Christiana Care’s sterile processing team reinvigorates quest for success

With a history of being bounced around on the organizational chart between perioperative services, materials management and back again, and working through long-standing process efficiencies, which soured its service relationship to the operating room, the department lost much of its credibility and influence in the system.

But rather than serving as a breaking point to decentralize sterile processing within the two-hospital system, this roadblock instead became an inspirational rallying cry for change by the sterile processing team – one that redefined and re-energized a lackluster and moribund department, transforming it into an integral part of the perioperative environment.

Such a 180-degree process and customer service turnaround in such a short period of time motivated Healthcare Purchasing News to select Christiana Care Health System’s Sterile Processing department as its 2008 Central Service/Sterile Processing and Distribution Department of the Year.

Prior to 2007, the road to sterile processing was rocky at best. Historically, the rotating reporting structure between perioperative services and materials management took its toll, undermining efforts to develop ongoing teamwork with the OR staff, according to Richard M. Bowling Jr., CPA, MBA, director of perioperative business operations and sterile processing.

Over time, [the] volume of surgical services grew – total number of cases – but no one took a look at what investments in capital and human resources were needed to support the growth of OR volume, Bowling noted. When additional capital was recommended for increasing the instrument inventory it was frequently diverted to other ‘special needs,’ he added.

What drove the "long history of surgeon and OR staff dissatisfaction," according to Vernon Alders, corporate director of operational excellence, was SPD’s baseline case cart completion rate was 35 percent for Christiana Hospital, the largest of four surgical sites performing inpatient and outpatient procedures with 26 ORs. Indeed, it was a figure Bowling characterized as "far less than optimal." 

Christiana Care Health System’s Operational Excellence team (left to right): Vernon Alders, corporate director; June Estock, senior operational excellence consultant; Jesse Moncrief, senior operational excellence consultant; and Cengiz Tanverdi, director, management systems

Subverting the status quo 

Clearly, a new vision and strategic operational changes were needed. Joan G. Thomas, R.N., M.S, F.A.C.H.E., Christiana Care’s now former senior vice president of perioperative services to whom SPD reported, recognized this and initiated action in October 2006. Thomas recruited assistance from the organization’s operational excellence (OE) department, which focused on internal process improvement.

The OE team developed a collaborative effort among key members of the OR, SPD and infection control staff, including directors, managers, nurses, supervisors and front-line personnel. At the core of this initiative was a joint SPD/OR steering committee that met biweekly to lead the redesign process conducted by nine multi-disciplinary teams focusing on inventory, set density, preference cards, sterile storage and case cart assembly, wrapper hole, resource matching, vendor loaner/consignment set, SPD/OR set quality and SPD/OR share day (for mutual departmental orientations). The nine teams tackled 40 specific performance areas that required improvement.

For example, clinical improvement opportunities included adherence to AAMI standards, quality controls and staff clinical training and competency, such as design considerations, cleaning, packaging, care and maintenance records and quality control. Operational improvement opportunities included logistics, equipment quality and adequate inventory and staff resources for case cart preparation.  "Based on a review of completed OR staff surveys, we identified additional performance improvement areas that needed to be addressed, including case carts that were incomplete or contained instruments that were broken, defective or packaged in torn wrappers," Bowling said. "These problems often resulted in delays and increased utilization of sets per case.

"The analysis also revealed that while 85 percent of OR cases were performed between 9 a.m. and 5 p.m., 80 percent of instruments were not returned to SPD until 6 p.m.," he continued. "This meant the workers who were responsible for building case carts often hadn’t received the necessary instruments by the time their shift ended at 5 p.m."

Carmen Laws assembles an ENT set.

Because of the communication break-downs the OR didn’t realize SPD’s ongoing plight.

"Often OR staff, frustrated with the accuracy and speed of instruments requested, were unaware of the associated system issues such as resource conflicts, delays in receipt of instruments in SPD and SPD equipment failures," said June Estock, R.N., MSN, CPHQ, senior operational excellence consultant. "As a result of this finding, OR and SPD staff met to openly discuss their current instrument cleaning processes and by researching best practice were able to identify opportunities for improvement in both areas. For instance, best practice indicates wiping used instruments in the OR with a water moistened sponge, irrigating lumened instruments with sterile water and moistening instruments with enzymatic solution for transport to SPD to help make it easier for SPD staff to remove bioburden."

