Central Sterile/Sterile Processing Department (CS/SPD) professionals across the U.S. and across the globe are transforming their operations in the name of better patient care. By implementing process improvements such as Lean Six Sigma, enhancing staff training and education, and implementing evidence-based decision making, CS/SPD departments are achieving tremendous success. In this month’s article, HPN shares strategies and tactics from successful SPD operations both in the U.S. and abroad.
While Texas Health Harris Methodist Fort Worth’s (THFW) surgical business continued to grow over the years, its SPD had not. In 2014, THFW opened a new 12,000 square foot state-of-the-art SPD that was built in accordance with Association for the Advancement of Medical Instrumentation (AAMI) standards. It features advanced technology, processes and staff training and education designed to boost the effectiveness and efficiency of its SPD operations. Key features include:
- Staff Enrichment: Everything from adjusting the techs’ work schedules to meet the business needs of the operating room (OR), to staff “huddles” to discuss instrument needs and issues, to assigning each staff member to a different position in order to rotate through all areas of the department weekly (i.e., decontam, assembly, sterilization, case pulling).
- Educational excellence: Hired a Master’s-prepared nurse with both CNOR and CSPDT certifications as an SPD educator. As of March 2016, 96 percent of SPD staff members are certified and plan on renewing this year. THFW had also become a clinical externship site with a local sterile processing program. In order to encourage teaching, they have put into place a preceptor program for SPD technicians.
- Lower IUSS rates: Reduced immediate-use steam sterilization (IUSS) rate from approximately 80 percent in 2009 down to less than 2 percent today. Key to this shift was the adoption of OneTray containers. Although using OneTray helped significantly, they continue to strive for a minimal rate.
- Enhanced tracking: Implemented the Censitrac instrument tracking system, which has added capability to: note ultrasonic cycles, washing instructions and assembly notes for specific trays or instruments; determine any special sterilization cycles by placing that information on the Censitrac labels and affixing to sets; track the sets’ usage, location and maintenance schedule; train the OR staff to scan the case carts to the OR upon use to facilitate tracking those instruments to a specific patient.
- Better bug detection: Implementation of the INSPEKTOR, a fiberoptic camera system to improve inspection capability of suctions and small-lumen items for bioburden or damage. Once a foreign item is discovered, the Adenosine Triphosphate (ATP) machine differentiates between rust or bioburden, so the item can be appropriately repaired or cleaned.
The University of Wisconsin Hospital and Clinics (UWHC) in Madison, WI. also faced the challenge of managing growth as it merges with the University of Wisconsin Medical Foundation, which operates many of the system’s off-site clinics. The organization also recently opened a specialty hospital and acquired an additional hospital via a merger. To be more efficient and effective in its sterile processing operations, and enforce best-practice patient care, UWHC has implemented a number of improvements:
- OR Collaboration: Greater collaboration with OR administration and team care leaders, including weekly meetings with OR stakeholders; streamlined drop-off and pickup workflow for nursing floor; and established a centralized management structure in key clinical departments and off-site clinics to streamline processes.
- Improved Tracking: Implemented a computerized instrument tracking system with real-time information on status of instrument sets. Capabilities include: individual technician productivity monitoring, an interface with OR scheduling and charting system, RFID tracking of patient care equipment and instrument sets, and a first-in/first-out cart system within the set assembly area to improve efficiency of workflow.
- Stronger teamwork: Frequent use of internal “Hi-5” awards to allow peer-to-peer positive feedback; well-defined roles within the workflow for better teamwork and corrective feedback when necessary; consistent staff presence in all clinical areas for expedited problem solving, and greater communication and comradery.
- Enhanced education and training: Hired a dedicated education specialist with an OR background; provides frequent staff in-services to teach and reinforce basic skills and knowledge; offers computer-based instruction for staff who are unable to attend training meetings; and simplified the competency review process and documentation. As of March 2016, 95 percent of eligible staff were professionally certified.
