Throughout the healthcare delivery continuum, stakeholders are trying to improve quality, whether it is quality of operations, clinical processes, patient outcomes or some other factors. Quality improvements in the Central Sterile Supply Department (CSSD) department have the potential to positively impact clinical customers (e.g., procedural areas) and their patients in terms of safe and effective instrumentation available when needed.
While the healthcare industry likes to talk about quality, what does this mean to CSSD department leaders and their teams and how do they concretely identify, pursue and achieve and measure improvements that make a difference?
When thinking about the CSSD and Infection Prevention (IP) functions, it seems obvious why the two teams must work together on quality improvements. Sterile processing plays a central role in infection prevention, by decontaminating, cleaning and sterilizing instruments and devices for safe patient care.
But in today’s healthcare environment where preventing hospital acquired infections (HAIs) is critical to not only patient outcomes but also payer reimbursements, the IP team can be pulled in many different directions. Quality oversight of the CSSD may take a backseat to more high-profile priorities, such as an outbreak of central line-associated bloodstream infections (CLABSI) or catheter-associated urinary tract infections (CAUTI).
The same holds true for operating room (OR) clinicians. While the patient on the table is their priority, their work to prepare used surgical instruments prior to their trip to decontamination, including point of use (POU) cleaning, ultimately impacts care and safety.
“It is important for the OR and SPD staff to work hand in hand to raise the bar on sterility and quality assurance,” said Healthcare Sterile Processing Association (HSPA) Secretary-Treasurer Jan Prudent, BA, CRCST, CIS, CER, CHL, CFER, FCS, Sterile Processing Manager at Eastern Idaho Regional Medical Center in Idaho Falls. “Continual education and better understanding about processes are vital to both departments. What one does not see, someone else often does. A well-rounded, in-depth system provides that needed protection.”
CSSD, IP and Perioperative professionals offer their advice on collaborative quality improvements and share success stories working with multidisciplinary teams in U.S. healthcare organizations.
A roadmap to surgical services and SPD quality
As voting members on the ANSI/AAMI ST90 Processing of Health Care Products - Quality Management Systems (QMS) for Processing in Health Care Facilities committee (Lewellyn the main, Billingslea the alternate), they are committed to helping teams establish strategies and action plans that improve quality throughout the surgical services and CSSD continuum.
Quality audit and planning
As Lewellyn explains, there is no one-size fits all quality plan. Therefore, establishing a QMS begins with performing an audit of the CSSD department. “Walk through the touchpoints in your process for producing a tray for the end user and compare them to your policy and procedures or even to best practice of care and handling of the instrumentation,” she stated.
Lewellyn and Billingslea stress the importance of having a multidisciplinary team that performs the rounding to examine processes and identify potential quality issues and improvements. In addition to the CSSD team members, it should also include personnel from infection prevention (IP), risk management, and end user customers, such as operating room (OR) staff and stakeholders from the other departments served by the CSSD (e.g., wound clinics, labor & delivery).
Lewellyn says they’ve found rounding teams are not always clear on what they should be inspecting throughout the process, so they’ve developed a program to teach them the critical quality checkpoints. She stated:
“Rounding is the key to a quality program, but the key to initiating a program is to first teach the rounding team what to audit. Do they understand the tasks and hands on touchpoints they should be looking for that might be missed during the round? How do you teach them to poke their head in the door and identify right off the bat what they could be doing better or even seeing missteps?”
Start small with quick wins
The rounding and audit process helps a CSSD team prioritize target quality improvements. It instills a culture of best practice among staff members, says Lewellyn, teaches them to keep an open mind, set aside old bad habits, and learn how to perform their roles in compliance with policy and procedures.
If there are no “big fires” identified in terms of quality, such as bioburden on trays coming down from the OR, Lewellyn recommends CSSD leaders prioritize “low hanging fruit” in their quality action plans.
“One of the easiest quality check points to start with is the sterilization record because most CSSD techs are aware of the importance of having a complete and accurate record. Acclimate and cross-train all techs to this best practice, not just the techs on the sterile side but those in decontamination as well. Huddle for five minutes each day to discuss recording requirements and audit the record at every shift. In my experience, beginning with one area of quality, and demonstrating successful improvement trickles down through not just the CSSD but also other departments, resulting in a much higher quality of care.”
Gaining support from key stakeholders
While some CSSD leaders are fortunate to have the support of hospital leadership and clinical stakeholders in making improvements, others must garner it, sometimes having to mend previously strained relationships.