Furthermore, they also discovered fundamental staffing problems that contributed to serious workflow challenges. "We found that 65 percent of the workload was occurring when the majority of staff shifts were completed," Bowling said. So earlier this year the SPD restructured staff to meet workflow demands by moving more workers – including lead technicians in supervisory roles – to the evening shift to meet peak demands. As a result, case cart completion rates for first cases jumped.

A much-needed boost in inventory also helped remedy the "miserable track record of customer service" due to incomplete case carts and complete case carts with dirty or broken instruments in the sets. In June 2007, eight months into the performance improvement redesign initiative, Christiana Care invested approximately $800,000 in new set inventory. Within two months of that investment, case cart completion soared to 75 percent from the 35 percent baseline reported in October 2006, according to Bowling.

Carole Ruby inspects orthopedic instruments  before peel-packing.

In fact, as of May, SPD’s first case completion rate jumped to 99 percent with the overall case cart completion rate hovering around 85 percent.

Adding instrument inventory to "what really amounts to a supply chain problem" was a  necessary step in any SPD improvement project, Alders emphasized. SPD needed a minimum requirement of "at least enough inventory to allow for one day of usage, one day for processing safely and one day for building case carts, transfer and room set-up," he said. "Once you evaluate this against existing inventory it is easy to see where the shortages are."

SPD also focused on improving accountability and productivity by moving sterile storage from the SPD to a "pick room" on the same floor as the operating rooms, while the instrument processing area remained two floors down. 

"All of our sterile sets and instruments are now stored in a central location only steps away from the operating rooms. When we moved storage for sterile instruments to an area adjacent to the OR this enabled us to start managing processed set inventory levels and decrease the lead time needed for case cart delivery to the OR," Bowling said. "This created a staging area for case carts, eliminated the awkward process of transporting carts via dumb waiter, and also made instruments more accessible. This also had the benefit of having the instrument sets closer to the operating room staff, thus increasing their confidence that sets would be available when requested."

With the extra space in the processing room, SPD expanded the assembly area by four workstations and two large wrapping tables. 

Kalimah Goldman receiving a set into prep and pack

Empowered by customer feedback, the committees created dashboards to measure performance improvement throughout the initiative.

To more effectively and efficiently track SPD performance and service levels to the OR, one of the teams developed a comprehensive online instrument quality assessment reporting tool to provide real-time data capture of information. The tool is a required page in the Cerner Surginet Perioperative Online Documentation System. The circulating nurse in the operating room must fill out the report for every case and provide information for items missing from case carts, dirty or broken instruments, holes in wrappers and modifications that need to be made to the preference cards, according to Connie Przybylek, R.N., MSN, clinical project manager. Previously, the QA tool consisted of a paper form.

"One reason that SPD had difficulty managing case cart completion rates was that the software used by the department was never designed to track this," said Jesse Moncrief, senior operational excellence consultant. "Operational Excellence worked with SPD to develop a custom program to track the completed case carts using existing data from their computer system. Staff can now bring up a report in ‘real-time’ to show cart completions for that shift."

Matthew Gould organizes general instruments during assembly

Another recurrent issue was the quality of the instruments SPD provided to the OR. A multidisciplinary team identified and implemented SPD and OR interventions to fix the vulnerabilities in the system and to prevent and monitor the recurrence of dirty and broken instruments, according to Bowling. SPD created a QA station within the prep/pack area, dedicating a staff member to remove sets out from the washer, inspect them for bio-burden and distribute them to the prep and pack stations for assembly. "After doing work sampling studies we found that during peak hours there was always someone walking to the conveyor to take a set off and distribute it to the appropriate station," Bowling said. "We felt that during these times we could assign that task to one person who would also QA the sets to ensure they were within cleanliness standards."

The result? Dirty and broken instrument rates plunged to approximately 1.5 percent as of May.

All of these efforts and outcomes established the foundation in rebuilding the culture of customer service and good will with the OR, rooted in such core values as caring, teamwork, excellence, integrity, leadership and service.

But it continues to be an ongoing challenge, Bowling admitted. "It is a matter of delivering a consistent message to the staff and following up with positive coaching and, if necessary, disciplinary action to ensure that staff understands that previous behaviors are not going to be tolerated," he said. "Culture takes time to change so I never had the expectation that it was going to happen overnight."

