When Courtney Mace Davis arrived at NorthShore University HealthSystem’s Sterile Processing department as Director in 2019, she brought to the multi-hospital system’s team extensive experience in quality improvement and process management and immediately put those skills to work by observing operations.
Her keen, trained eyes spotted something worth noting: “SPD wasn’t always set up for success due to the way the instruments were arriving in decontamination,” she recalled.
“There was already a process in place to provide feedback to the OR when this happened, but SPD staff was not following the process – just as the OR wasn’t following the process to report issues back to SPD,” she said. “I knew that tackling this was one of the first steps to compliance [and] in building a strong collaborative relationship with our OR partners.”
She targeted point-of-use (POU) instrument care and pre-treatment in the OR as an area that needed measurable and sustained improvement.
Mace Davis and the SPD team embraced and pursued compliance to Association for the Advancement of Medical Instrumentation (AAMI) standards and Association of periOperative Registered Nurses (AORN) guidelines to the point that 99.5% of the trays that come to decontamination from the OR comply with POU AAMI standards and AORN guidelines every day, according to Mace Davis.
How? Through education and regular communication with SPD’s “perioperative partners,” she insisted. “It’s the trust that was really improved throughout this process and acted as a catalyst for other improvements,” she added.
For the leadership team overseeing NorthShore’s multi-facility SPD team, which includes Mace Davis and extends to Matt Belanger, Director, Clinical Operations, and Gus Granchalek, Vice President, Perioperative Services & Anesthesia, success represents more than just a hard-earned seven-letter word.
It’s more like two seven-letter words because the first leads to the second. The root word? Respect.
NorthShore’s SPD team learned how to engender respect for what it does by concentrating on the pursuit of quality service through partnerships, by actively collaborating with fellow departments through multi-disciplinary “Connections” meetings, by educating and demonstrating the critical importance of what they do and by streamlining processes through automation, integration and specialization to deliver quality, reliable and uninterrupted service – even during a massive construction project and a global pandemic. For these reasons, NorthShore earned the 2022 SPD Department of the Year Award by HPN, the 30th organization to be honored for providing exemplary service.
NorthShore, based in Evanston, IL, the suburb perched just north of Chicago, comprises four hospitals in as many suburbs north-by-northwest of the city – Evanston, Glenbrook (in Glenview), Highland Park and Skokie.
Recently, NorthShore, which also includes Chicago-based Swedish Hospital (acquired in January 2020), and Northwest Community Healthcare, Arlington Heights, IL (acquired in January 2021), finalized its merger with Edward-Elmhurst Health, a three-hospital system based in Naperville and Elmhurst, west of the city. Continued integration of SPD operations will become a major project for Mace Davis, Belanger and Granchalek throughout 2022 and into 2023.
Device care at POU
Pre-treating instruments at the point of use, namely, the OR, has been an emotionally charged issue between SPD and OR for many years and has intensified in recent years due to the increasing complexity of minimally invasive surgical devices and media reports of surgical infections linked to sterile processing issues.
NorthShore’s SPD and OR teams broached and blunted the topic right away in a detailed but effective process.
It works like this: If SPD notices a POU care issue, such as instruments not being sprayed, SPD sends an email or text message to the OR educator using a bar code scan via its Sonar instrument tracking system, according to Mace Davis. The OR educator then verifies the issue with the decontamination team. Both teams work together “to better define and update training materials as needed,” Mace Davis indicates.
“We track and present these metrics monthly which serves to reemphasize the importance of treating the instruments at point-of-use for our OR and SPD teams,” she continued. “This simple and ubiquitous task of consistent POU instrument care was one of the most challenging initiatives to work on with the OR. However, we were able to show that these findings had a direct correlation to the quality of trays the OR received from SPD. Through this process we demonstrated metrics are not punitive, but instead can be used as a roadmap for improvement and an objective way to understand what’s working and what’s not.”
Through this process, SPD established metrics and accountability, and demonstrated compliance and an improvement of 19% from a previous system average of 126 occurrences in a month, Mace Davis notes. This contributed to the 99.5% tray processing accuracy throughout 2021, she adds.
Prior to this process being implemented, friction between SPD and the OR ensued due to challenges with tray error reporting.
