by Rick Dana Barlow

If you could design the optimal central service/sterile processing and distribution department it most likely would include several key elements: Data at your fingertips, open and fluid lines of communication with all your customers, lean thinking-driven operational efficiencies and a clearly defined ladder of advancement for all staffers, fortified by a strong emphasis on education and training.

Developing any one of these characteristics alone takes a lot of effort and time, in addition to commitment, perseverance and trust. Implementing all four means you’re positioned to perform as a fine tuned machine consistently delivering solid support and customer satisfaction that helps patients receive high-quality healthcare.

The central sterile supply department at NYU Medical Center (New York) recognizes and understands this better than most. While many CS/SPD departments agree in theory that these principles define success, the CSS team at NYU Medical Center actually put them into practice, uprooting inefficient and outdated procedures and processes.

Whether picking up improvement tips from vendor site visits or polling their union peers, NYU’s CSS team led by Manager Mary Olivera, M.S., CRCST, CHL, did the actual trench work themselves and have the stripes – bad and good – to show for it. That’s why Healthcare Purchasing News selected NYU Medical Center’s Central Sterile Supply Department as its 2006 CS/SPD Department of the Year.

Surgical strikes

Because of their size and market stature, larger urban healthcare facilities tend to fall under two stereotypes, typically hinging on funding and reimbursement. They’re either tech-savvy, top-flight healthcare fortresses or generic bargain basement medical factories. State of the art vs. in spite of the art.

The CSS team’s accomplishments align NYU Medical Center more closely with the former than the latter. And all they’ve achieved within the last few years has not been easy.

"Change is hard when you’ve been in an institution for 30 years and used to doing things the same way," Olivera said. "But we needed to upgrade our department, including equipment, processes and staff. New York is a place where you don’t have a lot of real estate so you have to be creative in everything you do."

Unsatisfied with the status quo, Olivera placed everything in the department under the microscope – from room layout to staffing to training – that affected customer service and productivity.

CSS developed several performance improvement teams with the nursing and surgical areas to address and solve problems. Each group meets regularly to discuss concerns together and resolve issues as a team, according to Olivera. They draw up timetables for assigned projects, and each team member is held accountable for completing his or her task and reporting progress at the next meeting.

"We started the process with the Day Surgery program and initially focused on team building," she said. "We talked about accountability and responsibility without blaming and pointing fingers."

Their mutual efforts led to award-winning hospital-wide recognition in 2003.

Upper left - Josephine Holton, CRCST,
Upper right - Wilston Ellington, CRCST
Lower left - Philip Darko, CRCST,
Lower right - Seli Agbota, CRCST

Meeting with the surgical services staff was even more of a challenge, Olivera recalled. "It was really tough when we started with them because they would beat us up," she said. "It was really bad." So Olivera and her team decided to take more control of their situation. Over time, armed with data from their instrument and inventory tracking systems, CSS illustrated all that they did for the operating room with such statistics as trays completed, on-time deliveries, quality assurance and percentage of recycled trays. "When they saw what we did because of what we showed them the whole process changed," she said.

As a result of their joint efforts, CSS increased its surgical instrument inventory by 23 percent, implemented a labeling process by which the surgical staff is alerted about sterilization parameters, according to the manufacturer recommendations whenever they need an item in an emergent situation, and enforced delivery of loaner trays to the hospital within 48 hours of scheduled surgery. Olivera indicated that their most prominent accomplishment has been the collaboration of the O.R. nursing staff recognizing the need for obtaining and reading the manufacturer recommendations for all new and current instrumentation.

In fact, in late July the O.R. asked CSS to take over its instrument room, which houses many physician-specific products. "The O.R. told us they wanted everything to be done with the same quality and under the same standard – our standard," Olivera said. "We’ve been playing a major role with them." CSS is scheduled to begin the process on Jan. 1, 2007.

Such recognition represents a noteworthy vote of confidence in Olivera’s group, which is responsible for organization-wide training in standardized decontamination, preparation and sterilization processes. In fact, orientation for all new employees, including surgical services nurses and nurses’ aides, goes through CSS.