Avoiding OR shutdowns
The main hospital campus of a large, nonprofit, Magnet designated healthcare system located in Southern California was struggling with a Central Sterile Supply Department (CSSD) challenged by increased processing volumes. The C-suite was concerned that without a CSSD renovation, OR shutdowns would be the result.
At 50 to 60 cases/day the CSSD had reached its capacity with no room for future growth or ability to reprocess ancillary items. It was at high risk to revenue loss caused by OR shut downs and delayed cases. Furthermore, the hospital experienced an upward trend in year-over-year departmental costs associated with equipment, maintenance and overtime labor.
The hospital partnered with Belimed, a leading global supplier of cleaning, disinfection and sterilization solutions, to create a new, state-of-the-art CSSD based on detailed data analysis to mitigate potential OR shut downs, maintain surgery volumes, and protect revenue, within the same footprint. A collaborative team was formed consisting of the CSSD renovation project team, a water conservation specialist and Belimed’s Project Planning Group. They developed a design, layout and capital equipment plan that addressed improvements to workflow and wasted space, and maximized throughput.
Once the system went “live” marked improvements in throughput, water usage and operating costs were observed. The results of the new layout and equipment mix produced a 40 percent increase in tray throughput resulting in an additional 69 trays/day of reprocessing capacity. Eliminating labor-intensive activities, such as hand drying instruments and materials handling, resulted in an 8 hr./shift reduction in labor. Hot and cold water consumption was reduced by 87 percent, from 22,000 gallons/day to only 2,800 gallons/day. Finally, with all of the CSSD improvements, worries over department morale, errors, and patient outcomes diminished.
In its first year, the CSSD renovation delivered $326,724 in savings, including:
- $154,000 in direct department cost savings
- $143,489 in internal labor cost savings
- $29,235 in water cost savings
A CS/SPD team transformation
University of California, San Franscisco (UCSF) Medical Center is a high volume, high intensity teaching and research institution where an average of 33,000 sets/items are reprocessed to support an average 3,500 surgical cases performed each month. Soon after the February 2015 opening of an expansion hospital located in San Francisco’s Mission Bay district, the senior leadership at UCSF recognized a need for improvement in its SPD operations.
Beginning in May 2015, C&R Healthcare Partners was engaged to conduct a detailed assessment, provide a roadmap for sustainable change, assume interim management of SPD operations, and implement a number of quality and performance improvement initiatives. Since June 2015, UCSF has conducted focused improvement efforts within the SPD areas at its three campuses: Moffitt-Long, Mission Bay and Mount Zion.
While some transformation efforts are still underway, the significant changes already made have yielded meaningful benefits:
- In June 2015 about 42 percent of the SPD workforce was certified in good standing. By July 2016, after developing an in-house SPD certification training program, 73 percent of the workforce is now certified.
- A number of new leadership team members were recruited and a governance structure was implemented, which follows a shared decision-making model adapted from concepts applied in nursing magnet programs. This innovative approach has been embraced by the staff and aided in strengthening the relationship between management and labor, and this is crucial for a union represented workforce. The staff perception is such that they feel the leadership is actively listening and responding to their needs.
- The Joint Commission conducted a thorough accreditation survey in Spring 2016, which was a true litmus test of whether the improvement efforts to date were effective. Surveyors were highly complementary to the SPD team and no significant issues were found. UCSF leadership indicated that this result was the best accreditation survey, with regard to SPD, in nearly a decade.
Tackling L&D trays
Duke University Medical Center’s labor and delivery (L&D) department had logistical challenges that led to trays sitting in waiting for an extended period of time versus being sent down to the SPD soon after the completion of the case. The factors that contribute to this are the absence of a dumbwaiter and staffing challenges within SPD. Because of the nature of the surgeries in L&D, many of these instruments are heavily soiled with bio-burden. This made decontamination very difficult for the SPD staff, prolonging the process.
“The workaround for us was to use brushes to ease the removal of bio-burden but that created an issue with removing the pacification layer of the instrument, which then will promote rust forming, pitting and shortening the lifecycle of the instruments,” said Marquita Hedgepeth, Assistant Operations Manager for Duke’s Sterile Processing Department. “Additionally, any discoloration of the instrumentation upon opening a surgical case would be ‘rejected’ and documented. These were unnecessary delays that we wanted to eliminate from happening. Consistently cleaned/sterilized product became the biggest issue for both departments.”