“Because SPD did not consistently report or act upon the data, the OR was resistant to communicate any tray issues,” Mace Davis recalled. “When SPD took the initiative to focus on reporting, the clinical staff didn’t believe the accuracy of the numbers. And they were right to question the accuracy. What we learned together is that SPD was reporting everything we were aware of, but the OR wasn’t reporting all of the issues. Through SPD’s monthly report-outs of issues to both the OR and Infection Prevention, as well as SPD’s root cause analysis and action plan for resolution, the OR started to see value in reporting. SPD, in turn, was able to focus on the most important issues, notice if there were special circumstances contributing to quality issues, and address issues with particular team members on a more a timely basis.”
Both SPD and OR knew that quality events, unrelated to patient safety, were under-reported, according to Mace Davis. Therefore, when reporting accuracy improved, the situation appeared to be worsening.
Mace Davis recognizes that this always will be a work in progress. “Trust takes many months/years to build and can be lost so quickly,” she said. “Unfortunately, quality events will happen, but it’s SPD’s responsibility to communicate and learn from these events.”
Banking big wins
NorthShore SPD banked two more big wins for the organization last year, addressing two prominent sterilization processes: Ethylene oxide (EO) use and immediate-use steam sterilization (IUSS), otherwise known as flashing.
In short, SPD worked closely with the OR to eliminate both in 2021.
“NorthShore has long been committed to sustainability and environmental stewardship, and our perioperative team proactively decided to move away from this method of sterilization,” Mace Davis noted. These decisions involved identifying alternate instruments that could be processed in a different manner as well as investing in instruments that could be used in existing sterilization methods, according to Belanger.
“From a fiscal perspective, we were fortunate to work with leaders in the organization that appreciated the trade-offs and cost of purchasing – or not purchasing – new instrumentation,” he said. “We approached these questions with data and partnered with colleagues in our perioperative business services team to understand volume projections and scheduling practices.”
SPD also conducted a “meticulous review” of the device instructions for use (IFU) to determine validated alternate sterilization methods.
SPD implemented the use of OneTray to cease IUSS practices because they recognized how quick turnovers could contribute to “quality events” in the OR.
“A review of perioperative services drew attention to an elevated IUSS rate at one of our hospitals, and it became an area of focus,” Belanger said. “Within a 90-day period, OneTray technology was implemented across our hospitals to more safely support ‘quick turns’ and eliminate IUSS.”
Using OneTray, SPD demonstrated to the OR that they could turn over instruments quickly if needed, but the OR also had to provide accurate feedback as to when a tray actually was needed, according to Mace Davis. “Most of the time, a quick turnover was not needed, but there was a just-in-case mentality we had to overcome through trusted performance on the SPD side,” she added.
As a result, SPD improved quick turn rates for the OR by 67% to just under 2% for the system.
Not surprisingly, instrument access and availability represented SPD’s top-quality event to tackle in 2021. Incidents of missing and wrong instruments dropped by more than 23% once SPD improved loaner tray delivery compliance, courtesy of its Sonar instrument tracking system matching count sheet accuracy and completion via part numbers and pictures, according to Mace Davis. No more relying on memory to assemble trays.
“As the POU compliance numbers improved in decontamination due to the OR keeping sets together, the number of opportunities for SPD staff to assemble trays with wrong instruments was reduced,” she noted. “We are dependent on each other for our success!”
“It is nearly impossible to manage loaner tray delivery compliance without vendor cooperation,” Mace Davis said. “Without vendor collaboration, any wins are temporary and not sustainable. We are actively working with a couple of our largest vendors and are close to having some major improvements in delivery compliance. We need our vendors to trust our SPD team to process their trays appropriately and completely, and our SPD team needs the correct and complete information – including IFUs – from our vendors.”
Working with OR, SPD installed an electronic display of vendor performance that shows such data as on-time delivery, check-in compliance and volume, for complete transparency.
“To take this a step further our SPD team is leading monthly multi-disciplinary meetings with our tray vendors, loaner tracking system, the OR, and procurement to drive improvements – similar to what we’ve seen internally – with this same approach,” she said. Casechek serves as NorthShore’s loaner management system. SPD is working with DePuy Synthes and Zimmer Biomet to launch this data-driven project. “I’m really impressed with the cooperation these two vendors, in particular, have provided and am excited to see how this project evolves!” she added.
This project also will help SPD as it processes more than 2,000 loaner trays a month at NorthShore’s orthopedic hospital in Skokie alone, according to Mace Davis, as they must be processed twice – once before they can be used and again before they can be returned.