Not only has CSS standardized all decontamination and sterilization processes, but it also has standardized basic instrumentation throughout all the surgical areas to include manufacturer catalog numbers, uniform descriptions and instrument photographs via its instrument tracking system. Olivera decided that the military names and descriptions worked best for basic instruments. "My staff thinks I trained in the Army anyway," she quipped. A data analyst maintains and manages the system.

To shed light on instrumentation loss with the goal of reducing costs, Olivera’s team created a chart that illustrates the monthly and quarterly expense of basic instrumentation replacement. The chart identifies instruments lost and the quantities, along with their prices, and tabulates total costs over time. "We spent a lot last year on replacement instrumentation – $133,000," Olivera said. "Because it was so much we wanted to make everyone aware of it." She indicated that she’s received positive feedback because "the chart is a tangible piece that the O.R. practitioners can appreciate, which motivates them to help us control the cost." The chart is conveniently posted next to the O.R. schedule, courtesy of the assistant director, and in the central sterile processing area. Olivera’s inventory coordinator manages it.

CSS also updated its automated inventory system, which helped the department decrease on-hand inventory by $300,000, reduce logistics process time by 40 percent and correct $200,000 in inventory discrepancies, according to Olivera. She translated these results into "dramatically higher service levels, shorter lead times, reduced administrative efforts and increased transparency of information" for customers.

But that’s not enough. CSS strives to maintain "continuous communication" with its customers. That includes assistant managers providing reports to surgical services areas on a per-shift basis, nurse managers each shift receiving electronic shift management reports listing all daily events that may have affected the function and throughput of the department, and daily staff shift reports distributed to staff members at the beginning and end of each shift. Finally, CSS conducts customer service surveys to assess what areas of performance need improvement.

Lean machine

Olivera relied on "lean manufacturing" principles to improve CSS’ operations, including sterile processing, supply distribution and more recently inventory management, which led to reducing the number of items stored and increasing space. It’s a business philosophy that originated outside of healthcare but has increasingly been implemented by healthcare facilities. And she urged that it’s not a one-time event but an ongoing process.

As the only department within NYU Medical Center to implement lean manufacturing principles and the Six Sigma process, CSS’ timing couldn’t be better for the materials management department to which it reports. That’s because materials management is migrating the inventory management and supply distribution functions from CSS to another area within materials management just as CSS assumes a greater role with the O.R. As a result, CSS’ inventory will become "official."

CS Attendants Standford Dyer (top), Emmanuel Jetu, CRCST (middle) and David Santiago (bottom).

"What we do is a business," Olivera said. Because her department’s inventory is "unofficial" and accounted for on the operating budget, "we charge [our customers] for supplies and for our services."

So it only seems logical that a business-minded CSS department would turn to lean manufacturing techniques to streamline operations. But in a hospital, pairing sterile processing with Six Sigma represents a rare occurrence at best, even though it makes a lot of sense if you view the function from a manufacturing perspective. So where did Olivera learn about lean thinking? A vendor site visit opened her eyes.

Olivera toured third-party reprocessor Alliance Medical Corp.’s [now Ascent Healthcare Solutions] main plant in Phoenix. "They had just finished implementing lean manufacturing to reorganize their operations and were very proud of their work," she recalled. That’s when she had her epiphany. "I realized that this was the same business we were doing and if it worked here it should work in my department." She researched the process and secured a grant from the union to recruit experts from aeronautics and electronics systems manufacturer Lockheed Martin Corp. to train her staff on the lean Six Sigma process.

As a result, CSS has been able to eliminate waste (including products) and work more efficiently in a better-organized environment, Olivera noted. For example, CSS removed a large table in the decontamination room that needlessly blocked the path between workstations and the ultrasonic washer. CSS also redesigned the workstations within the prep-and-pack area to include instrument-stocked pegboards to facilitate set assembly so that staff members no longer had to leave their area to get what they needed in huge cabinets across the room.