“Part of it’s a mirrored look,” said Billingslea. “How well is your CSSD department partnering with the OR? Let go of negative interactions from the past and look for ways to make things easier for the OR even if it makes things temporarily harder for your department. Because in the big picture, if you’re taking stuff off their plate, it will be easier to get that partnership. I promise, if you go out of your way, they will soon be going out of their way to support you.”
Sometimes CSSD teams get pushback from other departments when attempting to engage them in quality improvements. In Lewellyn’s experience, a central cause for this discord is lack of understanding and comfort with the sterile processing workflow.
“One of the things we have done to help overcome this challenge is having the CSSD team host a lunch in their breakroom for their clinical customers and others critical to quality initiatives,” Lewellyn commented. “It can initiate a great beginning, helps everyone acclimate to the CSSD, and even facilitates healing of relationships that had been previously burnt.”
“Be sure to include your hospital’s IT team and teach them about the CSSD,” Billingslea added. “The investment you make in that relationship will pay off. We’ve seen IT become a CSSD team’s best advocate and help them avoid survey hits.”
Keep the CSSD team at the core
Billingslea has seen situations where the CSSD leader will share their action plan with all involved departments but not their own, but as he explains, “your players need to know the score.”
“It’s like the scoreboard at a game. The people watching on TV know the score but imagine how a game would go if the players on the field didn’t know who was winning? One of the things I always remind leaders is we must make sure we include our team in the scoreboard if we want them to hit a home run. Without that visibility, they don’t know whether they are behind or not. It shouldn’t be just the CSSD manager sharing it with stakeholders. It’s about the entire team working toward same goals.”
Billingslea recommends that CSSD leaders advocate for designated quality technicians to lead quality improvement initiatives. He stated:
“There’s probably nothing that will increase your quality quicker than assigning quality techs, whether this is a full-time responsibility or an assignment they carry out as part of every shift. When we go to turn around an account, that’s one of the first things we do. It’s a tried-and-true approach that always works. For the technician, it’s a very pleasing role that adds steps to their clinical ladder. It’s a win-win.”
Intermountain SPD and IP unite in quality improvements
During the Association for Professionals in Infection Control and Epidemiology (APIC) 2022 Cleaning, Disinfection, Sterilization Conference, held November 10-11, 2022, Caitlin Brown, MPH, MLS(ASCP), Infection Prevention Coordinator, and Eduardo Velazquez, CRCST, CHL, CFER, Sterile Processing Department Manager, both of whom work at St. Joseph Hospital in Denver, Colorado, shared some of their experiences with collaborative quality improvement.
Review of sterilization practices in the OR and SPD
Saint Joseph Hospital, now part of Intermountain Healthcare, has a robust sterile processing department comprised of 40 technicians. There are 21 ORs and approximately 230 cases/week. The health and safety of Saint Joseph Hospital’s patients, physicians, associates, and community are top priorities. The hospital recently took the opportunity to review its internal infection control processes thoroughly.
Given the focus on Infection Control and knowledge that sterilization practices are areas of regulatory scrutiny, an intensive review of all practices was performed using tracer tools that followed the requirements outlined in their Sterilization Policy and Procedure. Process issues were internally identified that triggered performance improvement initiatives.
The IP department wasted no time making enhancements when it discovered some challenges with pre-cleaning. “Saint Joseph’s has long had processes regarding infection control that exceed the basic industry standards,” noted Brown. “However, the IP department is not satisfied with exceeding expectations. We want to always be the best!”
Team effort for process improvement
“We jumped into action,” Brown recalled. “This was a collaborative endeavor. Infection prevention partnered with the stakeholders, from frontline staff and all levels of leadership to refine and enhance processes as described below.”
OR point of use precleaning and pretreatment
“We started out in the OR where pre-cleaning occurs, and we looked at every detail,” said Valasquez.
To address pre-cleaning, and end-of-case pretreatment at the point of use (POU), OR and other staff began performing additional audits at the end of cases to ensure proper instrument preparation. This also ensured that instruments were returned to their proper trays, with all hinged items open for thorough pre-treatment. It also helped ensure the consistent use of non-enzymatic spray to keep instrumentation moist and disposable items were removed, creating efficiencies for SPD to clean instruments and prevent paper from entering washers.
