For such a storied academic healthcare organization with an Ivy League-like reputation and international renown, the CSR team consistently failed to demonstrate it was pulling its own weight and was buckling under the pressure.

In fact, back in late 2004, Dartmouth-Hitchcock’s senior leadership struggled with an issue that "threatened the otherwise untarnished name of the institution," according to David Walker, director, supply chain management. The albatross turned out to be something familiar to many healthcare facilities now grappling with federal reimbursement limitations: "Alarming increases in postoperative infection rates."
 

Decontam: Diane Dods (Pod Leader), Donna Mullins, Brian Stout, Daniel Dixon, Joe Wilson, Deborah Roberts, Jake Woodward, Jeremy Bernier, Sean Fisher. Not Pictured: Lyle Quackenbush. CT/ Vasc/ Neuro: Cheryl LaPlaca (Pod Leader), Maxwell Ribeiro. Eyes/ ENT/ Oral/ Plas: Loren Smith, Ron Goodearl. Not pictured: Gloria LaBombard (Pod Leader). Gen/ Transplant/ BI: Cinderella Sanders (CSR Liason), Richard Arnold, Wayne Pfenning. Not pictured: Alan Lefebvre. Gyn/ Urol/ Pedi/ Robot: Linnea Palmer (Pod Leader), Larry Adcock. Ortho: Jessica Willett (Pod Leader), Glen Locke (Pod Leader), Barry Page, Cody Minckler, Derek Day, Sue Bowen. Trays/ Phones/ Autoclave: Mary Gardner, Mirka Wilczoch, Jenny Tuthill, Peter McCusker, Sheila Janas, Michael Kenney. Washers: Kaitlyn Gibbons, Angela Kohanski. Computer Support: Ashley Grantham (Pod Leader), Koreen Grantham. Third Shift: Gregory LaRose (Core Tech) , Regina Lowndes, Thomas Preston, Vicky Morin, Not pictured: Michael O’Hora, Roxanne Johnson. Training: Venkata Kuppa, David Chelsey, Joshua Adams, Seth Bubb, Colin Sainsbury. Part Time/Disability: George Mossey. Not pictured: Kimberly Winot, Ray Sarette, Melinda DuBeau, Lynn Goodrich, Jim Plummer.

Dartmouth-Hitchcock’s senior leadership reviewed the organization’s overall operations and pointed to the "likely root cause, its Central Sterile Reprocessing department, after finding it not to be operating at peak performance levels," Walker indicated. "It was clear that the department required a complete turnaround, which would refocus its value contribution and service proposition to the organization."

Amid other potential culprits like medical errors in the operating room or lax infection prevention procedures, top management didn’t arrive at its decision to lay the blame on CSR lightly, Walker assured. "After a review of the possible areas of infection variability, CSR was identified as being most likely to be the cause of the problem than other areas," he said. "The conclusion was arrived at through observation and comparative evidence of other potentially causal areas."

Rather than "quickly coming to terms with the magnitude of the problem," Walker noted, CSR simply plodded ahead. "A lack of organization-wide understanding as it related to the critical nature of the CSR process" seemed to shield the department, he added. In effect, the organization itself served as an enabler of less-than-acceptable practices.

"There was a general lack of deep understanding surrounding the importance of the CSR process and its potential clinical impact," Walker said. "Previous processes had been going on for a long time, the impact of which was not immediately acknowledged."

Walker traced the laissez-faire attitude to the large number of internal department workarounds to supplement CSR’s poor service.

(L to R) David Walker, Director of Supply Chain Mgmt., Alan DuBeau, 2nd shift supervisor, Tracey Rapp, DHMC CSR Leader, Lacey Fellows, 1st Shift Supervisor, and Diane Dods, Decontamination Service leader

"People were doing an awful lot of cleaning and sterilization in-house simply because we weren’t doing our job and could not be depended on," said CSR Manager Tracey Rapp, a 30-year veteran in sterile processing operations management, recruited to lead CSR in January 2005 in a massive turnaround effort. "The problem with that is that if we don’t do our job appropriately, the patient is in trouble."

Despite the fact that other clinical departments were handling their own sterile processing, CSR was held accountable because very little would be gained by spreading the blame, Walker acknowledged. "Instead, it was much more important to centralize the activity and provide the department with the tools and resources to solve the problem," he concluded.

Rapp, a U.S. Naval Hospital Corpsman with decades of experience running sterile processing departments on the West Coast, including two major Level 1 trauma centers, embarked with her team on centralizing CSR operations, providing clear accountability for customer service and improving sterile processing practice patterns and output, restoring morale, order and trust in the department.

Now three years after the turnaround and rebuilding efforts, Dartmouth-Hitchcock’s CSR team has bonded and matured into a first-class operation, reprocessing 343,000 instruments per month for multiple facilities, generating vastly improved clinical customer service ratings and contributing heavily to the organization’s 27 percent infection rate decrease. Walker noted that CSR today is considered and widely recognized as one of Dartmouth-Hitchcock’s "model departments" and "a key operation within the organization."

