With a nursing background, Kras arrived at Moffitt in 2004 and received a crash course in SPD operations that highlighted the tension with the OR.

"I felt that we needed to build a better playground," he said. "Having worked in the OR as a registered nurse, I knew that we were ultimately attempting to accomplish the same goal — better patient outcomes."

But Kras needed to overcome some hurdles of his own. The first was misplaced guilt.

"I was tired of seeing hard work and the actions of SPD go unappreciated," he said. "I used to joke that if something somewhere in the organization, even if in another building, either got broke or was lost, SPD would somehow get blamed. I used to get e-mails from departments we didn’t even service asking for me to replace items we never touched. SPD has traditionally been the scapegoat for so many years that blame was automatically placed on them. I wanted to change this mentality."

The second was fear.

"After much brainstorming, I decided that I needed to face my fear head-on and have a face-to-face sit down with all of the players of the operating room," Kras continued. "We arranged to meet and discuss our frustrations that led to a better understanding of each others’ business.

"Since we were on the short-end of the stick most of the time, we decided we needed to make the change," he admitted. "However, I respect the OR for stepping up and meeting us in the middle to work together."

This initial huddle helped to lay the foundation for a "long-term sustaining culture of respect and professionalism," one that incorporated every member of either team and unclogged communication lines.

But it wasn’t easy. In fact, first contact was tense and it took "several uncomfortable meetings" before SPD and the OR realized they needed to work together.

"It was apparent that we would have rather been somewhere else than sitting across from each other," Kras recalled. "We started out sitting at opposite ends of the table at the first several meetings but we soon discovered that unless there was going to be some ‘give and take’ that we would not gain any momentum."

So John Rettig, director of materials management, suggested they move the forum to a "neutral zone" and have dinner outside of work.

"At first, there was a lot of pushback since both departments did not have a lot of professional respect for each other," Kras noted. "We most certainly did not want to spend time together at work let alone meet on our own time outside of work. No one wanted to budge as we were worlds apart."

Kras highlighted one bone of contention as indicative of the gulf between SPD and OR. "SPD asked why the dirty instruments come down to [the] decontam room so messy and bloody," he said. "The OR asked why it took so long to get instruments turned over. We explained each other’s businesses and through a better understanding had a better appreciation for what we each did and that it just wasn’t intentional delays or game playing on our part. There actually is real science to what we do in SPD, and it takes time to make sure we do it right. We never have and never will take shortcuts in our work. It is too risky for our patients, and we will stand behind this commitment 100 percent."

To entice everyone to attend the dinner Kras made reservations at one of the toniest restaurants in town. "To this day, the walls that came down at that dinner were historical in nature," he said. "It was the best thing we ever did. We discovered things about each other that made us laugh and cry and we saw the humanistic side of each other. We realized that behind those masks at work there were kind and compassionate human beings, all after one main goal to provide the best possible care to ‘their’ patients.

"The nurses in the OR thought that the patients were their sole responsibility and belonged to them," he continued. "We saw it differently and felt that we also contribute to the welfare and care of our patients, and we wanted respect for our contribution. We discovered that we actually liked each other and that we could get along at work. We identified our strengths and weaknesses and together acknowledged the opportunities that lie ahead of us. We set out to change the mindset of all the others in our respective departments, to let them know that we were going to make this thing work, no matter what. It took a lot of give and take but we eventually got to the point where we literally bend over backwards for each other. It is a mutual respect. SPD and the OR are interwoven, and we understand that concept. We know that we directly impact each other’s business and that if we want to go from good to great we need each other and don’t stand a chance alone! It was and is, all about creating and sustaining trust."

April Sanders checks rigid scope for processing	Mikel Shans prepares tray for sterilization

Dotted lines

From there, SPD and OR recruited key individuals from both departments to serve on a strategic team that meets bi-weekly as part of a program with an acronym similar to the plastic, dual-functioning, picnic-favorite fast-food utensil, the "Sterile Processing & Operating Room for Continuous Quality" or SPORCQ.

Conceived to create shared business intelligence SPORCQ enabled SPD to co-own the process under which they and the OR would be operating.

"It was an educational opportunity for each member to walk the walk and talk the talk in shoes from those worn by others," Kras said. "We learned that each area has unique and varying responsibilities and skill sets that must be mastered, but yet are static and constantly changing. It was an opportunity to get the OR to understand that CS employees are not machines, routinely pumping out tray after tray, but instead unique individuals with strong and creative minds. [They are] individuals who routinely intercept and troubleshoot issues with a transparency that keeps the healthcare facility running effectively and efficiently."

