontamination, preparation and assembly, sterilization, storage and distribution.

When Wykoff consults a facility, he uses a more detailed form to determine if processes are being followed correctly. For the decontamination process, he addresses proper set-up and use of personal protective equipment, whether instruments were cleaned properly (and according to manufacturer instructions) and placed in the basket correctly. He then thoroughly addresses each step of the sterilization process. His checklist covers whether the rack or cart was loaded properly, whether the contents on the cart were properly documented, and whether the biological indicator was in place and checked and recorded at the end of the cycle. Wykoff also scutinizes various aspects of O.R. trays, including whether they were correctly labeled, whether instrument wrappers were free of holes and tears, whether instruments were properly cleaned and assembled, and whether missing or damaged instruments were identified.

Whittlesey adds that mapping out hours of operation, staffing, individual cycle times and turnaround time, and then benchmarking that data against similar facilities, may also help SPDs pinpoint areas in need of improvement. "Having all that information at your fingertips allows you to ask the critical questions, ‘What are we doing?’ versus ‘What should we be doing?’"

Documenting trends

Depending on the situation or outcome, both a proactive and reactive approach to performance improvement may be in order. When the O.R. complains about a specific situation, such as a missing instrument in a set, for example, that will require a reactive response to remedy the situation quickly. But a good performance improvement improvement strategy "also requires a proactive approach where SPDs work to make sure that same problem doesn’t keep occurring," said Wykoff. "That’s how quality is improved in the long-term."

Moving from a purely reactive approach to a more proactive one requires effective, consistent documentation. Unfortunately, that’s one step that many SPDs tend to overlook, according to Richard Schule, director of clinical sterile processes for Clarian Health Partners, Indianapolis.

"Many times, [SPD staff] may think they’re listening to their customers, but if they’re not adequately documenting or surveying their customers – and then using that information to their best advantage – they can’t expect to effectively track trends and identify problem areas," he noted.

Another reason to continuously monitor and document? According to Wykoff, some CS customers, particularly the O.R., may become so frustrated with ongoing instrumentation problems that they eventually stop complaining. "This can lead to a false sense of security that everything is fine, even when many problems exist. It’s critical to work with customers and follow-up with them to stay on top of any issues and resolve them as quickly as possible."

In its own customer surveys, STERIS found that the O.R. is looking for three basic things from the SPD: clean and sterile instruments, complete instrument trays and on-time delivery. "By establishing mutual expectations for these three deliverables, in number goals, the SPD manager can recalibrate their workflow and prioritize their efforts to meet the daily requirements of the O.R.," explained Duckett.

Still, Schule acknowledged that it can sometimes be difficult for departments to assess their own processes and shortcomings. He recommended forming a network with other facilities, and even other industries, to foster new ideas on how to improve quality.

"A fresh set of eyes can be very helpful," he said, adding that local chapters of quality improvement groups, such as the American Society of Quality, can offer a wealth of information. "Basic quality improvement concepts are the same, regardless of the industry [in which] they’re applied."

The ASQ cites the four-step Plan-Do-Check-Act Cycle as one of the most widely used tools for continuous improvement. Put simply, the cycle revolves around identifying an opportunity and plan for change; implementing the change on a small scale; using data to analyze the results of the change and determining whether it has made a difference; and implementing the change on a wider scale, if it was successful.

Participation in JCAHO’s performance improvement goals can also help. Through case study presentations and panel discussions, participants will have the opportunity to assess their organization’s compliance with the performance improvement standards and compare their facility’s activities with those of the featured case study organizations.

Partnering with a consultant is another option, and may be the right choice for SPDs with management vacancies and high staff turnover, Duckett pointed out.

"Using an outside resource to act as a catalyst for change [can be highly effective]," he said. "Healthcare customers need consultants who will roll up their sleeves and actively lead the improvement process rather than merely provide ‘white paper’ information." SterilTek Professional Services, a subsidiary of STERIS, was developed to help SPD customers meet the expectations of each department they serve within the hospital. Specifically, the team is driven to help customers achieve the ultimate sterile processing goal of "100 percent clean and sterile, 100 percent complete and 100 percent on-time."

Testing the system

Like any implemented process, performance improvement strategies must be tested to determine their effectiveness – and whether additional adjustments are in order.

To improve the quality of instrument trays, each CS supervisor at Bronx, NY-based Jacobi Medical Center opens up ten random sterilized trays per day (except weekends) to closely examine their assembly and contents. The supervisors pay close attention to the way the instruments were wrapped and whether the instruments were properly cleaned and assembled, for example. The facility carefully documents the findings to pinpoint trends.

