CHOP CPD team makes service central to clinical core competencies

The journey started seven years ago, according to Pete Schemm, Senior Director, Supply Chain Processes and Technology.

“Beginning in 2012, Supply Chain made a commitment to Perioperative Services to improve overall operations,” Schemm recalled. “Progressive rounds to identify process improvement opportunities were implemented, including conversations around how we could optimize all of the supply locations, relocate the case cart picking area, and install a kanban system for replenishment. The partnership culminated when we integrated a Supply Chain solution during the Epic OpTime [operating room management system] rollout. This integrated the item master from [Infor’s] Lawson [supply chain module] directly into Epic OpTime, automating patient charging and improving preference card data. The OR leadership recognized our efforts and noted marked improvement in the availability of supplies on the shelves.”

The Senior Director of Perioperative Services had been striving to improve OR “On Time” starts and “Block Time” usage, Schemm indicated. Based on Supply Chain’s track record of making supplies available to the OR, Supply Chain was tapped to manage instrument availability through CPD under Schemm’s oversight so that the Perioperative team could focus on optimizing OR throughput. Schemm briefly led CPD on an interim basis before Silverstein joined the organization in 2017 from Chicago’s Rush University Health System.

CHOP executives recognized that organizational expansion was starting to outpace the OR’s and CPD’s capabilities to meet demand and knew more operational improvements were needed.

“We had increasing volumes in our surgical services, had recently opened new surgical centers and the OR Director’s scope of responsibility was also expanding,” noted Joni Rittler, Vice President, Supply Chain. “It was a strategic decision to have our OR Director focus on clinical improvements. In conversations with Paula Agosto, Chief Nursing Officer (CNO), I expressed that Supply Chain could facilitate improvements in CPD. There was confidence in making this change as Supply Chain has a proven service record and has demonstrated the commitment to excellent patient care.”

Because Supply Chain already had cultivated credibility and trust with the clinical team, both departments accepted the challenge even as some CPD members expressed “initial concern,” Rittler acknowledged. To soothe anxieties, Rittler turned to her clinical contacts.

“To support the transition and assure connection to clinical care, I requested that we have a surgeon, Peter Mattei, M.D., work with us as a sponsor throughout the transition,” Rittler said. “Dr. Mattei visited CPD and was impressed with the volume of work that the team handled. His simple expression of gratitude for making his job easier meant the world to the CPD team! He also championed the change with the OR Steering Committee to gain support from clinical leaders.”

Silverstein dismisses the contention that the sterile processing and distribution function logically fits as part of the OR because of its functional connection and proximity. Their reasoning centers on centralization of services, he emphasized. In some facilities, several clinical departments may handle their own supply chain operations, which may not be as efficient or effective. In addition, sterile processing functions in today’s healthcare landscape span other services, not just the OR, he added.

“By centralizing to one department, an organization can create greater scale and have experts performing the work,” he noted. “In addition, this structure enables an organization to standardize operations and supplies, and allows for more powerful data and analytics, driving regulatory compliance and improved business decisions. It is about forming relationships that allow for open communication and trust. With those two things, it doesn’t matter what department is on your badge. At the end of the day, we are all here for one thing: Making sure our patients and families have a high quality and safe experience every time they come to CHOP.”

Go rounds

Roughly a year into the transition, one of the key goals Supply Chain and CPD sought to tackle was to consolidate and centralize the organization’s high-level disinfection and sterilization work to CPD on the main campus with a focus on standardizing procedures, reducing any vulnerabilities, and developing a sustainable education and training program that supported employees and encouraged collaboration throughout CHOP’s hospital, ambulatory care and specialty care facilities, according to Rittler and Silverstein.

A multi-disciplinary HLD/S Steering Committee that spanned Central Processing, Infection Prevention and Control, Regulatory, Facilities, Ambulatory Surgery, Perioperative Services, GI, Respiratory and Performance Improvement, oversaw activities and progress. The group identified functional “work-streams” on which to concentrate efforts, including inventory management/technology optimization; education/competency steering; airway scope optimization; quality, safety and performance improvement; consolidation and policies and procedures.