In July 2014, Duke converted all of its L&D inventory to the Restore iNTELLIGENT Tray System. The Restore system and methodology took advantage of several methods to address faster processing and safer storage of instruments to reduce damage and exposure. By providing their validated tray system, which included their iQ platform, advanced stringer technology, tray modules and methodology, the department was able to achieve:
- a 62 percent reduction in “direct” instrument handling time, which translates into a 57 percent reduction in labor/handling cost
- labor savings ranging from $94,340 – $428,340
- optimal opening for cleaning, which Restore has independently validated to produce a 99.999 percent reduction in bioburden
“Furthermore, because our instruments are better organized beginning at the point of use, we fully expected to see a reduction in our instrument repair/replacement budget as well as eliminating the likelihood that SPD personnel will accidentally cut him/herself or otherwise experience a percutaneous exposure from a needle inadvertently left on a needle driver,” added Hedgepeth.
The quest for quality
The Central Sterilizing Services (CSS) department at the University of Iowa Hospitals and Clinics (UIHC) took a new management approach focused on quality systems and process improvements.
The results in 2015 were impressive: an 82 percent improvement in IUSS rates, 36 percent reduction in the number of defective trays that made it to the MOR, and staff turnover was reduced to 22 percent (29 percent improvement), the number of trays in “Work In Process” was reduced by 29 percent, while the processing time from decontamination to sterilization reduced by 18 percent.
The system they built to gain and sustain these improvements includes:
- Strategic alignment: The UIHC CSS leadership team participated in an off-site retreat focused on alignment to the UIHC strategic plan during which they broke into teams to define current state through a SWOT (strengths, weaknesses, opportunities and threats) analysis, reinforce where they wanted to go and how they were going to get there. They were then able to define CSS specific strategies and tactics to communicate and post for staff to realize how they can all contribute.
- Staff development: The team increased communication by implementing regular all-staff meetings, during which they recognize staff members with quality and service awards. With executive level support, they were able to hire seven new positions focused on quality and increase their training budget. They created new job descriptions that require certification and provided a voluntary internal 28-hour training course to prepare staff. During the last half of 2015, the number of certified technicians increased from five to 12 (a 140 percent increase).
- Education: Education took on many forms. The team invited patients and physicians to speak at all staff meetings to reinforce the importance of the work they do every day. They trained staff on “soft skills” such as time management, professional communication, completed a behavioral trait (DISC) assessment, and learned about generational differences. They also joined the Iowa Lean Consortium, participated in AAMI workgroups, increased vendor in-services and networked with other institutions.
- Standardization: To enforce standard work, the team needed to hold staff members accountable to the department’s standards. When a mistake is made, they rectify the situation as soon as possible and conduct a root cause analysis focused on prevention. When solutions are implemented they are diligent about 30-day, 60-day, and 90-day checks to make sure the solution is sustained and working as intended.
Four years ago the SPD at Williamsport Regional Medical Center (WRMC) was restructured, expanded and consolidated into a single department separate from the OR. In the past year, the staffing model was restructured to create a chain of command for this growing area. Since that has occurred, staff turnover has dramatically decreased, certification rates have soared, immediate-use steam sterilization rates have dropped to an astonishing 0 percent and teamwork, productivity and customer service have moved to the forefront of this processing department’s initiatives.
Specific changes include:
- Clinical communication: The department has taken strides to increase the flow of communication between both the OR and other departments for which they provide service. These new initiatives include purchasing cell phones so that the OR can give the department time-sensitive information, such as sets needed for quick turnovers. In addition, they have formed more direct relationships with departments such as ENT Central and Labor & Delivery, personally delivering their instruments to them.