In recognition of such noteworthy performance improvement, Healthcare Purchasing News chose Dartmouth-Hitchcock Medical Center’s Central Sterile Reprocessing department as its 2009 Central Service/Sterile Processing and Distribution Department of the Year.

Dartmouth-Hitchcock’s 49-member CSR department handles all cleaning, decontamination, disinfection and sterilization of reusable patient care equipment and instrumentation for the 396-bed medical center, the state’s only Level 1 trauma center; the Norris Cotton Cancer Center, one of only 40 National Cancer Institute-designated Comprehensive Cancer Centers in the U.S.; and Children’s Hospital at Dartmouth, the state’s sole children’s hospital.

Newly empowered by the hospital’s infection control committee and supported by senior management, Rapp reeled in the Dartmouth-Hitchcock’s decentralized sterilization activities, according to the compliance standards of the Association for the Advancement of Medical Instrumentation (AAMI).

For about six weeks, Rapp conducted a thorough systems review, observing and analyzing processes and work practices, interviewing staff and clinical customers and inspecting instrumentation and equipment.

Such exhaustive efforts, which included building relationships with perioperative and clinical staff outside CSR, identified 579 specific issues that needed to be addressed to re-establish CSR as a safe and stable operation.

Rapp evaluated all core CSR processes using such performance improvement techniques as Rapid Process Improvement (RPI), workflow analysis, employing "5S" workplace organization, value stream mapping, and capacity and bottleneck analysis to determine throughput requirements, calculate time and identify major process constraints. She started with basic cleaning in decontamination.

Rapp tapped Alan DuBeau, a four-year veteran at the time, as the service leader for decontamination. "Very few people wanted to work ‘the pit,’" recalled DuBeau, who currently functions as CSR supervisor. "The lines of dirty case carts and instruments used to get backed up and we didn’t have a consistent process for handling our workflow. Because of the dedication of our people and our focus on quality, we always got the job done, but the work was often grueling and thankless."

One important change made by Rapp, DuBeau and the rest of the CSR team in the decontamination area involved standard layout of equipment such as carts, tools and storage items. "In the past, if we needed a certain size brush to clean a particular scope we had to search around for it, which took a lot of time," DuBeau said. "Now, everything has a place and stays in its place, and every workstation is set up the same way. Items are even color-coded for easier identification."

To streamline decontamination workflow, CSR developed laminated, digital picture boards with cleaning instructions for different pieces of equipment, posted at every workstation. Dedicated workstations cover such areas as eye instrumentation, flexible scope cleaning and lead testing, bed pans and commodes and anesthesia products. They set up loading cart wash racks in a standard configuration to coincide with downstream production processes to maximize throughput.

CSR also created a decontamination service team, fully trained and led by Diane Dods who received her certification as a flexible scope reprocessing technician.

To ensure consistent quality, according to Walker, CSR limited the number of technicians processing flexible scopes due to the complexity of the devices and the precision required to assure scopes are processed correctly. These specialized technicians reprocess an average of 300 flexible scopes per month for anesthesia and the OR. They also routinely invite flexible scope manufacturers to review and evaluate the operation, he added.

CSR developed measures to monitor the mechanical cleaning cycles, such as washer decontaminator cycles per AAMI guidelines and installing an advanced pumping and alarm system that assure the appropriate amount of chemical dispersion to perform cleaning effectively. If the dose to an individual unit is incorrect, an alarm sounds and the cycle will not advance. "This is critical since cleaning is the most important process we perform," Rapp said. An automatic dispensing system at every sink automatically dispenses the correct amount of enzymatic cleaner, Walker added, and an automatic chemical pump station feeds seven pieces of equipment.

To further centralize all instrumentation processing for the entire organization, CSR implemented an outpatient clinic initiative that adds 10,000 instruments per month for 54 clinic areas to its workload to the 5,000 products already handled. Previously, CSR sterilized only equipment as the clinics were cleaning, packaging and doing some sterilization. An outpatient clinic service leader oversees the process for CSR.

Jeremy Bernier (R) and Dan Dixon (L) checking equipment.

CSR now processes 343,000 instruments per month, up from 293,000 in 2007. The orthopedic service represents its largest volume customer at about 100,000 instruments per month, accounting for about 30 percent of the total.

The department recently implemented a tracking system for equipment and is in the final stages of implementation of a new electronic documentation and surgical instrument tracking system (Getinge’s T-DOC). It’s also looking into equipment, such as robotics, to help address current capacity constraints, according to Walker.

CSR favorably converted the impressions of Karen M. Gollegly, director, orthopaedics. "CSR has been a foundation for the Department of Orthopaedics’ growth in surgical activity," Gollegly insisted. "In the past five years, there has been an 83 percent increase in the number of orthopedic surgical cases. Not only has the volume increased, there has been a significant increase in the complexity of the surgical procedures and the case mix severity of the patients. This has been associated with an increase in the demands for equipment, both in number and variety."

Rapp recognized that process review and re-engineering wasn’t enough.

