SPDs share renovation best
practices and lessons learned
by Kara Nadeau Della Vecchia
Mississippi Health Services, like many healthcare systems, had outgrown its
central sterile processing (CSP) department. While the number of operating
rooms grew over the years, the CSP department didn’t. As a result, CSP staff
members were using an outdated space with outdated equipment to support a
growing number of advanced surgical procedures.
"We were providing service for 36 clinical
areas out of a 4,300 square foot space," said Mike Switzer, Vice President
of Supply Chain for North Mississippi Health Services. "Some instruments
would come out of the OR and sit for days before we could clean them. We
knew there had to be a better way."
Countless healthcare organizations face the
challenge of operating with inadequate sterile processing and distribution
departments. While ORs and other clinical areas become more technologically
advanced to support higher quality patient care, SPDs often lag behind, with
staff having to clean, sterilize and maintain a broad range of complex
instruments in departments that were designed and built decades ago.
North Mississippi Health Services and other
healthcare organizations have transformed their CS/SPD operations through
comprehensive renovations or rebuilds that provide staff the space and
equipment they need to support today’s fast-paced and cutting-edge clinical
Typical SPD challenges
found in older hospitals
Jeff Asproth, Supply Chain Manager at
has supported numerous SPD redesign and rebuilds, helping healthcare
organizations apply LEAN manufacturing principals to their SPD operations.
He notes how older hospitals often must contend with long travel paths from
one place to another, narrow hallways that pose the risk of
cross-contamination and basement level SPDs serving ORs on the upper floors
of their facilities.
"In many cases there are instrument carts
just sitting there waiting to be processed and all of a sudden 10 things
come down from the ORs at once and decontamination is slammed with a bunch
of work," said Asproth. "The farther apart SPD is from the ORs, the bigger
issues they have in terms of communication and workflow."
Asproth believes a sterile processing
department should be viewed as a "mini plant" where LEAN manufacturing
practices can be leveraged to reduce waste, boost efficiency and improve the
quality of service. He points out that hospitals taking a LEAN approach
often relocate their SPDs closer to the ORs, sometimes right next door, to
facilitate greater visibility and constant communication.
"From a LEAN perspective, the more visible
things are the easier they are," said Asproth. "When those cases break, the
SPD staff can see those empty case carts and immediately pull them in for
processing. Furthermore, clinical staff can give the [SPD] immediate
feedback so SPD staff can better prepare for the next case versus when the
ORs and SPD are on separate floors and staff rarely talk with one another."
Image courtesy 3M
Level Process Map for Sterile Processing Flow
Asproth notes that visibility and
communication within SPD are equally important. He’s seen many older
facilities with concrete walls separating the decontamination and assembly
areas, which helps prevent cross-contamination but can hinder workflows and
"Concrete walls make sense because they
prevent dirty and clean parts from getting together but a better alternative
is glass," said Asproth. "With glass windows or walls, those in assembly can
look over and see when decontamination is busy while they are not and offer
their assistance, and vice versa."
Taking it off-site
Best practices for care and repair of surgical instruments
To optimize the care
and repair of surgical instruments, Matt Rudolph, Vice President
of Operations and Chief Customer Advocate for
Instruments/STERIS Specialty Services, suggests that healthcare
facilities incorporate the following technologies and processes
into their SPD rebuilds or renovations:
• Task lighting at the
• Adequate work
• Magnification for
proper instrument inspection
• Education on
proper instrument inspection and testing
• An insulation
tester to detect failures in laparoscopic instruments
• Scissor test
material for weekly testing
• A demagnetizer
for surgical instruments
For Switzer and his team at North
Mississippi Health Services, the solution to their CSP challenges was to
build an off-site 33,233-square-foot CSP and case cart assembly plant
designed using ideas and best practices from pharmaceutical companies,
manufacturing and hospitals in the U.S. and Europe. Through technological
advances and automation, the North Mississippi Health Services CSP
department is now processing 28.6 percent more sterile sets and 40 percent
more sets per full-time employee.
The facility’s design prevents cross
contamination through technological advancements, including robotics, and
design enhancements such as replacing single door technology with double
door technology for all sterilizers, providing airlock doors to prevent
mixing of air from each of the three processing areas, and dedicated HVAC
units for the four areas in the building (Decontamination, Prep/Pack,
Sterile Room, and Common Area).
"We looked at the whole process and
implemented LEAN practices to come up with something that would support our
growth through the next 20 years," said Switzer. "In the end, we applied
more ideas and practices from manufacturing than we did from other
The facility also includes its own reverse
osmosis or water purification room. This capability provides pure water that
does not include any chemicals or minerals. This is ideal for use with
stainless steel, plastics and glass. The purified water is turned into steam
by the in-house steam boilers. Switzer notes that clean steam provides a
longer life for the instruments and allows the jacket of the sterilizers to
not lose efficiency during its life span.