Mary Conkey wraps a basin set

Through workshops and other inservices, SPD staff learn new techniques for collaborating with colleagues and improving service to customers, he added. "We also encourage our employees to take ownership of issues that arise even when they are not directly involved," he indicated. "This has helped improve the collaborative relationship between the operating room and SPD staff."

For example, SPD accepted responsibility for retrieving dirty sets from all clinical units requiring use of sterile sets, something previously under the auspices of materials management when SPD reported up through that department, so that SPD could focus solely on processing instruments and building case carts. Unfortunately, before SPD assumed responsibility for this, the task was not always performed consistently and often resulted in dirty trays sitting on the units for long periods of time, Bowling noted.

To further increase productivity and improve throughput, SPD is in the process of implementing $800,000 in equipment upgrades to its fleet of washers and sterilizers. In fact, SPD has four cube washers, one walk-in sterilizer and a Sterrad 200 in the budget for fiscal year 2009. The department already purchased a Sterrad 100 NX to phase out the ethylene oxide (EO) mix sterilizers this year with plans to acquire a 100 percent EO sterilizer on the horizon, according to Bowling. SPD also switched some 250 sets to containers to avoid using disposable wrappers. 

Bowling quickly asserted that any process redesign had to be preceded by fostering teamwork and motivating staff members to work together "to propose new ideas and develop approaches to removing obstacles for improving processes."

While the OR may have a vested interest in the success of SPD for obvious reasons, SPD needed to believe in itself, too, he emphasized.

"We needed to address processes as well as the people," he said. "We needed to take steps to make sure the staff knew they were valued to give the department a sense of pride and a realization of how important they are in the perioperative process."

Nelsonya Forte QAs an orthopedic set before assembly

Until January, morale issues plagued SPD to the point that the shifts created three separate teams often engaged in shift wars, according to Bowling. "These shift wars were many times the result of supervisors not communicating effectively," he said.  "Consequently, work was being held over to other shifts from the previous shifts and negatively affecting morale. To address this problem, at shift change the outgoing supervisor has been using the last one-half hour of their shift to round with the incoming supervisor to review any ‘held over’ work." With this mutual accountability efforts and the addition of lead techs the shift wars cooled.

While competition sometimes can be a positive event this wasn’t the case at Christiana Care. "Shift competition breeds dissent," said Alvin Adams, SPD system manager. "We want the staff to understand that no one person or no one shift is bigger than the whole. It takes all of us, as one cohesive unit to provide the highest standard of clinical support to our patients."

Furthermore, SPD lacked sufficient clinical training and competency, according to Bowling. "The SPD staff felt frustrated that they were not given the proper training to perform their duties and no structure existed to provide support when needed," he acknowledged. So SPD hired an educator to develop a preceptor program that paired new hires with experienced SPD techs. In addition, SPD staff members are cross-trained in all aspects of sterile processing to provide coverage during vacations and absences. 

Christiana Care also instituted an annual competency assessment process for performance measurement where each SPD employee is evaluated on five major areas, which include decontamination, prep and pack, sterile storage, sterilization and case cart assembly.

Kent Ritson-Smith loads a sterilizer

Even though sterile processing associations historically have emphasized the need for and benefits of education and training, the communication challenges and lack of dedication to and understanding of SPD at Christiana Care prevented change. "For years, like many SPD departments across the country, people did not look at the importance of what SPD really does," Adams admitted. "This perception that all we do is ‘wash dishes’ has stifled resources needed to provide the proper education and training. The multidisciplinary teams have brought our department to the forefront, thereby allowing us to tap into all available resources for training and education."

Christiana Care requires – and pays for – SPD techs to become certified within three years of their hiring. "The three years is just the time frame to give staff ample time to feel comfortable that they have learned enough to take the certification exam," Adams said. "But our focus on mandatory training, education and providing a great place to work is a continual process."

Many of SPD’s process improvements were implemented at Christiana Hospital, the organization’s flagship, but Wilmington (DE) Hospital also reaps benefits. Christiana Care’s two ambulatory surgery centers house onsite sterile processing teams – composed of patient care techs who report to ASC management – that are being incorporated into Christiana Care’s SPD direction.

Sandy Jackson moving a completed case cart

Overall, however, Christiana Care plans to expand the SPD process improvements throughout the organization, including consolidating some functions on each campus and implementing a centralized instrument tracking software system that can track individual instruments system-wide. In 2010, Wilmington Hospital is scheduled to undergo a major expansion that will require it to replicate Christiana Hospital’s case cart system, according to Bowling.