- Collaboration: Within the past two years, they have created two positions for Certified Surgical Technologists (CSTs) as Lead Technicians on first and second shift, in addition to Sterile Processing Technician Leads (CRCSTs). The CST Leads act as liaisons between the OR and SPD. As a result, communication has vastly improved between the two departments, as well as diminished issues in instrument reprocessing and turnover cases.
- Teamwork: A group of Lead Sterile Processing Techs and Lead Surgical Techs has been established to provide direction, address issues and provide opportunities for growth and change to enhance the department’s efficiency and atmosphere. The institution of shift huddles has enabled each shift to work more efficiently because they are equipped with the information needed to complete tasks timely and accurately. Team morale has also increased, as the department has become very successful at working together and the workload is shared among everyone.
- Education and training: Orientation is about six months long, during which time new employees are paired up daily with existing staff members in each area of the department. All techs must be CPR certified and complete yearly education, read current literature, attend in-services, department and OR staff meetings. All members of the team are required to become certified within two years of hire, or by July 2016 if grandfathered in. The facility assists with the costs of the initial certification and offers an increase upon obtaining it with a promotion to a Tech II status. As of July 2016, 69 percent of staff members were certified and two others have test dates scheduled.
An investment in staff yields significant results
In 2011, Highland Hospital, an affiliate of the University of Rochester Medicine System, determined that its Central Sterile Processing (CSP) department was the one department in the entire hospital that was not prepared to work alongside leadership to improve their satisfaction score. The organization developed a strategy to address this culture, which required listening to the entire staff with fairness and consistency while simultaneously meeting the workload.
As a result of CSP staff identifying the need for more opportunities in career growth and increased compensation, the department developed a career ladder based on professional certification, experience and the acceptance of additional responsibilities. It consists of Tech I, II, III, Preceptor, Orthopedic Specialist, Supervisor, Educator, Assistant CSP Manager and CSP Manager positions. The department filled all of the positions by promoting from within the department, which boosted moral and accountability. The department has achieved nearly 100 percent certification and all of the certificates are displayed at the entrance of the work area.
Another area of concern among CSP staff was work/life balance. To remove the requirement for the majority of CSP staff to cover weekends, leadership created four 12-hour shifts, which are rotated over the weekends. The new 12-hour shift weekend staff are also able to take advantage of a seven-day-off period built into their schedule every two weeks which helped address child care issues. There were additional unanticipated benefits. The dedicated weekend staff became very competent in meeting the weekend needs, which are very different from weekday. They became fluent in picking supplies for emergency cases and a valuable resource for the OR. Complaints from the weekend OR staff decreased dramatically.
Highland Hospital has made many other changes directed at boosting CSP department satisfaction, including implementation of a Censitrac instrument tracking system to quickly uncover and address issues; a formal lack list to better facilitate the case cart picking process; initiatives for pre-cleaning intraoperatively and in decontamination to reduce bioburden; and inventory adjustments to ensure the CSP is always meeting customer needs.
One of the CSP department’s proudest achievements is reducing the Immediate-Use Steam Sterilization (IUSS) rate. After an analysis revealed that 70 percent of incidents of IUSS were due to instrument turnover, CSP leaders and clinicians leveraged LEAN concepts to establish a priority instrumentation process, which reduced the IUSS rate from 9.22 percent in 2014 to 3.81 percent the last six months of 2015.
The backbone of any hospital
University Hospital located in Augusta, GA, describes an effective SPD as “the backbone to any successful hospital.” Recognizing the critical importance of SPD operations, the organization has made major investments in this area that have yielded impressive results:
- Reducing OR Frictions: Not only does University’s SPD meet the needs of the OR and other departments served, SPD has lowered its OR Frictions by 98 percent over the past three years. OR Frictions, a measure created and trademarked by IMS, represents the count of avoidable errors by SPD or OR that cause “friction” or problems for the clinical team. Reduced OR Frictions leads to increased OR performance and surgeon satisfaction. Key to this endeavor is maintaining open and transparent communication between the OR and SPD to help SPD prioritize trays in accordance with upcoming cases and respond to evolving needs.