Along with new HLD/S Program Manager Jill Manuola, RN-BC, Silverstein and his team focused on “rapid execution” of the improvement plans through HLD/S rounding where Silverstein and Manuola routinely traveled to the outlying facilities to ensure competencies were completed and practices were standardized. Rittler expressed appreciation for the improvements, adding that they represented “a level of support that did not exist previously for remote teams.”

CPD used a structured approach to consolidating reprocessing staff and equipment, according to Cheryl Gebeline-Myers, Senior Director, Clinical Operations and Programs. They also worked with Infection Prevention and Control to solidify a training program that focused on safety and efficacy, as well as developed a comprehensive, data-driven approach to quality and performance measurement and improvement that included easily accessible standardized policies and procedures. The group also evaluated and implemented technology for scope storage, transport and tracking, Gebeline-Myers noted, and standardized HLD/S-related equipment and tools as necessary.

During the last year, the team transferred instrument processing and other HLD/S work to local surgery centers from four specialty care centers. They also centralized this work to CPD on the main campus in Philadelphia from three other outlying locations.

CPD, Supply Chain and Perioperative Services have realized marked improvement already.

“Like many organizations who have grown substantially in a quick period of time, we had departments that were high-level disinfecting/sterilizing their own items,” Manuola noted. “Each individual site was responsible for maintaining competency dates for their own staff. This made it extremely difficult to plan education because, at any given month, there were multiple staff members due for re-validation of their competencies throughout the enterprise. Our previous process was not standardized or timely.

“In addition, only the main hospital and surgery centers have dedicated CPD employees; the other areas relied on their clinical staff to perform this work along with their other responsibilities,” Manuola continued. “This creates many challenges if there is not close oversight and excellent collaboration. By centralizing as much as possible, we have individuals who are specifically trained in this field performing the work, and we have more controls in place to address any quality or operational concerns. This model also narrows down the number of staff that needs education and training annually. I believe the most important element is standardizing how we perform the HLD/S work, as that ties directly to patient care. This model also narrows down the number of staff that needs education and training annually.”

One useful nugget CPD carried forward in its redesign is its Qualified Observer Training program that fostered competency leaders at each site, according to Manuola, who worked with CPD Educator Lila Price, CRCST, CHL, to develop and launch the first annual HLD/S Qualified Observer Training session.

“We chose to hold an in-person session annually so that HLD/S Qualified Observers throughout the entire CHOP enterprise could join together and learn from each other,” Manuola said. “We also used this time to kick off the new Competency Process and ensure that all the qualified observers have the tools and resources they need to re-validate staff on their competencies. Since these competencies are reviewed annually, it made sense to run the training annually.

In fact, within one year of the new model’s implementation, CHOP recorded 100 percent competency completion and compliance across the entire network, according to Silverstein.

CPD also encourages staffers to learn more about their customers directly and vice versa, Silverstein noted.

“We do provide opportunities for CPD staff to round with our customers to learn how their work plays such an instrumental role in the caregiving process,” he said. “In addition, CPD routinely opens its doors for nurses, clinicians, etc. to tour our department so they have some insight into our world and understand our processes/procedures. During our HLD/S Qualified Observer training, we did offer tours of our CPD department for those working at other locations. We also allowed time for staff to network with each other and discuss best practices. Our first session focused more on back to the basics — Infection Prevention and Personal Protective Equipment — but we are looking to include more detail [and] hands-on experiences moving forward.”

Periop partnerships

To solidify and strengthen its relationship with the OR, CPD measures and reports two primary statistics daily: OR Success and Fielded Instruments.

Silverstein defines OR Success as “how the team performed in the eyes of the nursing staff from the previous day’s cases,” or more tactically as “a surgical procedure with no issues filed.” CPD tracks this figure via an electronic survey nurses complete after every case that asks about missing instruments or supplies, bioburdens, hair, etc. CPD set its goal at a minimum of 88 percent after initially achieving 70 percent; it exceeded and has sustained an average of 91 percent since fiscal year 2018.