"We keep records for two to three years, so we have adequate data to work from," said Don Gordon, CS network director for Jacobi Medical Center. The process has helped Jacobi’s SPD identify various areas in need of improvement, including wet packs, which were able to be quickly remedied by the use of tray liners and extended drying times.

When Wykoff consults SPDs in the area of performance improvement, he also encourages managers and supervisors to perform random set checks. "I recommend pulling two random sets from each employee each week, so they can get a clearer picture of what’s going on, and what additional training may be required," he said, adding that such checks also allow supervisors to give credit for a job well done.

Innovative products and solutions can also boost SPDs’ performance improvement efforts by targeting some of the perennial problems plaguing the department. In March, Verimetrix LLC, St. Louis, MO, introduced Veriscan, the first automated endoscope leak testing technology. Veriscan is said to provide a precise, repeatable and documented process that reduces total repair costs by roughly 50%, while also reducing cross-patient infection risk. Veriscan also has the ability to automatically record each leak test and retrieve it on command via the LCD display, printing or downloading to a computer, allowing facilities to analyze scope damage, track procedure activity and ensure every endoscope is properly leak tested

"Scope damage is common. Unfortunately, scopes are difficult to leak test. Entry level staff perform the task, turnover is high and short staffing leads to rushing," noted Pat Holland, R.N., former president of the Society of Gastroenterology Nurses and Associates. She added that undetected leaks are frequent, and can lead to annual repair costs of $100,000 or more at many institutions. Catching a faulty endoscope early can mean the difference between a repair of as little as $200 versus a repair of $8000 or more, Verimetrix reports. Veriscan product trials at Duke University Hospital, Barnes Jewish Hospital, the Sisters of St. Mary’s Healthcare System, and others, revealed a reduction in endoscope repair costs by as much as 70 percent.

If used to their fullest potential, automated instrument tracking solutions can also boost performance improvement efforts by providing SPDs with a broad range of meaningful and easily accessible data. Today’s instrument tracking systems are more sophisticated, allowing users to pinpoint and categorize a list of problems, and run detailed reports that can be broken down by specific function, cycle, employee and shift.

No end in sight

When embarking upon a performance improvement initiative, sources agreed that SPDs must be willing to settle in for a long journey. That’s because no matter which tools and protocols are used, and the level of staff commitment and buy-in, the performance improvement process never draws to a close.

In fact, committing to performance improvement can be a bit like opening Pandora’s Box.

Everyday too many healthcare workers unintent-ionally cause illness and sometimes fatal harm to patients under their care. Hospital-acquired infections, or infections that are obtained through contact with healthcare professionals or treatment, are a leading and persistent cause of unnecessary patient harm and death. Most of these infections are transmitted on the hands of healthcare workers who have failed to properly wash their hands. Despite numerous regulations and tomes of data that show a simple hand washing can prevent the spread of infection, compliance of healthcare providers remains unacceptably low – generally below 50%. Because the problem stubbornly persists, The Institute for Healthcare Improvement (IHI) in collaboration with the Division of Healthcare Quality Promotion of CDC, Association for Professionals in Infection Control and Epidemiology (APIC) and the Society of Healthcare Epidemiology of America (SHEA) have developed a practical tool kit for hospitals and health care workers. The free kit is available at ihi.org at:

http://www.ihi.org/IHI/Topics/CriticalCare/
IntensiveCare/Tools/HowtoGuide
ImprovingHandHygiene.htm.
Links are also available on APIC,
CDC and SHEA’s websites.

Global access to HIV therapy tripled in past two years

A report by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) shows that the number of people on HIV antiretroviral treatment (ART) in low- and middle-income countries more than tripled to 1.3 million in December 2005 from 400,000 in December 2003. Charting the final progress of the "3 by 5" strategy to expand access to HIV therapy in the developing world, the report also says that the lessons learned in the last two years provide a foundation for global efforts now underway to provide universal access to HIV treatment by 2010. Progress in treatment scale-up, while substantial, was less than initially hoped. The report notes, however, that treatment access expanded in every region of the world during the "3 by 5" initiative, with approximately 50,000 additional people beginning ART every month in the past year. Sub-Saharan Africa, the region most severely impacted, led the scale-up effort, with the number of people receiving HIV treatment there increasing more than eight-fold to 810,000 from 100,000 in the two-year period. By the end of 2005, more than half of all people receiving HIV treatment in low- and middle-income countries resided in sub-Saharan Africa, up from one-quarter two years earlier. Between 2003 and 2005, global expenditure on AIDS increased from US$ 4.7 billion to an estimated US$ 8.3 billion.