"You can have the best processes in the world but without motivated, well-trained, dedicated people, they can’t be sustained and you won’t succeed," she noted.

Rapp promoted DuBeau and Alarnie Fellows, a certified surgical scrub technician, to supervisory positions to spearhead the transition with her. Using a team-based management structure, the trio trained staff and aligned practices with AAMI and equipment manufacturer standards.

CSR provided education and training in specific clinical areas, focusing on clinical applications and hands-on participation. For example, staff members have participated in bone plating and laparoscopic labs. As the education and resources service leader, Fellows directs inservice training. "Alarnie [Fellows] has immense clinical knowledge which has greatly enhanced the technical insight for the staff," Rapp said. "Alarnie’s expertise is extremely valuable to the department, and she also functions as a liaison to the OR staff and surgeons."

CSR established an alliance with the OR to incorporate CSR training as part of the OR Scrub Technician’s certification criteria for the Dartmouth-Hitchcock program. But CSR employees do not scrub into surgical procedures or go on rounds with clinical staff, Walker indicated. "The one exception to this is to operate the STERIS equipment as required," he said. "CSR employees are rotated to observe surgical procedures to gain an understanding of instrumentation use and the need for robust cleaning and maintenance practices."

Newly created service leader alignments to match the coverage responsibility of the OR Clinical Coordinators have also been very effective from a communication and customer service standpoint, Walker emphasized. They serve as subject matter experts and team facilitators, creating the necessary management support structure required by the needs of the different services in the OR, he said.

Refocusing CSR staffers as a cohesively integrated team and not as a divergent group of individuals extended beyond the training limits, according to Rapp.

"We used the need to protect and care for our patients as the central focus of our change management program — anything that got in the way of that became an issue to address," she said. Those who did not "see the efficacy of that focus were asked to reevaluate their own individual career path," Walker added. CSR’s guiding credo elicited "some staff turnover," he admitted.

Jenny Tuthill - Tray & Phone services

CSR’s efforts and achievements have made believers out of several clinical leaders.

"The CSR department has risen to the challenge in multiple ways," Gollegly noted. "The leadership and staff of CSR immediately respond to questions and concerns and always keep the patient the priority. The collaboration with CSR is enhanced by weekly meetings with the ortho OR schedulers and OR coordinator to review the upcoming week’s schedule for potential equipment conflicts, the need for immediate equipment turnover, and to anticipate loaner/consignment equipment arrivals.

"This ongoing communication has created a culture where all orthopedic staff and surgeons feel comfortable calling CSR with questions or concerns," she continued. "When problems arise, CSR responds immediately, conducting a root-cause analysis of the situation with feedback to the surgeon and department. This collaboration extends to ongoing discussions with Infectious Disease in the evaluation of infections in the operative and hospital setting."

Carol Majewski, R.N., MS, clinical director, perioperative services, concurred. "The OR has seen a tremendous improvement in customer service through the alignment of staffing assignments in CSR in a similar structure to that of the OR, [via] service teams," she noted. "This has enhanced direct communication and improved efficiency in daily operations." In addition, the quality of care has improved through reduced anesthesia time related to supply delays that had previously occurred and improved patient satisfaction with fewer OR delays, she continued. "This alignment has also promoted a greater sense of teamwork, uniting the departments in a positive, outcome-oriented way."

Kathryn Kirkland, M.D., Dartmouth-Hitchcock’s hospital epidemiologist and medical director of the Collaborative Healthcare Associated Infection Prevention Program (CHIP) expressed personal satisfaction with CSR’s performance improvement.

"I consider myself a big customer of CSR," Kirkland said. "I have grown to rely on its responsiveness, its thoroughness, and its sense of responsibility for all aspects of cleaning, disinfection and sterilization. Almost every concern that I bring to CSR is an issue that it has already identified and acted on, which creates a sense of confidence on my part, and a lot fewer sleepless nights! The CSR department takes its work extremely seriously and has incredibly high standards, and our patients are safer because of this."

Dartmouth-Hitchcock’s CSR team is
exploring whether and how to extend its service to support other healthcare organizations, and is in the early stages of developing the concept of a regional certification center to ensure a steady supply of highly skilled certified professionals are available to meet the ever growing needs of the industry, Walker revealed.

"Our strategic plan calls for CSR to partner with the Patient Safety Training Center in order to create a dedicated educational program which essentially provides training to employees prior to being put in service," he said. "This is driven in part by the fact that there is a lack of certified technicians in the area."

Reinforcing the "patient first" philosophy also perked up senior management’s impressions to the extent that they promoted CSR’s turnaround effort and actively participate in CSR’s open house during CS Week, providing tours to educate customers. They are keenly aware of how important CSR’s connection to infection control, patient safety and the organization’s financial outlook, according to Walker and are "very supportive" of CSR’s value and contributions.

"Clearly, the hard-earned efforts of the CSR team have brought a new competitive element to Dartmouth-Hitchcock’s value proposition, which directly affects its ability to provide competitive and quality healthcare to its patient community," he said.