Decontamination
SPD leadership and IP round in the decontamination area once per week and conduct audits of the OR carts and make notes about how well the techs are cleaning the instruments and following existing protocols, including:
- Proper brush size use on all instrumentation
- Appropriate disassembly of equipment
- Verification of items that require sonic decontamination
- Proper sink detergent dosage and sink temperature
- Ensuring techs follow instrument instructions for use (IFU)
The SPD and IP also implemented a new case cart protocol that requires the cart to be delivered from OR to decontamination with:
- No sharps in any of the instrumentation
- No biohazard bags and waste
- All instrumentation unlatched
- All instrumentation adquately saturated with a non-enzymatic spray
If the SPD receives into decontamination a cart that appears not to meet the protocol standard, they return the cart to the tech to fix it.
Assembly
Velazquez outlined the standards in place to maintain quality, noting how instrumentation is carefully inspected for cleanliness, proper function, and possible defects, including:
- Testing insulation on a laparoscopic instrument (functionality)
- Testing the sharpness of scissors (functionality)
- Testing instruments for proper lubrication (functionality)
- Inspecting items with the borescope (cleanliness)
- Inspecting items with the lit magnifying glass (cleanliness and functionality)
- Inspections can consist of looking for debris, rust, pitting, and bioburden
Once properly inspected after coming from decontamination, the instrumentation is assembled, packaged, and labeled for sterilization. If an instrument doesn’t meet inspection expectations, the SPD uses a “White Tag System” to record which instrument has an issue, what the issue is, and the tech who found it at what time. The information is then communicated to decontamination. The team also gathers data related to the White Tag system along with data from weekly tracers by IP and SPD leadership.
Quality assurance
Saint Joseph Hospital uses audit tools, such as tracers and instrument inspection logs. To ensure a sustainable quality assurance program in the SPD, a multidisciplinary team analyzes data collected throughout their processes and sends regular reports to an internal Infection Control Committee, Perioperative Services Committee, and Quality Committee. They follow up on audit findings, then aggregate and trend data to find commonalities that can be systematically addressed.
Saint Joseph Hospital is proud of its reputation for clinical and operational excellence. Over the past five years, numerous independent agencies have recognized the hospital for quality and operational excellence (CMS Five-Star Quality Rating, Healthgrades “America’s 250 Best Hospitals Award” for delivering clinical quality and outstanding patient experience, Leapfrog Group “A” rating for best safety measures and strong track records).
As Brown stated: “We all work toward improved patient safety and improved patient outcomes every day here. That’s what we are always aiming for.”
Atlanta’s Northside Hospital takes a team approach to CSSD quality
“Here at Northside Hospital, we have developed a robust Sterile Processing quality management system that includes participation from SPD and OR leaders, Infection Prevention, Quality & Education, and Quality Improvement departments,” said HSPA Board of Directors Member Tracy Davenport, CRCST, CIS, CHL, Sterile Processing Manager, Northside Hospital, Atlanta.
Davenport explained how the program’s foundation began with the creation of several sterile processing focused quality leadership and support roles: “Pre and post sterilization quality inspections are performed by Quality Specialists, who report to our SPD Quality Manager and are based within our sterile processing department. Our Infection Prevention department has also added Infection Prevention Sterilization Specialists, staffed by experienced Sterile Processing Subject Matter Experts.”
Northside Hospital also leverages a quality tracking system, which is based on a low-code, cloud-based platform called TrackVia. It is available for users to access in each of the Surgical Service areas, including inpatient and outpatient OR departments, along with Labor and Delivery, and Sterile Processing.
“With this system we are able to track and document quality in all steps of the reprocessing cycle, including point of use (POU) instrument care, decontamination, inspection and assembly, sterilization, and transport,” said Davenport. “It was necessary to provide easy and automated reporting and notification to all stakeholders.”
In decontamination
Quality Specialists perform audits on trays coming from the OR and record their findings in the quality tracking system database. Scheduled notifications are sent via email to OR leaders at that same time each day, listing the specific trays that were not pre-cleaned and/or treated (sprayed) appropriately before being sent to decontamination.
“This allows OR leaders to follow up with the nurses and technicians who were assigned to those cases to provide just-in-time education,” Davenport explained.
In assembly
In the assembly area, Quality Specialists perform quality audits on trays that are straight out of the washers to ensure minimum cleaning criteria are met (e.g., instruments fully opened, levels are separated, etc.).
In sterilization
They perform audits on assembled and containerized trays waiting for sterilization to ensure staff have not missed inspection points, and trays and containers are assembled appropriately.
“In our sterilization area, audits are also performed on sterilizer loading and documentation,” said Davenport. “All SPD findings are recorded in our quality tracking system and the results are automatically sent to the SPD managers and employees’ direct supervisors.”