“There are many factors that impact these metrics,” Silverstein acknowledged. “Some are within CPD’s control and some are not. For example, OR Success includes items such as missing instrumentation, broken items, holes in wrappers, etc. Some of these are normal operational issues, but including them in this metric allows us to quantify and track them in order to establish targeted improvement efforts.”

Fielded Instruments represents a measurement of the amount of completed instrumentation in CPD’s tracking system, which is Microsystems’ SPM. Instruments qualify by having completed the sterilization process and assigned to a storage location. CPD tracks all sets not located within a CPD processing area, including decontamination, assembly, sterilization, cooling or missing, according to Silverstein. CPD set its goal at 82 percent after initially recording 64 percent; the team met its goal in fiscal 2018.

CPD originally set 85 percent as a possible target rating, accounting for sets that could be broken, instruments could be loaned out to other areas or missing, Silverstein indicated. “Progressive improvement of the data and operations allowed us to see major improvements, but 100 percent is not realistic,” he admitted. “The key goal was to demonstrate that CPD could make as many sets as possible available for the next day. Things like emergency overnight cases would cause challenges.”

Notably, convincing OR nurses to complete an electronic survey after every case drew support from a joint team of surgeons, nursing staff, anesthesia, CPD and process improvement specialists because the group recognized that they had to measure something before improvement could be quantified and tackled, according to Schemm. The initial response was 35 percent, but after four months it jumped to 85 percent and higher. “A key enabler was the fact that the survey process and the case schedule allowed the team to identify the surgeons and nurses who were not completing the surveys, and the nurses did an effective job of self-enforcing the process,” Schemm said. “We are currently looking into capturing this data in a more efficient way for the nursing staff, perhaps within a tool they use every case so we aren’t asking them to use separate software.”

Last fall, in collaboration with performance improvement advisors, CPD identified an opportunity to improve point-of-use instrument spraying. The product utilized at the time was “clear, difficult to use, and not easily visible on the instruments,” Silverstein noted.

“We quickly formed a sub-group with members from CPD and OR,” Silverstein said. “Different products were brought in and were tested by OR staff. These products were ranked according to visibility and ease of use. Based on the results, the new product was selected with collaboration between CPD and OR leadership. The product was first introduced to the OR, then launched throughout the enterprise. This change allowed for a more effective way of identifying whether the instruments had point-of-use spraying. Continued education and training on point-of-use instrument spraying continues to be a key component of our program today. We value the importance of the initial point-of-use spraying as it contributes to the overall sterilization process and helps maintain the integrity of our instrumentation.”

Perched atop CPD

Silverstein stresses the importance of CPD’s customer service as an instrumental contribution to patient care based on their performance.

“Our work really impacts on-time starts and delays, causing cases to go longer than expected,” he said. “It is very rare that we see issues related to these items due to something related to CPD.”

Executive leadership recognizes CPD’s value as well, according to Silverstein, to the point that CPD is now considered a strategic partner with all clinical teams throughout the organization.

“While in the past, the department was usually brought in after decisions had been made, we now sit at the table and help make the decisions that drive patient care,” he said. “We have data at our fingertips, open channels of communication, embedded lean thinking in how we approach our work, and a commitment to training and education to ensure we are placing our staff in positions to succeed. This is not accomplished without a dedicated team of front-line personnel who believe in CHOP’s mission. The individuals who truly make all of this happen are our staff. They understand this is a journey — one that requires patience, trust, and a commitment to something greater than ourselves.

“At CHOP we begin everyday with one goal, making breakthroughs for children,” Silverstein continued. “This is not possible without supporting departments like ours. What is unique about CHOP is that we really are a village. We all know we play a key role in patient care, and the clinical teams know how important our support services are to their success. I think historically many individuals did not have a true appreciation for everything our CPD did or was responsible for. They were also not privy to some of the barriers and challenges we face every day. Establishing clear channels of communication and sitting at the table as a partner you can trust goes a long way. I have never felt a need to convince someone that we are a strategic partner. You illustrate that by performing at a level that does not leave opportunities for concern or questions. That is how we approach our work and how we have been successful.” 

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