Over several months, SPORCQ led to SPD and OR crafting a mutually acceptable – and signed – service agreement that outlined what either department promised to deliver as a business unit and enabled more objective performance measurements in a neutral environment that fosters growth, according to Kras. The SPORCQ team tracks every CQI occurrence, such as sharps incidents and tray assembly errors, and disseminates details to the respective departmental staff and senior management. "We actually compete with each other to have less reported CQIs each month to show that we did a better job!" Kras exclaimed. "What turned out to be a formal written agreement to ensure we stuck to it became a labor of love that has served our partnership well and has blossomed into a great working relationship.

"We feel proud that what started out as two departments being worlds apart, are now considered inseparable," he continued. "We have become a true team that allows everyone to become outstanding patient advocates."

Melissa Metzger checks inventory supplies	Christina Poston places scope in AER

Positive reinforcement for jobs well done include verbal, visual or written acknowledgements; too many negative occurrences instigate re-education for performance improvement to formal counseling for behavior not corrected, Kras indicated.

"Each month every employee in SPD receives a grid that outlines any CQIs reported on their work so that they can see their aggregate ‘infractions’ in a snapshot," Kras said. "I challenged the staff that I would reward them with a dinner out if we go one month without any CQI reported. We came close several times, but so far my wallet has stayed in my pocket. At staff meetings, I give out prizes to individuals who have the lowest errors on instrument trays and pulling of case carts. It creates a positive competition amongst staff. We look at CQIs as an opportunity for improvement, an opportunity to be better. It is important as professionals to be held accountable for our actions. We need to act accordingly and perform within our scope of practice."

Six minutes of separation

The SPORCQ team also uncovered that SPD received a direct telephone call from the OR every six minutes and that the OR reported an inordinately high number of CQIs for missing items in trays and inaccuracies with case carts.

To solve the problem, Kras’ SPD team created the OR Support Specialist position, a new liaison post dedicated to the OR. Jason Rawlings, the appointed ORSS, sports a mobile phone that serves as a direct hotline to the OR. "He is the eyes and ears in the OR that allows us to be proactive," Kras added.

Further, Rawlings divides his time between SPD and OR in that he assists in helping the OR start up their first cases in the morning. With Rawlings handling double-duty between 6:30 a.m. and 3 p.m., OR calls to the main SPD numbers have decreased by 50 percent and CQIs for instrument errors have decreased by 70 percent. In fact, they’re currently running at less than 0.5 percent of all trays assembled, which totals approximately 3,700 trays per month. Plus, OR satisfaction levels, based on surveys, jumped three-fold, according to Kras. When Rawlings goes off duty, Mikel Shans, CSPDT, CSPDS, SPD lead technician, manages all calls as needed.

"Each person on our team has made the commitment to put aside his or her individual needs to work towards the larger group objective, which is to provide quality sterile goods and instruments to those we service in order to insure our patients receive the best care possible," Shans said. "This commitment extends beyond quality patient care and excellent customer service. We are also committed to our co-workers." 
 

Robert Wesley prepares instrument carriage for sterilization	Jason Rawlings uses instrument tracking system

To wit, SPD operates under a contract, "A Commitment to My Co-Workers," signed by all new team members, renewed annually and held accountable by each employee, according to Shans. "The essence of the contract states that we will maintain healthy interpersonal relationships with all team members, be respectful regardless of job titles, not engage in bickering, back-stabbing or blaming, accept each other as we are today, forgiving past problems, and find solutions to problems rather than complaining," she said. "We also acknowledge that neither of us is perfect and that human errors are opportunities, not for shame or to place guilt but for forgiveness and growth."

Bring on the PEONs

Kras’ team members formally recognize one another’s going above and beyond the call of duty with a "Providing Excellent On-Going Niceness" citation, or PEON for short. The irony – and humor – isn’t lost on Kras.

"SPD has always been referred to as ‘peons’ downstairs, and the Kelly Clamp is also referred to as a Peon Clamp in many institutions, so I coined the term based on these two factors to try and inflect some humor into what we do on a daily basis — reverse psychology maybe," Kras noted. "I was fearful that it might offend staff so I asked them, and they thought it was cool so we rolled with it.

"Healing begins with laughter, and I like to inflect humor into both my personal and professional life," he continued. "Working in healthcare and being an advocate of good health, it is good medicine, or should I say good nursing, that has worked well for me. It most certainly helped when we sat at that table with the OR. The tension was so thick that I needed to do something that would allow for us to open and remove the barrier between us."

Terra Simon working in decontam room	Cheryl Gionet pulls instrument tray for surgery

While seasoned with humor, SPD remains serious about its standard operating procedures and professional activism in that they willingly serve as information and supply sources to peers. "Although we are a business, we don’t hesitate to lend supplies to other facilities because the patient always comes first," Shans noted. Through their active involvement in IAHCSMM, AORN and AAMI, they also provide and help other facilities search for information on such topics as recommendations and standards for double peel packing, record keeping, using wrap in gravity loads and running Bowie Dick tests and biologicals after sterilizer repair, she added.