In the OR
In the OR, clinical staff utilize a customer feedback tool to submit quality tickets when they discover instrument tray errors. Findings such as no indicators or missing locks are sent to the SPD Quality Specialist assigned to the person who completed the tray. Upon receiving a quality ticket, the Quality Specialist performs an investigation and provides just-in-time education to the SPD technicians.
“If bioburden or foreign objects are discovered and reported through customer feedback, an urgent notification is immediately emailed to all SPD leadership so that someone can go directly to the room to follow up for an investigation,” said Davenport. “At that time, we provide service recovery, and have often found that some reports were not a sterility concern at all, allowing the surgery to move forward without delays.”
Continuous monitoring and feedback throughout the continuum
Northside Hospital’s IP Sterilization Specialists perform environment of care rounds within SPD, as well as a broader Sterilization Tracer performed once per quarter in collaboration with the hospital’s Quality & Education department and the health system’s Quality Improvement team.
“Those findings are also reported back to SPD leadership to take action where necessary,” Davenport commented. “Solutions and improvements are reported back to our Quality Improvement leaders during our weekly tracer report calls.”
To close the gap with everything tracked and compiled during the audits and provide follow up information to SPD’s customers on the issues that have been reported, SPD Quality and Operational leaders pull and review data from the prior month’s customer feedback submissions.
“Together we are able to identify potential causes and provide completed and/or proposed action items during our monthly SPD/OR Leadership meetings,” said Davenport. “During these sessions, we can collaborate with our customers to come up with solutions to quality issues, proactively prevent new occurrences, and find new ways to educate staff on opportunities to improve quality, and most importantly, our care to our patients.”
Quality assurance from start to finish
Healthcare Sterile Processing Association (HSPA) Secretary-Treasurer Jan Prudent, BA, CRCST, CIS, CER, CHL, CFER, FCS, Sterile Processing Manager at Eastern Idaho Regional Medical Center in Idaho Falls offers steps for improving quality throughout an instrument tray’s journey.
At the point of use (POU) in the OR: OR staff remove gross debris and put instrumentation/equipment back into their respective trays. They open hinged instruments and apply an approved solution to keep the equipment moist and inhibit drying of bioburden and the formation of biofilm.
In the decontamination area: Sterile Processing professionals review the case carts for any abnormalities in the progression, doing follow-up as necessary. Next, they brush lumens, clean and sort the instruments, and process them according to the manufacturers’ instruction for use (IFU).
It is in decontamination that SPD staff begin scanning all items via a tracking system, which continues at each checkpoint in the department (through to when the tray is stored or transported back to the OR).
Quality inspection and assembly: Sterile processing professionals complete trays with integrators (to monitor time, temperature and exposure) and package them with external indicators (color-changing tape for soft wrap packs and secure closures with color-changing stickers) to ensure they are processed.
Sterilization and monitoring: Next, they configure the loads and sterilize them with a biological and integrator challenge pack to ensure the cycle achieves the correct end result. They check external indicators and filters before the load is processed through the sterilizer as determined by the IFU. Once the sterilizer is complete, they scrutinize the sterilizer tape to ensure times and temperatures were reached. The staff member signs the tape, which is then attached to the load content sheet. The biological is incubated, and the results are documented.
They put aside the sterilizer rack for the contents to cool and use a temperature gun to ensure instrument trays are at room temperature before loads are put into storage. Another check of the external indicators and container filters is performed prior to storage.
Storage and transport: SPD staff members then pull trays according to patient/procedure specific lists, checking each item for sterility and package compromise before being placed onto the cart. They take patient specific cases to the OR suites where the staff there open the sterile instruments for surgery, using sterile technique. All external indicators, packaging, internal integrators, filters, and secure closures are diligently inspected by the OR personnel before being used on the patient.
“In summary, as each of the steps are performed, if there is any doubt in the process, the instruments should be considered contaminated,” said Prudent. “A thorough understanding and knowledge of the process and flow is imperative to achieve the highest standards necessary for the patient. All steps are combined to ensure sterility; none stand alone or work in a silo. It is essential that all staff, both in SPD and in OR, are educated and aware of those details.”
“And don’t forget a final step: quality checking the attributes of the inside and outside contents through a random opening of trays,” she added. “This is part of the daily quality check and allows a review of staff performance and a final assessment of educational follow-up and needs.”
Kara Nadeau | Senior Contributing Editor
Kara Nadeau is Sterile Processing Editor for Healthcare Purchasing News.