- Positive work environment: University has gone to great lengths to ensure a positive and structured work environment in which employees may thrive. Friday staff luncheons and other morale boosters such as Staff Bowling Nights serve as team building activities for SPD. The department also moved to an Employee of the Month recognition in 2015 rather than the previous quarterly recognition.
- Education: University held over 86 in-services for staff in 2015. In-services were offered monthly with at least seven opportunities each month to participate. SPD staff are given every chance to not only refresh their knowledge on current practices and procedures but to also stay updated on new training. Staff are reimbursed for all continued education fees related to training or certification. University also offers bonuses to staff once training is complete. Additionally, SPD created a staff “Quiet Room” with computer access for educational use.
- Instrument tracking: The SPD team recently implemented SPM 2015 updates that improved customer care service and was better able to track instrumentation. Tracking instrumentation not only allows SPD technicians more time to focus on more pertinent tasks (as opposed to searching for missing instruments), but it also decreases frustrations among SPD and OR staff.
Other improvements include: use of oneSOURCE documentation to alleviate much of the searching for missing IFUs, increasing staff productivity; repairing all case and wire carts, which has improved service to the OR; elimination of ETO sterilization, converting most of the scopes to Sterrad and replacing outdated scopes, which has saved University thousands of dollars.
Soon coming to the U.S.
Recently acquired by Mobile Instrument, DOVIDEQ Medical reports that CS/SPD Managers in European hospitals are having success with the company’s ScopeControl, a fully automated rigid endoscope testing system that ensures scopes sterilized and sent to the OR are ready for use. Mobile Instrument will start distributing the technology in the U.S.
“The reasons are simple,” says Jan Wilterdink, CSSD Manager CSSD for Radboud Medical Centre in Nijmegen, the Netherlands. “For the first time it becomes possible to check and control the quality process of endoscopes. Objective measurements result in improved work processes and high standards for the instruments used during the operations. This is what we need. We like to improve our service from the CSSD to our customer the operating room.”
A personal success story
A CS/SPD department can have the most advanced technology and processes, but without a strong, supportive leader, and talented and driven team members, success is far beyond reach. Rexell Baltazar, CBSPD, CRCST, CIS, CHL, Central Sterile Processing Manager for St. Mary’s General Hospital in Passaic, N.J. has been in the profession for nearly 20 years and knows first hand its challenges and opportunities.
In September 1997, Baltazar began career in CS/SPD as a SPD Aide for Hackensack Medical Hospital where he was later promoted to CS/SPD Technician and then Coordinator/Supervisor. He attributes his early success to his passion for learning, hard work and willingness to go above and beyond what was required of him.
“I wanted it – I wanted more,” said Baltazar. “On weekends the SPD Manager would give classes for techs who were not certified and I begged her to be in it. I was approved but only if I paid for my own test, and if I failed will not be reimbursed. So I went for it. I would always be the first one to come in and help her prepare for the class and last to leave because I had to clean up all of the mess. Test day came and I was confident yet scared. Out of the six employees who took the test I was the only one to succeed and passed as a certified tech. I truly believe that hard work, perseverance and dedication got me through it.”
After gaining his certification, Baltazar was promoted to SPD Technician then later to Lead Technician for the ortho/neuro loaners and trays. He notes how he earned the respect of OR coordinators by attending to their needs and his willingness to assist them in any way that he could. His hard work with the OR led to his promotion to Coordinator/Supervisor at the age of 23 and nomination as the Most Valuable Team Member in September 2004.
In July 2010, Baltazar took and passed a managerial exam. He then assumed the position of SPD Manager for Englewood Hospital and Medical Center in Englewood, N.J. where he cultivated an environment with high employee morale where “everyone was comfortable with one another, working as a group, working as a family.” And in May 2013, he was voted by his peers and received the Friend of Nursing Award.
In August 2015, Baltazar began his current role as SPD Manager for St. Mary’s Hospital in Passaic N.J.
“I bring with me my combined experience and knowledge in the CS industry,” he says. “This includes my dedication, never ending ideas for the continuous improvement of the department, the willingness to learn new things and most importantly, my dedication to make my staff happy.”