September 2007

15 organizations highlight their ‘best practices’

Central service/sterile processing and distribution professionals may be vital to hospital performance and patient care quality, but their valuable contributions can be overlooked or not taken seriously until an infection outbreak occurs or a surgeon is rankled.

From cleaning, disinfection and sterilization to customer service, kit/pack assembly, loaner implants, maintenance and repair and quality assurance, CS/SPD could be classified as a "hub" of the organization, as one CS department billed itself.

As a result, Healthcare Purchasing News Senior Editor Rick Dana Barlow consulted with a variety of experts on the provider and supplier sides for anecdotes, tips and tools on best practices in sterile processing – on paper and in practice – as well as with some of the recent years’ winners and finalists in HPN’s annual CS/SPD Department of the Year Award.

What they had to say may be old hat for some or helpful reminders for others, but at the very least their words of wisdom should be educational and enlightening, if not inspiring.

15 going on 52

• Always get manufacturing recommendations in writing. Having the information in writing ends the guess work. It’s a great reference to keep on hand in case the item is used rarely, and we forget the process. The written information provides all of the information needed to correctly process the medical device.

• Remember we are a service department. We are here to service the direct patient care givers. If we don’t do our job correctly, they cannot do their job correctly.

• [Quality assurance] checks are very important. We get what we inspect, not what we expect. QA checks need to be performed by checking work that is complete. These checks enable us to see what quality of products we produce and may serve as a corrective measure.

• Use mistakes as learning tools and don’t repeat them.

• Know the AAMI standards. Purchase the AAMI Steam Sterilization Standards ST 79. This document provides the standards along with the rationale of why the standard was written. It’s a great reference material.

• Achieve certification. It gives you the knowledge needed to perform the extraordinary work we do daily.

• Change cleaning solution frequently. You don’t want to wash instruments in dirty water.

• Use rigid tray liners to prevent tears in packaging.

• Use the right size brush for the lumen you’re cleaning and discard worn-out brushes.

• Don’t spread thumb forceps too far apart when cleaning them because that could damage them.

• Be sure to flush lumened instruments.

• Wash your hands often.

– Susan Klacik
Corporate Director, Sterile Processing
Forum Health, Youngstown, OH

One story I have related to my Central Service staff when I want to get the point across of giving your best effort in whatever you do has to do with my experience on the swimming team in college.

In college I swam both freestyle and butterfly, with the ‘fly’ being my most successful stroke. The following incident brings home that point. I had trained very hard throughout the week in preparation for my match-up against my archrival in the fly and our team’s archrival in the state. A swimmer was allowed to swim two events in a meet so my coach placed me in the 200-yard freestyle as well as the fly. Knowing that my ‘big race’ was coming up and I had no chance of placing in the freestyle event, and deciding to save my strength, I ‘dogged’ the race and finished about 5 seconds slower than my usual time. My coach was really upset with my effort, and when it came time to swim the ‘big race,’ he pulled me from the fly event and our team lost the meet. 

Dejected and embarrassed, the next day during practice I went to the coach with my swimming gear in hand and told him I no longer wanted to swim and that what he did caused our team to lose the meet. He turned to me and said...’Don, yes, we did lose the meet and as you know, you did not give our team your best effort in the freestyle. If you remember this important lesson and always give your best effort at whatever you do, we will win many future meets and you will become a better person for the rest of your life. Now go back in the locker room and get into the pool....practice has started!’ 

I never forgot those words and went on to place 2nd in the state championships the next year. I have always given my best effort throughout my life. That event and those words from my coach, helped me to focus on my endeavors to achieve success throughout life. 

– Don Gordon, MPS, CRCST, FCS
Director, Central Sterile Processing
Hospital for Special Surgery, New York

First join a local or state CS group. The networking is worth it. If there is no local or state group, join one of the national groups. Why reinvent the wheel? The knowledge gained in going to local and state meetings is worth its weight in gold. I made the mistake of waiting almost one year before joining my local CS group. I could have saved lots of time. I can say that I am very blessed that I have made many close friends because of this. They have supported me in both my personal and professional life.

