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The new Central Sterile Processing unit at Hospital for Special Surgery in Manhattan.

For rather obvious reasons, such inadequacies don’t bode well for a facility committed to quality patient care. If the CS department — which should ideally run like a well-oiled machine — isn’t able to perform optimally because of poor design elements and misuse of space, then how can healthcare organizations expect CS staff to process instruments safely, effectively and efficiently?

"The Sterile Processing Department is a major contributor to patient and surgeon satisfaction. To work efficiently and effectively, adequate space, efficient planning and proper processing equipment is needed," noted Nancy Chobin, RN, CSPDM, sterile processing educator for Saint Barnabas Health Care System, West Orange, NJ. She stressed that administration needs to be acutely aware of the critical role of the SPD and ensure that the department is designed with good work flow, people flow and infection control in mind.

While having administrative support is undoubtedly important, that’s only half the battle. Armed with that backing (and, in a best case scenario, a healthy budget to facilitate the necessary changes), facilities then face the daunting task of determining how best to go about improving upon the current design.

As many consultants and CS personnel can attest, a beautiful-looking department isn’t always synonymous with a well-functioning one. Being outfitted with the very best equipment isn’t enough, either, as Michael Kelly, associate product manager for Getinge Infection Control, explained.

"The overall design is essential. There are plenty of great equipment choices on the market. You can install the latest equipment, but it will not provide an efficient processing solution in a poorly designed space," he said.

To help facilitate the early planning process, Chobin said that prior to the first planning meeting the SPD manager should have a good understanding of what is wrong with the current design and how best to improve it. "It is recommended to maintain a list of problems encountered and how a new department could have prevented it," she said, adding that the data collection phase should begin as early in the process as possible.

Of course, working with an architect (and, in some cases, a design consultant) with experience designing for sterile processing environments is also key to creating a department that is not only comfortable and aesthetically pleasing, but also highly functional.

"To me, as a design engineer, I see that one of the biggest problems is designers who don’t specialize in cleanroom or [overall] sterile processing design," said Deric Haddad, president of Haddad-Wylie Industries LLC (HWI), a clean room design build company. "They often have to hire outside consultants and lack a solid understanding of the needs of [the department]."

Sources agreed that proper flow is among the most essential elements of successful design, particularly because SPDs often are at a loss for space. Put simply, flow serves as the hub, with equipment selection, storage and other elements acting as the spokes that further add to operational efficiencies.

John Kimsey, director of professional services for SterilTek Inc., a professional services subsidiary of STERIS Corp, explained that proper process flow includes the linear product flow, as well as "lean thinking philosophies to minimize employee and product movement" and provide a clear separation of soiled, cleaned and sterile items. He noted that items within the process flow should be separated to differentiate between types of items, types of sterilization, and incomplete instrument sets versus complete instrument sets.

"Planners have generally known there should be separate areas for decontamination, assembly (prep and pack) and sterilization, but they frequently didn’t understand or take into account the details of the sub-operations within these areas," Kimsey continued. "Combining solid SPD knowledge with solid process/lean/manufacturing knowledge enables the planner to incorporate a thorough design that supports the management of the process rather than inhibiting it."

Kimsey added that one of the most common design flaws relates to insufficient space in the assembly or prep-and-pack area. "Equipment planners know how much space washers and sterilizers require, but often do not consider the high level of activity that occurs between the washers and sterilizers," he said, adding that the hourly volume of instruments flowing through the entire department can also be overlooked in the assembly area. "Many SPDs have more than enough washing and sterilization capacity to keep up with the flow of soiled instruments into the SPD, but the department was only planned to handle 50 percent of that capacity in the assembly area. The result is a mountain of instruments backlogged in assembly, sitting on shelves waiting for a technician to reassemble them for sterilization."

Although an architect and consultant may recommend workflow and design considerations, it’s important to understand that the ultimate decision should still lie with the SPD manager. As Chobin pointed out, an opportunity for a new department presents itself about every 20 years, so it’s important to get it right. "There is nothing more frustrating to hear after completion of a construction project that ‘we were better off in the old
department.’"

Having SPD technicians actively involved in the planning and design process is essential. After all, these are the individuals who must function in the space on a daily basis and sufficiently meet the ever-growing demands of their customers.