Automated instrument washers at Sanford
Sanford Medical Center case cart staging
An in-house approach
Sanford Medical Center in Sioux Falls, SD
also faced the challenge of supporting procedural growth through a small
(5,000 square foot) Central Processing and Central Stores department. The OR
staff was processing and packaging its own instrumentation while CPD
performed the sterilization. The OR struggled to perform these functions in
the face of rising procedural volume but the CPD did not have the necessary
space or equipment to assume responsibility for them.
In 2006, the medical center opened a new
surgical tower to accommodate its growth and provide patients with a central
location for their surgical needs. The CPD department was relocated to a
17,000 square foot space located in the lower level of this new facility and
assumed control over all instrument processing, packaging and delivery. The
facility features a number of design and technology innovations to better
support CPD staff members in their work, including a case cart delivery
system, designated elevators for clean and contaminated equipment located on
opposite sides of the building and an electronic instrument tracking system.
Gail Doyle, CSPDM, CRCST, manager of CS/SPD,
notes how this transition required a major cultural shift on the part of the
"At first the OR staff had trouble
believing that we could do the job," said Doyle. "By approaching them with
the attitude that they are our customers and quickly addressing issues as
they arise, we’ve established a good working relationship and gained a
substantial level of confidence and trust".
According to Doyle, Sanford Medical Center
worked closely with its vendors to design its new CPD department. She
encourages other facilities going through a redesign or rebuild to involve
vendors early in the process to leverage their knowledge and resources.
"When most healthcare organizations think
about their vendors they focus solely on contracts and money and think
little about how vendors can provide added value," said Doyle. "What they
don’t realize is that vendors can play a critical role in helping them plan
their new [CS/SPD], by offering things like CAD drawings, 3-D images and
providing insights on process and technology improvements. I encourage
others to get their vendors involved and take advantage of what they have to
Steve Dillon, Vice President of Surgical
Instruments for Integrated Medical Systems International Inc. (IMS) agrees.
"Vendors can play a tremendous role in these renovations," said Dillon.
"They have the insight of working with several, sometime hundreds of other
facilities facing the same challenges. They can advise in areas such as
shelving design and needs, equipment needs, department layout infrastructure
Considerations for SPD renovations and
Whether a healthcare organization is
completely rebuilding its SPD operations or renovating an existing space,
there are a variety of factors that should be considered from the design of
the physical space to the training of staff members.
Randy Solomon, Business Development
Director for Getinge USA, advises healthcare organizations to consider that
renovation projects must be phased in such a way to maintain sufficient
processing capability to support scheduled procedures and answer the
• How many surgical suites are being
supported now and in the future?
• How many procedures are performed during
• What clinical services are associated
with these procedures? Consider that orthopedic procedures, particularly
revisions, profoundly impact the production capacity (throughput) equation.
"An instrument survey is the best method to
determine productivity requirements including the type and amount of
equipment along with square footage that must be allotted for all processes
within the space," added Solomon. "A facility’s vendors can work closely
with the architect of record and equipment planner to develop a design that
incorporates best practice, optimized workflow and the appropriate mix of
equipment to meet existing and future needs, all of this at no cost to the
facility, architect or equipment planner."
Medical Center’s prep and pack area
Securing internal support
Engaging C-suite support for a SPD rebuild
or renovation can be an uphill battle. Asproth urges SPD managers to compile
metrics that demonstrate how current equipment and practices contribute to
waste and how proposed changes could potentially cut costs, improve
productivity and enhance patient care.
"Metrics that demonstrate how SPD
improvements can cut down dramatically on the number of instruments
purchased each year or prevent contamination of clean product can help you
build your case to administrators and clinicians," said Asproth.
Switzer adds that a SPD rebuild or
renovation requires ongoing communication with various groups throughout an
organization. For the North Mississippi Health Services rebuild, Switzer
engaged the OR, facility operations and others in a multidisciplinary team
that provided input for the project to ensure the new facility met the needs
of all parties.
"We didn’t just do this on our own. We
included all of these folks from the very beginning," said Switzer. "Most
importantly, you’ve got to keep the OR involved and communicate with them
throughout the process."
Automating manual processes
The automation of manual tasks can play a
significant role in optimizing processes and reducing waste. Automation has
been a key factor in the success of North Mississippi Health Services’ new
CSP plant. The facility features robotics that loads and unloads
custom-built and fully automated washers. The units are programmed to
balance work cycles and loads the unit with the fewest cycles.