Get all the publications you can, read them and then share them with your staff. Put them out in the break area. Some say knowledge is power; I say sharing knowledge is the real power – the power to grow and make changes for better quality care concerning the patient. This also includes guidelines and standards from organizations like AAMI, AORN and the CDC.

Visit hospitals. Actually looking at and walking around another department is worth its weight in gold. Every department does something good. We all can adapt ideas and processes from other hospitals. When you visit, take a staff member with you. Having another set of eyes is great.  

If your medical facility has an OR educator this person should be one of your best friends. I have been blessed with having many OR educators to mentor me in writing policy and learning about my major customer the OR.

Lastly, ‘quality doesn’t cost, it pays.’ Don’t take short cuts. Do it right the first time no matter how hard it is. I learned the hard way. It is not about being right. It is about doing the right thing. Quality in the long run will win out. If you keep the patient first in your mind you will always do the right thing. I know it is overstated but always look at the patient as one of your family. If that does not motivate you to do the right thing each and every time, nothing will and maybe you are in the wrong job.

– Stephen Kovach, Director of Education
Healthmark Industries, St. Clair Shores, MI

Don’t underestimate the cost of a shutdown caused by a sterilant gas leak. While sterile processing lacks the visibility of other departments, it is no less important to the hospital, as rapidly becomes apparent if there is a shutdown. The fastest and most likely way to a shutdown is a sterilant gas leak, e.g., ethylene oxide (EtO) or hydrogen peroxide used to sterilize heat- and moisture-sensitive items.

A few weeks ago, a large hospital in Michigan experienced a leaking EtO sterilizer. Fortunately, they had a continuous EtO monitor installed that detected the leak, so they were able to take quick remedial action and prevent a minor leak from becoming a major evacuation. The May EtO leak and subsequent evacuation, including the ER in Pasadena, was highly publicized. Evacuations are more common than many suppose and in one of the few studies conducted [La Montagne & Kelsey, K.T. American Journal of Public Health, (1997), 87(7),
1119-1125] found that two-thirds of the responding hospitals (58 of 90) reported evacuations of the sterilization department or area due to a real or suspected EtO leak or alarms from 1985 to 1993.

Evacuation results in expensive disruptions to throughput and shortages of equipment supplies to the higher-visibility departments, and only if the leak is serious enough for hazmat and later litigation lawyers to become involved does the cost of the disruption alone appear to be more palatable. With most sterilant gases being imperceptible to human senses until exceeding hazardous concentrations, my advice is to install a continuous gas monitor since its the only effective way to detect a leak and provide a warning promptly, and to let the insurance adjuster sleep better at night.

– P. Richard Warburton, Ph.D., Esq
Vice President, Research and Development and Chief Technology Officer
ChemDAQ Inc, Pittsburgh, PA

We all know that communication is the key to all our success. I had an experience with a central processing staff that took communication to a new level in this organization. The central processing staff was the recipient of blame for all of the instrument issues that existed at the facility, such as supply of instrument sets for procedures, broken instruments, missing instruments and mislabeled instruments to name a few. The central processing department manager took the following steps:

Set up weekly meetings with the OR coordinators with the lead central processing technicians to discuss problems. Problems that were identified were listed by specialty on a board in the CS department, such as a change in an instrument set.

Central processing staff members were selected as liaisons to the OR coordinators for their specialties.

A weekly meeting was set on Thursday to review the OR schedule for the next week to identify any possible conflicts or deficiencies in instrumentation. The meeting was held in the OR scheduling office with the OR schedulers, OR coordinators and CS leadership. A plan was identified to meet the instrumentation requirements of the OR schedule.