Equipment vendors should also be kept in the design loop. Chobin explained that architectural firms often have a preferred processing equipment manufacturer and may design the department around that manufacturer’s equipment. "If the facility intends to bid out the equipment to ensure the best possible pricing, the competing equipment manufacturers should be contacted to draw up conceptual plans based upon their equipment," she said. Processing equipment vendors typically do not charge for this service. Because space and equipment needs go hand in hand, Chobin stressed that if project budgets are exceeded, equipment needs may suffer.

One Central Service Processing director discovered firsthand that designing a new department is a lengthy process that requires a substantial amount of planning, commitment and legwork. While working for Bronx, NY-based Jacobi Medical Center, Don Gordon took the planning and design reins, working closely with the architect to conceptualize a dream-worthy department. An SPD veteran, he knew what worked and what didn’t, and had a clear-cut view of the changes he and his staff would like to see implemented in the new facility. But he didn’t stop there.

Gordon took a look at some of the architect’s other SPD projects, making a point to take a tour and ask the staff what they liked best about the design – and what they would do differently if they had the chance.

Jacobi’s new SPD – which took five years, from conceptual planning to completion — proved to be precisely what Gordon and his staff had envisioned. Among the most brag-worthy features of the 6,000-plus square foot facility include state-of-the-art tunnel washers and conveyor systems to automate the decontamination process and increase efficiencies; a mix of sterilizers, including two large floor-loading units, a medium-size sterilizer for items that are needed more rapidly; ample bulk storage; streamlined work flow and larger, more efficient assembly areas; and two designated elevators – one for dirty case carts that opens directly into the decontamination area, and the other a clean one for sterile trays that leads to the clean-core of the OR. Prior to the new design, staff used a regular elevator to transport instruments in closed/covered carts to and from the OR.

"The dedicated elevators meant we no longer had to wait, so we could make better use of our time." Gordon, who initially had hoped for an SPD on the same floor as the OR, said an honest discussion with the architect made him rethink that approach. The architect pointed out that because the OR is a revenue-generating department, the facility may – down the line – decide to convert SPD square footage into additional surgical space. "When I realized that there’s no guarantee that the space you’re given will stay that way, I decided that having our department two floors below was a better option."

Despite the enviable department design, Gordon was only able to enjoy it for eight months. In May, he assumed the SPD manager position at New York City’s prestigious – and ultra-busy — Hospital for Special Surgery. Thankfully, his new department, which processes a whopping 400 to 500 trays a day, is just as awe-inspiring. "We have one of the largest decontamination areas in any hospital I’ve ever seen," said Gordon. Another perk? Like Jacobi, the department has its own dedicated elevators. "I consider myself very fortunate to have been able to work in two beautifully designed departments."

When designing for the SPD, sources stressed that worker comfort and safety should be at the core of the plans. That means addressing ergonomics with effective layout and user-friendly equipment.

Getinge’s Kelly explained that plans allowing for too much back-tracking and cross-traffic lead to inefficiencies and can hinder safe operations, while inefficient work stations can make the physical tasks associated with sterile processing difficult and strenuous.

"Design the department with good linear flow that eliminates any double handling," he suggested. Selecting equipment with versatile loading equipment and cycles that will allow processing of a large variety of items is a good idea, he added. If budgets allow, he recommends advanced automated equipment that boosts throughput while eliminating heavy lifting.

To proactively address worker safety, Natalie Lind, educational director for the
International Association of Healthcare Central Service Materiel Management (IAHCSMM), suggests having an ergonomics evaluation performed in the current work area and then incorporating some ergonomically-friendly features into the design. Installing adjustable height workstations – or, in the very least, varying work station heights – is one effective approach, along with design options that minimize equipment noise in work areas. "Install visual, as well as audible, machine signals and alarms."

Lind also recommends installing a wireless communication system to save steps and reduce fatigue, and placing handwashing sinks near department entrances. "Employees are more likely to wash their hands routinely if they don’t have to walk across the department to do it," he continued.

John Potter, an independent consultant who works for HWI and other companies, has built more than 1,000 clean rooms for virtually every industry, and is considered a foremost expert on clean room design. He has seen "real value" from incorporating various ease-of-use operating features into designs – from auto-sliding doors with touch-free controls (which allow for safe breakout in the event of a power failure) to hands-free clean hot air blowers (positioned at a practical height) and foot controls at sinks to easily modulate hot and cold water. Although automatic sinks may be appealing, he discourages their use because they don’t allow users to adjust the water temperature.