NorthShore University HealthSystem’s award-winning Sterile Processing team
Vice President, Perioperative Services & Anesthesia
Director, Clinical Operations
Director, Sterile Processing
Courtney Mace Davis
Operations Support Specialist
Manager, High Level Disinfection & Sterilization Operations
Manager, Sterile Processing Quality and Education
High Level Disinfection & Sterilization Support Specialists
Managers, Sterile Processing & Distribution
Assistant Manager, Sterile Processing & Distribution
Supervisors, Sterile Processing & Distribution
Lead SPD Technicians
Kenneth Guthrie Jr.
Carlo Delos Reyes
Certified SPD Technicians
Breda Diatounga Kissadi
Anil Kuruvilla Mani
Ana Dela Cruz
SPD makes ‘Connections’
Emphasizing that SPD doesn’t co-exist on an island or in a vacuum, Mace Davis and her team parlayed their joint accomplishments and trust-building with OR to reach out to other departments, including Infection Prevention (IP), Environmental Services (ES), Clinical Engineering (CE) and Facilities Management Systems (FMS), for routine meetings under the “Connections” banner.
Mace Davis extols the value between SPD and IP working together.
“Our teams weren’t collaborating,” she said. “Getting all stakeholders at the same table is so important! IP has been such a valuable resource for our SPD team as they bring in other standards that we may not be aware of. In turn, SPD is a valuable resource for IP as we are often closer to the standards and upcoming changes. As experts in our workflow, SPD may also be able to provide a variety of ways to meet a particular standard. Not everything in SPD is black and white, and we need partners who can critically think through compliance scenarios with us. SPD leaders have a responsibility to become familiar with the regulations, standards and guidelines that affect their department. Sitting back and letting others tell us how to run our departments doesn’t work as our devices, equipment and chemicals are all different and it’s our responsibility in SPD to know what makes our individual departments compliant.
“In my career, I have been fortunate to work with very knowledgeable and supportive IP professionals,” she continued. “If that trusted relationship is not established, IP may not have realistic expectations about how to operationalize the standards. If that happens, SPD may not be as transparent with issues or workflow changes [that] could lead to unsafe practices – and surprises during Joint Commission surveys. The IP relationship is key to a successful SPD department.”
SPD added ES, CE and FMS to the “Connections” meetings with OR and IP to foster collaborative solutions. In fact, ES leaders often add to discussions involving SPD and IP that are not related to ES.
“This is a great reminder that we all have something to contribute,” Mace Davis assured. “The advantage is that we can help promote consistency (high reliability) through metrics. The disadvantage is that when metrics are lacking, these discussions can feel blame-oriented. Our approach has been to offer assistance in working together and to showcase the improvements our teams have made collectively. This approach has ultimately promoted continued collaboration.”
Against the grain
As centralization of services and off-site reprocessing has grown in popularity, NorthShore detoured to explore something different that has proven successful for the organization and beneficial to the participating teams.
SPDs commonly struggle with outdated preference cards, poor workflow and equipment capacity issues, and face challenges with process standardization, staff education and oversight, according to Mace Davis.
“Off-site centralization of SPD may make some of this easier due to one physical location, but there are additional costs and risks with that model, as well,” she said. “At NorthShore, we have a hybrid model where some things such as clinic instruments are centralized, but each hospital has its own SPD department which reduces the dependence on transportation resources. As technology evolves and there’s a continued focus on minimally invasive procedures, medical devices themselves are getting more challenging to process. This is happening at a faster pace than the expectations and qualifications of our SPD professionals. The result can be poor quality as we’re expected to expertly process thousands of medical devices that are getting more complex.”
Instead, NorthShore trains specialized SPD technicians to align with their hospital’s specialty. For example, NorthShore’s Orthopaedic & Spine Institute (Skokie) not only includes high-tech surgical suites and specialized surgeons and clinicians but also an SPD team comprising experts in reprocessing orthopedic and spine instruments.
“Our team will have basic skills in decontamination, set assembly, sterilization and case carts to help other pavilions as needed,” she noted. “Specializing allows our SPD staff to become experts in the care and handling of those particular instruments. This specialized model is the same model we will follow as SPD prepares for the opening of a new NorthShore Cardiovascular Institute.”
Mace Davis cautions against perceiving specialization as somehow limiting.
