7 Steps Toward HLD Improvements in Healthcare Organizations
As a sterile processing leader, you’ve been asked to assume oversight of high-level disinfection (HLD) of devices that takes place outside of your department. The ideal scenario presented is centralizing HLD to the sterile processing department (SPD).
In my October 2025 HPN article on this topic (“Taming the Beast: Best Practices for Managing HLD Inside and Outside the SPD”), I presented a high-level view of challenges, opportunities, and best practices for making this happen. My initial thought for this follow-up piece was to offer a clear and concrete roadmap for getting from point A to Z with HLD centralization.
But the more I spoke with stakeholders to this process, including sterile processing and infection prevention professionals, it became clear that the topic was not so cut and dry. Each health system or hospital is different when it comes to where and how HLD is performed. While the priority is to reprocess in alignment with industry standards and manufacturer instructions for use (IFU), there are many nuances that can make or break HLD centralization efforts.
Furthermore, if a clinical department – onsite at a hospital or offsite in a clinic – is successfully performing HLD in alignment with industry standards and their healthcare organization’s protocols, why try to fix what isn’t broken? Most SPDs are resource strained, specifically when it comes to staffing. If a clinical department has the resources to perform HLD of their devices, and they are doing it well, keeping it there takes the burden off the SPD team.
As Amy DeGraw, BSHA, CRCST, CHL, clinical educator for the Healthcare Sterile Processing Association (HSPA), pointed out, managing HLD is not an easy task nor is it a one-and-done project. “It’s difficult to do and ongoing. It never ends. It's always transforming and evolving.”
While there doesn’t seem to be a one-size-fits-all solution for the HLD model – centralization to the SPD might make sense in one hospital but is not feasible or reasonable for another – the aim of this article is to provide SPD leaders with concrete steps they can take to help improve HLD efficacy and safety regardless of where it takes place.
DeGraw returns for this second article in the series, and she brings along former colleagues with whom she has collaborated on HLD optimization efforts: Mindy Nicklas, MPH, MT(ASCP), CIC, senior education & events specialist for the Association for Professionals in Infection Control and Epidemiology (APIC), and Matthew Hadley, CRCST, CIS, CHL, education coordinator for Mercyhealth in Janesville, Wis.
They provide real-world examples from their experiences managing HLD across various U.S. health systems and hospitals and pro tips that SPD leaders can implement in their healthcare organizations.
Step 1. Align with infection prevention
“Infection prevention is sterile processing’s greatest ally,” said Nicklas, who collaborated with DeGraw on ambulatory HLD and sterilization, maintaining oversight and standardization for a 10-hospital network. “It seems obvious that IP and SPD leaders would be in alignment on driving safe and effective HLD practices, but sometimes it’s like IPs don't realize they should lean into SPD and SPD doesn't always realize that they should lean into IP.”
“The work of both SPD and IP is tied closely to patient safety,” said DeGraw. “We are the ones who will have to answer for the ramifications of poor HLD reprocessing, whether it is by the SPD team or clinical staff members.”
Pro tip: Bring them into your reality
Hadley, who served under DeGraw over a decade ago, climbing the SPD career ladder from third shift technician to educator, implemented a job shadowing initiative at Mercyhealth to foster a collaborative relationship between the SPD and IP teams.
“While we had a good rapport initially because of our joint quarterly rounding, the IPs have told me the experience of coming into the SPD and seeing our processes firsthand has been eye opening for them,” he stated. “Together, we follow a case cart from the soiled elevator, through decontamination, washing, tray assembly, and sterilization so IP can understand our work and the complexity of the steps involved.”
Step 2. Engage physician leaders and executive sponsors
Any change to HLD processes, whether it is fostering improvements within clinical departments where they are performed or centralizing them to the SPD, will require buy-in from physicians impacted and resources from the C-suite (e.g., funding for equipment, supplies, FTEs).
“If you find an HLD process failure in a clinical department, you must take into consideration whether you have the authority to stop it,” said Nicklas. “Because there are big implications to telling a physician, ‘Your team can’t process scopes anymore,’ including potential revenue losses. Having someone at the physician leader level to be your champion, acknowledge the SPD team are the experts in performing HLD effectively and safely, and be willing to fix what is wrong will make or break your success in enacting change.”
DeGraw explained that her efforts with Hadley to centralize HLD processing in the SPD at Mercyhealth was easier to achieve from a physician buy-in standpoint because the initiative had strong support from senior leadership. In contrast, at another health system, centralizing HLD was more of a challenge.
“In this instance, trying to align the different services and locations was a challenge because we couldn’t necessarily have a phased roll-out,” said DeGraw. “Physicians often worked at multiple sites, and they had concerns about varying practices between locations. This required addressing an entire service line across the system, not just focusing on a single location, requiring larger buy-in from the start. This also required aligning multiple C-suite executives to ensure we provided a unified message.”
Pro tip: Engage leaders early and often
DeGraw stressed the importance of engaging physician and C-suite leaders before changes are proposed to frontline clinical teams and keeping them engaged throughout the process.
“It’s very important to have leaders with you when performing risk assessments of their departments,” she explained. “When you are walking through their space, have them at your side seeing exactly what you are seeing, where there are issues with HLD, why it is wrong, and how to do it right. That way, when you send them your audit report, they will have context around it.”
“It’s easier and more effective to identify and address issues with department leaders in person, in the moment so they can have real-time conversations with their staff members as opposed to sending them an email after the fact,” said Nicklas.