Potter audits facilities and processes to determine the proper height for tables, shelving and other design elements. "I am acutely sensitive to ergonomics. People aren’t all the same size, so designs need to be flexible and take those differences into consideration," he said. Potter is also a fan of camera handphone intercom systems that allow those working in clean rooms to see and communicate with those on the other side. To prevent heavy tray lifting, he crafted an elevator pass-thru (using simple Grainger parts) that raises trays a full 18-inches. Proactive planning is also essential for ensuring proper access to equipment once it’s installed. "We need to think about the people who will be maintaining the equipment. If there isn’t sufficient access, it won’t get maintained."

And don’t forget about adequate lighting. As Lisa Huber, sterile processing director for Maryville, IL-based Anderson Hospital explained, if lighting isn’t properly located, "there can be shadows and dark areas that affect a technician’s ability to inspect instruments well."

Aside from contributing to errors, inadequate lighting can also lead to fatigue and eye strain. To remedy the problem, Kimsey recommends individual table lights, magnifying glass lights, or new assembly-specific tables that include overhead lighting. "In designing new off-site centers we’ve been fortunate to incorporate the desired level of lighting (approximately 1000 lux or 100 footcandles), along with a bright and reflective ceiling, wall, and floor colors that increase the effectiveness. Simply repainting the SPD area with a reflective off-white paint can increase the lighting in the area." Kimsey noted that AAMI standards address the different recommended adequate lighting for each area of the SPD. "If the physical design of the department will not support overhead lighting to these recommended levels then each workstation should incorporate individual work surface lighting to make up for the deficiency."

Aside from enhancing efficiencies, user-friendly, highly functional and aesthetically pleasing SPDs can also do wonders for staff morale. Effectively designed SPDs incorporate a work environment that is positive and uplifting to the employees working in it, Kimsey said. "Too often SPDs are in a dark, dingy corner of the basement where cobwebs and peeling paint are the norm. Employee loyalty, quality workmanship and positive attitudes can be greatly enhanced by a clean, appealing physical environment." He added that when constructing new off-site SPDs the addition of windows can greatly improve employee morale.

Facilities that don’t have the luxury of scrapping their department altogether and designing one from the ground up can still make some noteworthy improvements. Often, it just takes some creativity – and in some cases, the willingness to negotiate with neighboring departments that rely on the services of the SPD.

Mansfield, OH-based MedCentral Health System’s SPD gained some valuable, much-needed space when the O.R. agreed to relinquish part of a corridor to the SPD’s decontamination area. "That extra space allowed us to double our work space by adding another washer and sink, and the OR benefited because we were able to get them their [materials] quicker," said MedCentral’s reprocessing manager/clinician David Narance.

With staff support and information documenting the need, the SPD also managed to secure some new equipment – including a new, highly efficient washer that augmented the more than decade-old ones that were already in place. Getting there required documentation of how equipment breakdowns were impacting quality service and how a new unit would boost efficiencies. Narance also looked at other areas of improvement. Recognizing that 25-30 percent of total washer time went solely to basin sets, he proposed – and was granted – a switch to disposable basin sets. "Expense-wise, it was a wash because we didn’t have to dedicate the supplies and resources to washing them."

"You don’t have to have an entirely new department to make positive changes," he said. "If you can show that improvements can increase throughput and have a real impact on revenue-generating departments, that will go a long way in driving change."

Better shelf configuration is also essential. If a shelf is 18-inches deep and the bins on them are 12-inches deep, departments are losing a full six inches of valuable space, Lind stressed. Shelving should also be durable and easy to clean, HWI’s Haddad pointed out. HWI offers a unique sterile shelving system constructed of high-density polyurethane that is smooth, seamless and has no exposed screws. Even better, the shelving is not much more expensive than standard shelving, which can be difficult to clean and can harbor dirt and debris in nooks and crannies, according to Haddad.

The overall message is that regardless of whether a facility is designing a brand new SPD or making do with an existing one, it’s imperative to make the most of every available dollar and square inch. "Even large, great-looking departments won’t be adequate if there’s misuse of space."