“All team members are cross-trained in basic decontamination, set assembly, sterilization and case carts,” she countered. “Specialization is by location. If a hospital SPD team is short-staffed one day, a team member from another hospital may travel to that location to help out but not in a specialization different than they are trained in. Instead, they would backfill a less specialized position and allow one of that hospital’s team members fill in for the more specialized tasks in which they are trained.”
NorthShore believes minimizing variation and developing experts in SPD have been keys to the department’s success, according to Mace Davis. The benefits of this model include built-in contingency, reduced instrument inventory needs due to shortened lead times and no long-term dependency on resources – trucks, people, dock space – for transporting instrument trays, she says. “People, process, and product are crucial attributes to any high functioning sterile processing team – but it’s our people in particular who set us apart from other organizations,” she added.
SPD’s management team includes four location-specific SPD managers, a high-level disinfection/sterilization (HLDS) manager, and a manager of quality and education, representing a “flattened organizational structure” that emphasizes valuable peer-to-peer support. “The advantages of this horizontally aligned team of six managers are that they are all peers and there to support each other every day,” she added. “Even though we are physically located at different hospitals up to 14 miles apart, we work very closely together.” The Director, HLDS manager and Q&E manager are system positions and travel between sites. NorthShore is in the process of securing office space for the system leadership team out of the Skokie hospital that is the most centrally located and highest-volume SPD to further solidify collaboration.
We, not me
Mace Davis remembers one SPD manager uttering a refrain about their philosophy that has become something of a motivator, if not a motto: It’s all about “we, not me.” Such an attitude makes standardizing processes and equipment across a multihospital system easier, she adds.
During the last half of 2021, NorthShore had to “decompress” the orthopedic specialty hospital during a massive 14-month SPD construction project that expanded SPD (footprint to 11,400 square feet from 6,000) to service up to 16 new ORs in addition to the existing 12 at one of the system’s highest-volume hospitals. After exploring every conceivable option, one of the vendors – Agiliti – stepped up to support SPD by transporting clean trays to another pavilion for processing and returning sterile trays back for storage. SPD organized a multi-disciplinary team that included the OR, IP, procurement and Agiliti to establish a transportation process with temperature and humidity monitoring.
“Through this exercise, we were also able to define a systemwide contingency plan based on a transportation solution that better prepares us in the event it is ever needed,” she said. “Not only did our vendor work closely with us to understand and meet our needs, we leveraged our strength as a system to ensure this change in assembly and sterilization didn’t adversely affect the OR.”
SPD standardized a host of processes, including the reprocessing of specialized instruments such as robotic arms, ophthalmology instruments and flexible endoscopes in addition to water quality testing, borescope testing and quality checklists.
Peel pack processing was a particular win, according to Mace Davis. “We not only standardized within the hospitals but also started transitioning the instrument processing from our clinics to SPD,” she said. “We know there is a lot of focus on the way these instruments are processed (opened, no staining, appropriate size pouch, no broken seals, etc.) and this centralization allows our SPD team to own the process as experts in cleaning, packaging and sterilization.”
Mace Davis admits that existing workflows, such as how SPD reprocessed robotic instruments, were the most difficult to standardize.
“Change can feel personal, and we not only included our SPD teams in the process reviews, but also the OR teams,” she said. “Specific to this project, there was a lot of debate over wrapped or peel pouched arms and which process was better. When multiple solutions are acceptable, consensus can be challenging! Getting the other side to try the new way often helps ease concerns – and presenting data whenever it’s available helps. Otherwise, we can spend a lot of time discussing all of the ‘what ifs’ instead of the problem at hand. Perfection can’t be the enemy of progress.”
SPD’s expansion and modernization project included a thorough capacity analysis based on actual cycle times and volumes because the typical capacity for a piece of equipment may actually be less than expected with larger, more complex orthopedic trays, according to Mace Davis.
SPD focused on staff safety when purchasing ergonomic sinks, flushing systems and workstations. They emphasized patient safety as they established one directional flow (to clearly separate dirty, non-sterile and sterile trays) with pass-through equipment including sterilizers (steam and low-temperature models). They installed quality stations for borescope inspections, and staff were trained on what to look for and how to document issues. SPD also initiated a partnership with a local vendor – Phigenics – to monitor water quality by collecting and testing samples and reporting results to NorthShore’s Water Management Committee, which promptly invited SPD to join as a member.
Mace Davis stresses SPD’s water works.
“I recommend this for all SPDs,” she said. “As an industry, we have learned so much in recent years about the importance of water quality and we’ve appreciated the dependability of this vendor partner.”