Minneapolis, MN-based M Health Fairview’s Lori Ferrer, Director, System Central Sterile Services department (CSSD), shared with Healthcare Purchasing News Senior Editor Rick Dana Barlow her team’s attitudes and motivations behind what helps them succeed in supporting surgical services and patients.
HPN: Your team reports up through Supply Chain and has for decades, which runs counter to the typical reporting structure that has developed over the years – as in through the OR. Last year’s winner, Children’s Hospital of Philadelphia, does the same, so we have back-to-back award winners bucking the national trend. How beneficial and valuable is it for your team to continue reporting up through Supply Chain instead of the OR and why?
FERRER: I have reported to both the OR Leadership and through Supply Chain Leadership throughout my career. I have had positive work relationships with both groups. Over the last 8-1/2 years I have reported to the Vice President of Supply Chain. LeAnn (Born) has been a great mentor to me and advocate for Sterile Processing. Having worked in the OR and in Sterile Processing has given me a well-rounded perspective in the operations of the respective areas. (Ferrer began her career as a certified surgical technologist.) Looking back through many years, all of the processing was done in the ORs. Throughout time the work transitioned to a central processing area, moving the function of instrument processing out of the ORs. In many settings the building of the surgical case carts also transitioned to the processing area. It is my opinion that these processes should be under Supply Chain as they are the subject matter experts in moving supplies. Other changes that occurred through the years included all of the ancillary areas, including ERs, OBs, and clinics needing items processed in addition to Surgery instrumentation. Their instruments are similar to supplies in regards to inventory management, distribution and PAR levels. The OR is focused on the quality care of our surgical patients and the capital equipment needs for the area. Supply Chain is expert in the logistics, and today’s sterile processing areas – unless they only are doing work for the OR – have a much more extended reach with many additional customers other than the OR.
Do you have any surgeons who serve as your team’s champion(s) among the physician community? Why?
Dr. Elizabeth Thomas served as our past Chief Quality and Patient Officer at Fairview Health Services. She spoke at our local Minnesota Chapter of IAHCSMM fall conference and again at the spring conference for the Western Wisconsin Chapter of IAHCSMM. She took the time to know what we do and as a surgeon shared her story of the impact that our work has for the patient, family, OR team and the surgeon. She presented at our annual IAHCSMM conference in 2019. Dr. Thomas toured our System CSSD and sent individual thank you notes – with chocolates! – to each of the individuals she spoke with during the tour.
Dr. Andrew Fink, General Surgeon, has worked closely with Sterile Processing over the years, learning the intricacies of the work, and serves as an advocate for all of Sterile Processing.
Dr. Bevan Yueh most recently visited our System CSSD-CPC for a quick overview of our work and said he would serve as a liaison with our surgeons.
How has your team’s efforts over time impacted OR partnerships and turnover rates?
Communication and building relationships with each other are imperative for continued process improvements to eliminate the finger-pointing when an issue arises. As a surgical technologist many years ago, it was my job to keep the bioburden wiped off the instruments in between handing the instruments to the surgeon. Instruments were soaked in a basin of sterile water after they were no longer needed. After the surgical procedure we would take the instruments to a soiled utility room and hand-wash the instruments before sending them to Sterile Processing. Today we are trying to get back to the basics. It is imperative that gross soil is removed from the instruments in a timely manner to make it easier to clean the instruments. Most often the OR states that they do not have time to wipe the instruments and remove the gross soil during room clean-up as this will delay turnover time.
How much sense does it make to “upgrade” the tours you enable into routine rounding procedures for CSSD staffers to see how the devices they process are used “in the field?”
It is something that would be advantageous, but it is difficult to find the time. I’ve wanted to get the frontline staff to observe in the OR for several years and had the opportunity to make it happen when we made it one of our goals in 2019. We are requiring that all new team members must observe a surgical procedure and tour a site CSSD.
M Health Fairview’s System CSSD was one of the pioneers in centralizing and standardizing processing for multiple facilities. That takes a lot of work to achieve. What are some of the end-game benefits that surgeons and patients alike are realizing from this decision?
Centralized instrument sets are maintained and updated. Large capacity sterilization eliminates the duplication of more equipment at each of the site CSSDs.
Does System CSSD process/track endoscopic devices and instruments in the same way? Why?
No. All of the site CSSDs process all of the delicate instruments, rigid and flexible endoscopes, DaVinci [robotic surgery] instruments and low-inventory instrumentation. The flexible endoscopes are tracked to each patient.
Point-of-use/post-surgical instrument soaking/spraying/treating in the OR seems to be a growing issue among SPD departments per discussions, educational sessions and trade show talk –including a growing number of SPDDOY nominations during the last few years. What will it take for this to become required standard operating procedure for processing effectiveness and efficiency (e.g., turnover rates) going forward? How would compliance be handled and by whom?
We want to be proactive as the OR teams and the CSSDs work together to identify the gaps in our process and the roadblocks that may occur in our workflow. Often the reason is that there is not time allowed to complete the point-of-use wiping of the instruments. Currently, the Site CSSD and the System CSSD decontamination staff are to report soiled instrumentation to their supervisor for follow-up reporting through our incident reporting system. The same is to be done if the System CSSD received soiled instrumentation. If System CSSD receives the soiled items it has already been missed in the OR and missed in the Site CSSD. These errors are reported again in our System Sterilization Liaison monthly meeting.