Since 1997, Olivera’s group has seen its workload volume increase more than 150 percent, transferred from surgical services to sterile processing. Last year alone, CSS processed nearly 203,000 packages, representing a 5 percent increase in volume from 2004, without additional labor hours, courtesy of lean, Six Sigma processes and the elimination of non-value-added work. CSS also worked with surgical services to reduce flash sterilization by 9 percent, confining the practice to emergent situations.

CSS implemented overlapping staff schedules, assigning staff to start work when the highest volume of instruments arrives in the department. That typically is in the evening and late-night shifts, Olivera noted.

"We implemented a work order system in which the operating room prepares a list of instruments needed for the next day based on the O.R. surgical schedule caseload," she indicated. "We call this the 5533 report. This work order of trays is expedited throughout the evening and night shift obtaining a 99.65 percent on-time delivery of all instruments needed by 6:30 a.m. For our main O.R. last year on average we received a total of 2,966 trays requested/month for next-day scheduled cases, of these, 47 percent of the trays were needed for the first cases. We met this demand without any setbacks."

Supply inventory turns nearly doubled to 15 last year from eight the year before, while adding more than $56,000 in new items.

CSS installed computers in the surgical service areas and trained the O.R. staff to search for instruments, send messages to the CSS staff to expedite the sets needed to be recycled and determine what’s needed for the next case.

Olivera’s team implemented a
variety of quality assurance and safety protocols on all instruments and equipment prior to use on a patient. One involves a safety check on all minimally invasive instrument shafts for pinholes and insulation failures before a surgeon works with them. CSS, infection prevention and control and surgical services also conduct random samples of finished products processed in the department. For the last two quarters, CSS’ clean assessment record is spotless.

"We work very close with infection control and prevention," Olivera said. "Everything we do goes through the infection prevention and control committee. When we get their blessing things go easier." That’s important because Olivera’s team is responsible for decontamination and sterilization policies and procedures throughout the organization, including affiliate hospitals and off-site and nonacute care facilities.

While CSS may not be a revenue-generating department, Olivera considers her group a bottom-line-minded business. They capture daily the cost of all transactions via a department-grown software program. For sterile processing they record such data as changes of a count sheet to the charges associated with running validation tests on new trays. For supply distribution, they record the cost of medical/surgical items for those units that are not connected to the hospital information system. "Every transaction captured is compared to resources, variances and budgeted dollars," she noted. "This process allows us to provide the nursing units with information that they can use for budget planning and financial projections to complement the strategic planning process." CSS processes approximately 8,700 items per month that have a monetary value of $58,600.

Working with the purchasing department, known at NYU Medical Center as the sourcing department, CSS participates in a number of projects to consolidate products and services. One recent success involved a contract for instrument repairs and refurbishing that helped the facility realize $200,000 in savings.

By the book

Implementing lean manufacturing techniques to improve customer service, productivity and quality performance may be an impressive accomplishment for a forward-thinking CS/SPD department. Yet for the CSS team at NYU Medical Center, education and training remains its pride, Olivera indicated. In fact, she considers the CSS educational experience intensive and second-
to-none.

"Education has been our priority, as we believe that a technician equipped with the necessary knowledge to do the job carries the tools to help him or her make decisions to positively impact the outcome of the surgical procedure," she noted. "Our training and education is geared toward the reduction of errors, reduction of cycle times by performing tasks more efficiently and attention to detail through proactive quality assurance to promote patient safety."

In fact, all new employees are not assigned to their shift until they are fully prepared to perform the functions of a CS technician, according to Olivera.

CSS has a dedicated training coordinator who trains new staff, maintains staff competences, supports customers with in-services and education on issues related to instrument processing and supports the CSS managerial staff competencies.

Unfortunately, low salary ranges countered the educational and training progress the department made, according to Olivera. She admitted it was frustrating. "We’d educate and train people and get them certified and then they’d go to the hospital next door for $1 more," she added. "We were training and then losing people." Her departmental vacancy rate reached 18 percent several years ago.

So Olivera surveyed hospitals in their union about salaries and responsibilities and appealed to administration to loosen the purse strings. She was convincing. "It was costing us too much to keep starting over with new employees," she noted. Or training them for other facilities.