A central processing technician was identified as the OR CS liaison. This staff member started at 6 a.m. and was in the OR checking that all instrumentation was sterile and in the ORs for first cases of the day. The CS liaison received a report from the OR charge nurse identifying OR schedule changes, emergency cases scheduled and potential instrumentation needs.

As a result of the above actions, the CS staff became more involved with the OR Schedule and demands on a daily basis. Both the OR and CS staff became acutely aware of how important it was to communicate changes and anticipate and respect the workflow of both departments.

I believe this is an example of best practice in CS by taking the initiative to improve process and communication so both departments could productively and efficiently meet the needs of their customers.

– Barbara Trattler, R.N., MPA, CNOR, CNA, Director of Clinical Education
Advanced Sterilization Products, a Johnson & Johnson Company, Irvine, CA

BAMC’s CMS has an ‘Outpatient Service’ for distributing prescribed disposable supplies, such as wound and ostomy appliances, urological supplies, dressings, tapes, various lotions, skin sprays, gloves and almost anything disposable that a patient would need for home use. This is one of the wonderful benefits provided for our active duty military and veterans. Instead of going to a drug store to purchase these items, they can get a doctor’s prescription, and we provide the product for them. If there’s a ‘special order’ item that we do not carry, the outpatient supply technician coordinates the acquisition of the product through our logistic support channels then calls the patient at home to let him/her know when the product has arrived. We have several patients who have avoided hospitalizations due to our intervention with their home-care needs — we will do whatever we can to decrease or prevent a patient from being hospitalized and instead, they can care for themselves in the home setting, resulting in a better attitude and faster recuperation.

– Central Material Service (CMS)
Brooke Army Medical Center, Ft. Sam Houston, San Antonio, TX

Implement and manage durable medical equipment for patients with asset tracking technology for equipment that functions on the same system as nurse tracking. This enabled our hospital to move toward unit-based equipment. The system allows us to locate needed equipment and shorten the delay for patient care.

Central service standards committee, which has representatives from each of the four departments within the system, meets quarterly to review and add policies and procedures. We have established one standards manual for all hospitals.

Monitor daily productivity and error rate in the following categories and present them to staff with open discussion on possible solutions for improvements on a monthly basis as well as balanced scorecards presented quarterly: Requisitions, par levels, decontamination, prep and packaging, sterilization, code/trauma carts and surgical case carts.

The key to success as an organization is making sure staff members in every department are aware they are a valuable piece of the puzzle. They also need to be able to see how their piece of the puzzle helps present a perfect picture. Our central service has found their piece to be continuous monitoring, evaluating for improvements as well as being very involved with different branches of patient care organizations within and outside the hospital.

– Central Services, CoxHealth, Springfield, MO

As a component of the orientation of new staff members, they have an opportunity to assist the OR personnel in setting up an OR room prior to the beginning of a case. At certain times, personnel may also be asked to view the procedure. Both of these experiences are designed to provide the sterile processing staff a first-hand look at the duties of the OR nurses, the challenges they encounter and how the work done in sterile processing affects the work of the OR personnel, physician and ultimately the comfort and satisfaction of the patient.

– Sterile Processing
Illinois Valley Community Hospital, Peru, IL

We are definitely the hub of our hospital. If anyone can’t find something, doesn’t want it, doesn’t know where to put or doesn’t want to do it, it falls to this department to accomplish.

All four employees are members of the infection control committee. This committee works very hard to monitor issues that arise hospital wide and host infection control in-services. They have come up with fun ways to present the needed and somewhat dry topics. A few of the in-services included, ‘Survivor’ theme, ‘Healthcare High School,’ and ‘Who Wants to Be a Billionaire.’

– Central Service
Kit Carson County Memorial Hospital, Burlington, CO

VMMC is very involved with the development of a Lean Production System based on the lean principles of providing the customer what they want, when they want it in the amount required. By using the Lean Principles, they mapped the steps in the processes and eliminated all wasteful steps. Using the lean methods the team was able to eliminate 2.5 FTE’s. The team was able to transfer one of the FTEs to supply distribution. All of the team worked together to make these changes happen and they have sustained their gains. The decontamination process is now completed in 32 percent less time and all staff members have standard work procedures.