There seems to be a consistent amount of construction/renovation going on with your team. Do you envision a time when that’s over for a while or have you designed it so that something is done every year? If there’s ever a lull in construction/renovation projects how do you think the CSSD will handle it?
Our last project to be completed in 2021 will be the last major construction for at least four or five years when the washers will need to be replaced. The construction will be complete but there are many other updates that will continue that will not require us to be under construction. For example, our ethylene oxide sterilizers will need to be replaced. Our instrument set containers and case carts are in need of replacement. We will also consider another Hänel storage unit for our sterile storage area as our storage needs increase with the addition of the 50 to 60 clinic sites. There are continually new processes and technology advancements to consider. Individual bar-coding of instruments and devices, utilizing laser technology for instrument identification, advancing sterilization technology particularly in low-temperature sterilization and the list could go on and on.
How does your team access IFUs? What is your biggest challenge with IFUs? Access? Content details? Something else? Why?
Our IFUs are found in OneSource, which is linked into our Censitrac Instrument Tracking System.
As a pioneering SPD team how does CSSD stack up against/with clinical teams throughout the organization? Strategic partner? Service entity? Something else? Why? What would you prefer?
We work closely with all of our clinical partners as a team. We are a service provider and a customer in our work with all sites. Communication is imperative with the OR departments, ancillary areas and clinic sites, particularly when the instruments are being moved from numerous sites back to the System CSSD. Our focus has been to meet with our customers from time to time to see how everything is going with the services we provide.
You mentioned Gemba in your nomination. How has CSSD embraced and applied Lean thinking?
We’re new to all of the Lean thinking methodology. However, much of it I’ve been doing during most of my career, but not in such a structured manner. I like the work, but it’s difficult to get all of the pieces of the puzzle put together in the process, while the daily whirlwind of work competes for our time.
Based on what your team has accomplished what processes would you recommend other departments, which may want to emulate your success, implement or improve for their own operations and teams?
Our centralized model had been established prior to my arrival in 2012. I had been teaching a Central Service class in 2007 or 2008, and one of the students mentioned that she had a sister who worked for a hospital in the Minneapolis area where the surgical trays were sent to a central processing site. At that time I had not heard of this process. Interestingly, a few years later I am working as the Operations Manager for the exact site that my student had referenced.
Here’s what we did. In the beginning during the early 1990s Fairview worked with a small consulting firm. Three options were developed, and the option of an off-site processing center was ultimately chosen.
1. First step would be to establish a meeting with all customers, presenting the ideas and getting their feedback.
2. Find a location for an off-site processing center. Ultimately, our off-site processing center was able to rent space within one of our hospitals. But it remains an off-site center located in a hospital. Our area is centrally located between most of the sites that we serve. The furthest location is 60 miles with the closest customers in the hospital where our department resides.
3. Determine what type of work is advantageous to be centralized. Currently, we have all of the “standard” instrument sets for each type of specialty surgery centralized. The average needed surgical sets used is two-to-three sets per surgery.
4. Determine what is cost effective to centralize.
a. Standard instruments are cost effective by keeping the inventory centrally and distributed as needed.
b. Clinic instrument processing. We’re currently bringing most of the clinics’ instrumentation into our central model so that the instruments can be processed by team members who are the experts in processing instrumentation and who do this every day. The clinic care team members can devote more time to patient care.
c. Flexible endoscopes may be too costly to increase the inventory needs or too delicate to risk the constant transportation.
d. On the other hand, if there is room available it would be advantageous to centralize all vendor loaner instruments. Advantages would include a standard team consistently processing the sets and who are trained and subject matter experts on all of the numerous details regarding the disassembly, decontamination, inspection, assembly and sterilization. We do not currently have the space to do this for the system. Our current set volume as a system is approximately 650 to 700 loaner sets per week. Centralizing case cart assembly could be cost effective if one would be fortunate enough to have the space needed to accomplish it. Working with standard work practices, all of the supplies would be delivered to one site, managed at one site and case carts would be delivered complete with basic instrumentation. Sites would need to add specialty instruments and have a smaller footprint for needed backup supplies on hand. At M Health Fairview’s System CSSD, our footprint only allows space to process and distribute the centralized surgical sets for all of our customers plus the clinic and ancillary instrumentation.
5. Set standardization throughout clinics and areas performing surgical procedures.
a. It is necessary that all instruments are reviewed on a frequent basis as we move into the future to help eliminate cost in processing. A centralized process where the same sets are used by several different hospitals may have a few more instruments in them that not “every” surgeon will use. This will continue to be a hot topic and healthcare costs have to be reduced. Working with the surgical teams is imperative in getting this work initiated and under frequent review.
6. Processing equipment
a. Do your research and determine what works best for the needs of your surgical instrument processing needs, your location, available space, HVAC, water steam, plumbing, electricity, workflow, proximity to a dock for transportation. Think ahead to potential new technologies for processing and sterilization.
7. Transportation concerns
a. Be sure to review state laws, use temperature-controlled trucks, closed cart systems, determine whether to use containers versus wrap and think about your storage system.
8. Tracking
a. Instrument tracking system is essential for instrument needs and preventive maintenance. Perform a data analysis of your current state to assist with projected numbers to move to a centralized model.
9. Communication Champion
a. Appoint or recruit a liaison(s) with our Surgeons and Surgical Teams who can meet face-to-face whenever possible. That person should be an active participant in project teams and sustainability.