In addition, Olivera and her management team created a career ladder for technicians in which staff is compensated financially for their certification and years of experience. Lead techs participate in leadership training, as well, with the potential of achieving Certified Healthcare Leadership (CHL) status. Olivera and her team also launched the Central Service Technician Advancement Chart (C-STAC) program as part of the techs’ upgrade path. The program includes educational modules in specific phases within sterile processing. Each progressive level has its own color. The highest level of expertise is "mentor," who earns a black stripe, similar to a Six Sigma Black Belt.

Olivera stresses certification with a goal to have all technicians whose assignments are directly preparing and sterilizing surgical instruments to be certified by year’s end. A decade ago, only 8 percent were certified; today, 80 percent of CSS technicians sport the CRCST acronym behind their names. Three percent also have achieved the new Certified Instrument Specialist (CIS) status with a goal of 30 percent by year’s end.

CSS hosted five unpaid interns this year, all of whom achieved certification. In the past when interns were hired into staff positions they hit the ground running. Using data compiled during the last two years, Olivera found that on average, the new hire productivity for an intern is 30 percent higher during the first month than that of new employees without prior experience.

All certified techs and certified instrument specialists have areas of expertise that qualifies them as "subject matter experts" to work with new employees and interns. CSS makes available a library of resources, as well as videos, pictures, posters and an interactive computer program that helps them maintain their competencies and "procedure slides" for complex processes. The procedure slides are recipes with systematic pictures of how the process is done.

"Ringi" leaders

Such a heavy emphasis on education and training foments teamwork. Olivera’s management team encourages this not just by words but also by actions. In fact, they follow the "Ringi System," which empowers those who are going to be directly involved with the implementation of a decision to participate in the decision-making process.

"If you’re doing something on a daily basis you ought to know how to do it better than if I simply told you how to do it," she said.

Such an attitude is reflected in the performance improvement teams, shift reports and communication board. CSS also is implementing a "section expert program" that assigns designated subject matter experts to different surgical service section areas. They’ll serve as liaisons with nurse managers and nurses to achieve complete trays all of the time. "We want to make sure that issues are addressed before they become a problem," Olivera added, "and planning and expediting sets before they are needed."

To demonstrate its commitment to teamwork and customer service, CSS learned that the supply distribution area, for example, needed some improvement. As a result, Olivera’s team ramped up customer service training, revised the hospital information system screens to make CSS more accessible, implemented second rounds during morning and evening shifts to support the equipment needs stemming from discharged patients, reinstated meeting with key personnel from the logistics team and clinical engineering to minimize equipment accessories loss and expediting of broken equipment and made a supervisor available 24 hours a day and on weekends through a pager and on-call supervisors to maintain customer satisfaction.

Staff members are rewarded for their productivity, perfect attendance, quality measures and customer service with a variety of incentives, including public transportation cards, food vouchers, merchandise and check cards.

Looking forward

Olivera set some lofty goals for her crew that hover around the figure 100 percent. That is, she would like her department to achieve 100 percent accurate, 100 percent clean, 100 percent complete products and services 100 percent of the time.

Education, training and certification contribute to that, as well as putting section experts, liaisons and a quality control specialist in place, and new decontamination and sterilization equipment. Moving into the next phase of lean Six Sigma with a focus on the "5S" (sort, straighten, shine, standardize and sustain) system will enable staff to continue redesigning their workspaces for maximum productivity and customer satisfaction. That includes reassigning non-valuable work to non-technical staff members so that instrument techs can concentrate on their primary tasks.

After all, Olivera’s CSS group is responsible for establishing and maintaining standard operating procedures for sterile processing throughout the organization, including its acute care and nonacute care affiliates. They give staff precise descriptions of each work activity specifying the time and the work sequence of a specific task and the minimum inventory of resources needed to conduct the activity to produce standard trays every time they are assembled, according to Olivera.

More advanced, minimally invasive and outpatient surgical techniques may be great for patients, Olivera observed, but it translates into a heavier workload for her team. With surgical cases becoming more complex almost everything has to be hand-washed, she added. "But that keeps us in business," she smiled. HPN