The IDN modified the Toyota Production System for healthcare operations and renamed it the Virginia Mason Production System, which CS adapted for its own improvement. The department targeted productivity, walking distances, parts traveled distance, safety, work-in-progress, inventory and physical space and devoted special emphasis on the value stream, which represents a conceptual ‘map’ of a process, and to the definition of standard work.

Virginia Mason uses cross-functional, multidisciplinary work teams that gather for five days in Rapid Process Improvement Workshops (RPIW) to analyze procedures, processes and performance facility wide and make improvements using lean thinking as a guidepost. CS conducts its own internal improvement seminars, which has led to efficiencies in its four primary functional areas: Sterile processing, supply distribution, linen and equipment.

The group used lean thinking to increase sterile processing productivity and maintain quality as surgical cases grew in volume and complexity. When the staff looked at the process of set assembly they found that the highly skilled instrument technicians were frequently interrupted, lacked teamwork and often participated in tasks that required little skill or training to accomplish. So the team established a "waterspider" or "waterstrider" role to solve problems. Typically, staff members responsible for assembling surgical sets complete their tasks in individual workstations where they remain for an entire shift. CS technicians serving as waterspiders, named for the bugs that can literally walk on water, select the next set for assembly, print a computer-generated recipe, prepare the set for assembly and perform an initial assessment for cleanliness. Then an instrument technician takes over and physically assembles the set, which includes a second check for cleanliness. Once that set is complete the instrument tech moves to the next available standard table already set up for them and focuses on accurate assembly.

The distribution team also implemented a number of operational and process efficiencies through lean thinking and without the use of costly technology. Instead, it used a kanban (pronounced "kahnbahn"). It’s a colored card placed at a reorder point in a bundle or stack of supplies. Once the kanban is reached the card is pulled and placed in a collection bin checked by CS regularly.

The group worked together to develop a regional Linen Disaster Plan after 9/11. It not only included 19 hospitals but two other laundry services joined for a unified treatment of laundry during a disaster. We provided information for biological, chemical and natural disasters for conservation, use and disposal of linen, depending on the circumstances.

– Central Services
Virginia Mason Medical Center, Seattle

Hamot formed specialty teams that coincided with the care teams in the surgical suite. The central sterile processing team members became experts in the trays related to their service area, while also maintaining competency in the other areas. They developed a CPD Pick List that printed the supplies, trays and linens that were required from their department only. At the same time, they lettered the storage racks and numbered their shelves in the area that houses the supplies where case carts are picked. Next they assigned a ‘location’ to each pack, instrument tray, supplies and linens. This information was loaded into the operating room information system, which allowed them to generate a report that is sorted by general location and bin location.

When the CPD Pick List is printed, the supplies are listed in the order they appear on the rack and shelves. These efforts resulted in a decrease in the use of paper and a 50-percent reduction in the amount of time it takes to pick a case cart.

The central sterile processing team also began putting minor equipment on their case carts, such as things that would be used immediately (e.g., sequential compression devices). They soon expanded their role to become a centralized distribution point for other patient care equipment, such as pacemakers. They were responsible for finding, testing and cleaning the pacemakers, as well as implementing a process for battery changes and testing. They created centralized locations for them, and our staff made sure they were in good working order. Because of their focused attention, we were able to reduce the different varieties of pacemakers, standardize their equipment and create a process to support our patients in terms of timeliness of access to devices.

The team’s most successful project in terms of equipment management has been the IV infusion pumps. The staff is responsible for cleaning the pumps between patients, pulling the pumps for preventive maintenance, ensuring the devices are plugged in and charged when they are not in use and making sure each unit has enough to service their patient population. The staff also assumed the responsibility for downloading IV pump data on a weekly basis.