"We used to have things that would sit for
days before we could clean them now everything is cleaned in a matter of
hours," said Switzer. "Through automation and process improvements, we’ve
increased our throughput on the number of trays by 40 percent per employee."
"Automation may also reduce injury rates,
eliminate unnecessary motion, reduce the amount of loading and unloading
equipment, relieve bottlenecks during peak processing times, simplify the
staging of loads, and improve turnaround of instrumentation," added Solomon.
This is a
working in-house lab managed by IMS adjacent to the sterile processing dept.
inside of a large California hospital. Trays can be brought to and from the
as soon as they are run through the washer.
Instrument maintenance and repair
As part of their CS/SPD rebuilds, both
North Mississippi Health Services and Sanford Medical Center implemented
electronic instrument tracking systems to better manage their surgical
equipment assets and facilitate proactive maintenance programs.
Sanford Medical Center uses its tracking
system for set contents, traceability of instruments throughout
reprocessing, immediate use sterilization logging, biological and chemical
indicator logging and real-time location tracking of instruments between
North Mississippi Health Services has
laser-etched all of its surgical instruments with 2-D barcodes and developed
a database through which it tracks product usage and determines when each
piece of equipment is due for preventative maintenance.
"It’s amazing what a difference this
approach has had on our instrumentation. Everything looks like new," said
Switzer. "And the doctors love it because they no longer have to play a role
in quality control. All instruments are in good working order by the time
they reach their hands."
The benefits of in-house labs
Both Rudolph and Dillon suggest that larger
facilities consider designing their new SPDs to include in-house instrument
repair and maintenance laboratories.
"To ensure immediate turnaround after
instrument repairs, it is most effective to design a sterile processing
department that includes space for an in-house repair lab," said Rudolph.
"Having a repair vendor embedded in the department helps assure complete
instrument sets that are patient-ready and patient-safe. An in-house lab
also reduces or eliminates the need for hospital assets to leave the
hospital for repairs."
"An in-house lab typically takes up less
than 1,000 square feet and will allow a full time resource for instrument
maintenance and refurbishment resulting in lower instrument replacement and
repair costs, increased surgeon satisfaction and decreased wait times," said
Dillon adds that storage space is another
important consideration when planning a new SPD or renovation.
"Storage planning is typically low on the
priority list, however inadequate storage leaves a facility few options to
properly shelve sterile items, many times resulting in trays stored
on their sides which can cause damaged tips and bent instruments," said
Technology for tracking
Getinge USA Instrument Traceability solution
According to Solomon, there are new
technologies available today that assure a much higher level of quality
assurance, reduce instrument loss and the investment in redundant or
obsolete instrumentation. He suggests that a healthcare facility in the
process of a SPD rebuild or renovation consider implementing a system that
provides traceability of instrumentation and mobile equipment and captures
live washer and sterilizer data.
"This system allows departmental leadership
to visualize what was processed, when and by whom, and cycle efficacy in
real time while integrating to OR scheduling systems, materials management
and financial systems," said Solomon. "The platform prevents contaminated
instrumentation from reaching the OR and ties instrumentation to the
processing staff members, equipment with cycle efficacy to the patient."
He notes staff can use this system to
generate customized reports that present production metrics, staff
productivity, equipment utilization, missing instrument information, stock
usage and complete cost including instruments, handling, sterilizer/washer
cost, and packaging along with usage per department, doctor and student.
The importance of ergonomics
non-standardized work station (above) to a standardized work station (below)
According to Asproth, ergonomics should be
a key consideration for a healthcare facility when designing a SPD space. He
suggests facilities make their spaces as ergonomic as possible and take into
consideration the height and accessibility of supplies and equipment.
"It’s important to look at the area itself
and minimize certain steps that aren’t adding value to the process," said
Asproth. "In one [SPD] that I visited, there was a 4' 9" tall staff member
who had trouble reaching up and getting cases off from a rack. We redesigned
everything so that it’s only three feet high, allowing for easier access.
These simple changes can make a big difference."
At North Mississippi Health Services, CSP
staff use ergonomically designed worktables and floor mats that relieve
pressure on the feet and knees and enable them to sit or stand while
performing tasks. Supplies are packed into height-adjustable carts so staff
members don’t have to bend or lift items over their heads.
Designing workflows that make sense
"Anytime that you can structure a workflow
in a straight line versus a curved spaghetti line is a good thing," said
When planning a SPD renovation or rebuild,
Asproth recommends a facility map out its current processes to find ways to
improve workflows, such as taking out a wall or building a new doorway. He
also encourages SPD staff to evaluate the procedures they support and
rearrange supplies so that those needed for higher volume procedures are
more easily accessible.