Because they believe that every patient deserves to have a certified central sterile supply department technician reprocessing instruments used on him or her, Moffitt instituted mandatory certification of technicians that directly prepare and sterilize instruments and lobbies the state for similar standards.

Fast Facts on Moffitt’s SPD team CSR FTEs 16 + 7 PRN Percent of FTEs certified 100% *exception of 2 new Tech I’s hired on March 7, 2011 (so they will be certified within one year) Number of acute care facilities serviced 1 Number of non-acute care facilities serviced 0 Number of certified inpatient beds 206 Number of OR suites 14 Number of surgical procedures per year 9,500 Number of patient clinics 25 Number of clinic visits per year 200,000+ Number of outpatient visits per year 325,000+ Number of bone marrow transplant cases per year 350 Admissions per year 9,000+ Annual Performance & Production 2009 2010 2011 (YTD - 3/29/11) Number of surgical cases 8,113 8,722 2,292 Number of sets/trays assembled/processed 42,012 44,240 11,664 Number of peel packs processed 42,465 42,524 10,563 Number of sterilizer loads processed 7,914 9,390 2,610 Total instruments processed 3,823,998 4,022,408 1,059,222 Vendor Loaner trays processed 2,306 3,172 926 Number of case carts assembled/processed 8,587 9,193 2,419 Total supplies for case carts 518,672 552,608 144,914 Error rates for instruments 0.41% 0.23% 0.15% Inventory line items 816 833 877 Inventory value $907,947 $1,105,325 $1,312,103 QA/Customer satisfaction scores QA Information for hospital-wide satisfaction scores: Prior to July 2010 Moffitt did all of the inpatient and outpatient surveying internally. At that time they were using a 5-point scale. As of July 2010, Moffitt started using Press Ganey for inpatient surveying and since they used the 100-point scale, Moffitt converted to that for its outpatient surveying at that time. Moffitt did not convert the prior data to the 100-point scale, but just began using it moving forward from July 2010 (Fiscal Year runs July 1st – June 30th). Point Scale Out of 5FY 2009 Out of 5FY 2010 Out of 100 FY 2011 thru 2/11 Inpatient 4.54 4.54 90.3 Outpatient 4.6 4.64 94.2 Source: H. Lee Moffitt Cancer Center & Research Institute, March 2011

"Certified sterile processing technicians are medical professionals and the first line of defense in assuring that all items are properly disinfected and sterilized based on standards and recommendations set by governing organizations," said Christina Poston, CRCST, CHL, SPD education specialist. "It is for this reason that we believe that every patient deserves the right to have a certified technician reprocessing their instruments, trays, scopes, etc. This enables us to ensure that the proper policies, procedures and techniques are being followed when decontaminating, assembling, and sterilizing. This not only includes patients in the OR, but also patients seen in our clinics."

Consequently, Moffitt’s SPD group runs an extensive three-month orientation program for all new hires as well as a lengthy competency structure for everyone that keeps pace with changing standards of practice, she added.

"There is too much technology, chemistry and biology required to perform and function successfully in this role," Kras agreed. "The tides are changing, with many states mandating licensure to work in this environment. A certain level of knowledge and skill sets are now required in this complicated world of microorganisms and metal. We want to stay ahead and forge the way with setting a higher level of learning."

To attract and retain high-caliber staffers, Moffitt created an upwardly mobile clinical ladder with accompanying compensation levels.

"You can no longer hire someone off the street to do this type of work," Kras noted. "The tools of the trade have changed. Medical device sophistication has dramatically increased with manufacturers’ instructions varying from device to device and numerous new disinfection and sterilization methodologies are in play today. We are all challenged to stay current. [We seek] only individuals that are committed to this industry and are willing to adapt and remain in this profession. It weeds out the non-players. It is very serious work."

SPD also maintains a collegiate relationship with local vocational training schools to provide a clinical rotation site for scrub tech students, according to Kras. In fact, SPD is exploring the feasibility of establishing its own "SPD School" where "we can create a didactic and clinic internship training program to ‘grow’ some of Moffitt’s own employees from other departments who show an interest to enter our profession," he added.  

There is much more to the story! Moffitt - SPD of the Year Moffitt SPD stoked on scope, device control Moffitt SPD morphs into lean machine Moffitt’s Kras demonstrates SPD class Moffitt’s staff affection Moffitt's Continuouse Quality Improvements chart Moffits CS Sample forms: PEON Nomination SPORCQ-CQI Tracking Form Service Agreement With Operating Room Vendor Instrument Tracking form