Every piece of equipment is treated as if it would be used on one of our own family members. For this reason, our staff uses innovative approaches to gain staff support in caring for this million-dollar resource. The team created a poster campaign that outlined the facts of what actually occurred when an infusion pump was left unplugged and the battery died.

– Central Sterile Processing
Hamot Medical Center, Erie, PA

Each OR specialty has a matching coordinator, educator and SPD point person. This aligning of service lines assists with communication and efficiency. Each SPD shift team leader has a counterpart in the OR. Their frequent communication allows SPD to flex and readjust priorities as the OR schedule changes due to emergencies and cancellations.

The tracking of loaner instrument trays is a common problem in many hospitals. The SPD team devised a tracking system that is simple to use and very efficient. It involves a four-page carbon copy tracking form. The sales representative fills out the form with all required information. The SPD tech then checks the instruments and determines their priority in the cleaning and sterilization process. The white sheet (original) is placed in the SPD Loaner Logbook. The pink copy goes to processing so the personnel sterilizing instruments can prioritize their work. The yellow copy is placed on a case cart or specific shelf in the case cart area awaiting the cooled sterile instruments. The last copy is returned to the OR by the sales representative. He places it on a specific bulletin board for the orthopedic specialty coordinator or ortho team member to review as they prepare for the day’s schedule. If there is a question concerning whether a loaner tray was delivered and processed, this paper trail leads personnel efficiently in the right direction.

– Sterile Processing
Poudre Valley Hospital, Fort Collins, CO

In its two-room sterile storage area, the material processing team decided to mimic the storage patterns of any major manufacturing and retail businesses to better reorganize a layout that included disposables, peel packs and trays mixed together. They split the two rooms into two sections. The first room contained all of the disposable supplies and linen with like items placed together; the second room housed all of the bundles, peel packs and trays, the latter of which were organized by service. After looking at lead time, use, unit of measure, unit of issue and whether an item was stock or non-stock, the team was able to "right size" the inventory.

To prevent missing or misplaced instruments, they created an instrument facilitator position to be responsible for sorting and tracking trays at the point of use. Equipped with a voice pager for surgery to call immediately after a case, this person gathers all the sets in a soiled utility room designated by surgery, scans the sets using an information system, sorts them, restrings, opens and disassembles all instruments and sprays them down with foaming enzymes. As a result, the facilitator can ascertain when an instrument disappears before leaving surgery.

– Material Processing
Reid Hospital & Health Care Services, Richmond, IN

Using a digital camera we put instrument pictures in the count sheet format as a reference, which helps with specialty trays. Because some instruments are so similar that only looking under a magnifying light will you see the difference, the picture gives us a visual to zone in on. We also take pictures of loaner trays for more accuracy in placing the instruments.

We show appreciation. With the mindset of getting more with honey than with vinegar, we started with the ancillary departments. Looking for procedures and processes being done correctly or as requested, we started writing ‘Thank You’ notes. Skepticism turned to surprise and a smile when they realized we were not being sarcastic but meant what we said in the note. Having the procedure done correctly is now the norm instead of the exception. We carried this same concept into the OR by using a communication board to list ‘appreciations’ for improved communications and procedures.

– Central Sterile Processing
Heart of Lancaster Regional Medical Center, Lititz, PA

To reduce and prevent instrumentation loss, the central sterile supply 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. The chart is conveniently posted next to the OR schedule, courtesy of the assistant director, and in the central sterile processing area.

CSS implemented overlapping staff schedules, assigning staff to start work when the highest volume of instruments arrives in the department.

The 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.

They capture daily the cost of all transactions using an internally developed 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.

All new employees are not assigned to their shift until t     hey are fully educated and prepared to perform the functions of a CSS technician. 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.

CSS also developed a ‘section expert program’ that assigns designated subject matter experts to different surgical service section areas. They serve as liaisons with nurse managers and nurses to achieve complete trays all of the time.

– Central Sterile Supply
NYU Medical Center, New York