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KSR Publishing, Inc.
Copyright © 2016

         Clinical intelligence for supply chain leadership



June 2013

CS Connection



SPDs share renovation best practices and lessons learned

by Kara Nadeau Della Vecchia

North 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number of operating rooms grew over the years, the CSP department didn’t. As a result, CSP staff members were using an outdated space with outdated equipment to support a growing number of advanced surgical procedures.

Mike Switzer

"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 environment.

Typical SPD challenges found in older hospitals

Jeff Asproth

Jeff Asproth, Supply Chain Manager at 3M, 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

High 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 hamper efficiency.

"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."


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 Spectrum Surgical Instruments/STERIS Specialty Services, suggests that healthcare facilities incorporate the following technologies and processes into their SPD rebuilds or renovations:

• Task lighting at the work stations

• Adequate work space

• 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



Taking it off-site

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 healthcare facilities."

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 Medical Center

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

Gail Doyle, CSPDM, CRCST, manager of CS/SPD, notes how this transition required a major cultural shift on the part of the OR staff.

"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 offer."

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 challenges."

Considerations for SPD renovations and rebuilds

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 following questions:

• How many surgical suites are being supported now and in the future?

• How many procedures are performed during peak periods?

• 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."

Sanford 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 department
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 storage areas.

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

Matt Rudolph

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.

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 Dillon.

Getinge USA Instrument Traceability solution

Technology for tracking
and reporting

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.


From a non-standardized work station (above) to a standardized work station (below)

The importance of ergonomics

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 Asproth.


Best practices for equipment care and handling

Chadd Bliss

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 dropped

• 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 equipment

• 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

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.

"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 Asproth.

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) certification.

"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."