Best practices for equipment care and handling
Chadd Bliss, Corporate
Midwest & Western Regional Director for
Mobile Instrument Service &
Repair states that good handling and care of instruments begins when
contaminated items are brought back for cleaning and continues through
assembly and storage. Bliss offers up the following best practices for
equipment care and handling when rebuilding or redesigning a new SPD:
• The decontamination
area should be of sufficient size to allow for a backlog of case carts
and instrument sets without impeding flow to washing areas
• Sinks should be of
sufficient depth and width to accommodate a set of instruments inside
• Since bio debris can be
difficult to remove at times, consider adding pressurized air and water
to the cleaning areas
• Provide plenty of flat
work surfaces to place sets as they are being prepared for washing
• Design space near
cleaning stations to store both internal and external cleaning brushes
and other supplies
• Ensure there is space
and adequate power and ventilation for separate decontamination to house
water purification system hardware and related supplies
• Consider installing
washable rubber mats on the floor in areas where sets are opened and
instruments removed to cushion any instruments that are accidentally
• Allow space for a sonic
cleaning system if one is desired to be installed in the SPD operation
Best practices for preventative maintenance
In order to design a
sterile processing department that promotes preventative maintenance,
Bliss suggests healthcare facilities incorporate the following elements:
• Design each assembly
workstation exactly the same. Variations in workstations cause
instrument to be mislaid, piled and dropped which causes damage. When
every workstation is the same, the risks are reduced significantly.
• Design assembly
workstations to accommodate electro surgical insulation testing
• Provide space for
storing and using basic instrument testing supplies including rubber
products for testing cutting surfaces and tags to mark damaged items
along with cards for set or instrument specific notes
• If you use computer
workstations in assembly, consider adding high power digital microscopes
to each to allow technicians to inspect instruments more closely than
with their eyes
• Designate a specific
area for damaged instruments ("the repair bin") and for storage of sets
that have been pulled for routine preventative maintenance inspections.
Make this easy to access for your repair supplier.
• Provide a bulletin
board on each workstation with space for a "basic inspection" poster
that shows techs what to look for on basic instruments to ensure they
are OR ready
"If 50 percent of your surgeries are knees,
put everything related to knee surgery next to the dumb waiter so when you
are loading that next case cart you are walking only five feet versus 500
feet around the room to gather the necessary pieces for that surgery," said
North Mississippi Health Services has
implemented LEAN processing methods to help staff members quickly identify
trays. By organizing each tray by specialty, employees no longer waste time
looking for specific sets in prep/pack room because each specialty has
designated wire racks for each of the six specialty services. The racks are
clearly labeled along with clear instructions for procedures that require
multiple sets to complete a surgical case.
Space, supply and process standardization
Asproth also encourages healthcare
facilities to build standardization into their new or renovated SPD
operations as a way to boost both quality and productivity. In his
experience, those facilities that have disparate workstations spend up to 30
percent more time assembling supplies for cases. Standardizing assembly
areas can improve efficiency and the overall quality of services.
"Let’s say each staff member spends 15
minutes of his or her shift just getting things set up. If a facility were
to set up each work area in the same way with everything the staff members
need within easy reach, that’s time that could be better used elsewhere,"
said Asproth. "Having every workstation set up in the same way also supports
muscle memory. A tech knows exactly where to reach for a certain supply
whether he or she is in workstation one or workstation five."
Staff education and training
According to Doyle, staff education and
training was critical to the success of Sanford Medical Center’s CPD
rebuild. She notes the first year of operation in the new facility was spent
building a team with the experience necessary to manage the new
responsibilities and workload.
"Getting staff hired and trained was the
most critical issue for us," said Doyle. "Administration needs to be
involved and understand the importance of our work and the staff levels
required to undertake it. A healthcare facility must communicate upfront
what it needs in terms of staff and training prior to the rebuild so it has
competent, well-trained staff in place at the time of opening. Otherwise,
you will find yourself behind and always playing catch-up".
Switzer from North Mississippi Health
Services also emphasizes the importance of staff training and education. He
and his team have developed an orientation program that outlines each of the
services within the central processing plant. After six months of
employment, the organization offers its employees additional training with
an outside vendor to continue their central sterile processing studies.
Employees have one year from the start of employment to earn International
Association of Healthcare Central Service Materiel Management (IAHCSMM)
"This project has really inspired
staff to give us some great ideas," said Switzer. "These ideas have enabled
us to evaluate situations from different perspectives
and enhance what we initially had planned."