Step 3. Develop and apply a standardized risk assessment
When asked what SPD and IP should look for when assessing HLD processes in clinical departments, the answers from DeGraw, Hadley, and Nicklas could have filled an entire article. They cited evaluation of the physical space where HLD is performed, workflows used, IFU adherence, and staff training, among many other factors for consideration.
Space, storage, and equipment for HLD
“A big part of risk analysis is assessing the physical space to determine if they can safely perform HLD in the space they have available,” said Nicklas. “Often the answer to the question is ‘No’ in the ambulatory setting.”
“I’ve walked into spaces where HLD is shared with the lab or there are biohazards stored right next to their sterile supplies,” said DeGraw. “In another, they had only a tiny handwashing sink for HLD.”
Hadley recounted how one department had installed a motion sensor-controlled sink in their HLD area, stating: “They had just finished the space and were told they needed to install new plumbing fixtures. That was a lesson learned. But it was a valuable lesson.”
“It goes to show there are things that clinical staff members don’t consider when it comes to HLD,” said DeGraw. “That’s why it is so important to have SPD and IP walk through their space with them to identify overlooked items that could pose risk.”
People and processes
According to Nicklas, process issues are high on the list when performing HLD risk assessments. She stated, “They're just not following the correct steps. They're not following the equipment IFUs.”
“In most cases, they are not intentionally doing it wrong,” she added. “The people performing HLD in clinical departments aren’t typically asking to do this work but rather they are stuck with it, especially in ambulatory settings. If you're lucky enough to have somebody in that department who truly gets it, wants to own that process, and do the right thing, that’s tremendous. But it isn’t always the case.”
Pro tip: Revisit to reassess
When performing an HLD risk assessment in a clinical space, IP and SPD team members can’t always catch process failures in the moment. DeGraw and Hadley provided two examples of where reassessment uncovered previously hidden issues.
“In one department, staff placed towels on counters to dry instruments, with the expectation they be changed daily,” DeGraw said. “During our initial assessment, the team claimed this was done, but I was skeptical. So, I used a pen to put my initials on a towel used for this purpose, flipped it over so my initials were hidden, and returned a week later. It was the same towel being used.”
“Inconsistent use of personal protective equipment (PPE) during HLD reprocessing is another common problem,” said Hadley. “I’ve seen PPE covered in dust and asked clinical staff if they use it regularly. Although they told me ‘Yes,’ I returned three months later and the same dusty PPE was still in the drawer.”
Step 4. Review and refine HLD policies and procedures
DeGraw, Hadley, and Nicklas acknowledge how some health systems and hospitals have HLD policies and procedures that are specific to the SPD and do not address the realities of reprocessing in clinical departments.
“Many times, policies and procedures for reprocessing are written with just the SPD in mind and don’t always touch on what's happening outside the department,” said DeGraw. “That’s why it’s important to evaluate what your hospital has in place before doing a deep dive into HLD changes.”
The process of refining HLD policies and procedures can present the opportunity for clinical departments to align with industry guidance and guidelines. In other cases, where the departments just don’t have the space and resources of an SPD, it can make sense for SPD and IP team members to revise HLD policies and procedures to align with what the departments have available – if they are able to perform HLD effectively and safely.
Pro tip: Consider your options
To determine the best path forward, DeGraw suggests asking the following questions:
- Are your current HLD processes and procedures realistic in the clinical department setting?
- Do they need to be rewritten to align with what clinical departments have available?
- Should you develop a separate document that provides guidance in alignment with industry standards for HLD performed outside of the SPD?
Step 5. Define the target HLD operating model
Once a united SPD and IP team understands where HLD is being performed and whether it is being performed in alignment with policies and procedures, they can leverage this knowledge to guide decisions on their approach moving forward.
Does it make sense to keep HLD in clinical departments? Should HLD be centralized to the SPD? Is there a hybrid approach where only some departments transition HLD to SPD? Or is there a completely different alternative?
“If a department has the right space and the right processes for HLD to be safe and effective, those who are performing it are dedicated to doing it right, everything is just spot on, then it could make sense to leave HLD where it is,” said DeGraw. “Especially if it is a busy practice, you don’t want to unnecessarily disrupt their workflows.”
“But in instances where processes are unsafe and jeopardize patient care and safety, there must be a hard stop,” DeGraw continued. “There are times when we have identified issues and provided training and competencies, only to come back and find the process still isn’t being done correctly. Quality keeps slipping and the staff can’t maintain it.”
Pro tip: Take a hybrid approach
Hadley acknowledged how there are times when a clinical department is compliant with most devices they are processing on-site, but there is one item with which they struggle. In this case, it could make sense for the SPD to take over reprocessing of this item for the department.
Pro tip: Consider disposables
During their risk assessments, DeGraw, Hadley, and Nicklas consider not only whether a department’s items should remain on-site for HLD or be moved to the SPD, but also whether switching from reusable to disposable products makes sense.
Nicklas commented on how she recommended the transition to single-use bronchoscopes in the hospital and single-use cystoscopes and rhinolaryngoscopes in the ambulatory setting. Hadley noted how Mercyhealth’s urology clinics are currently transitioning to disposables.
Step 6: Manage change
Regardless of the chosen model – working to improve the effectiveness and safety of HLD reprocessing in clinical areas, centralizing HLD to the SPD, switching to disposables for some items, or some combination of these approaches – change management is critical to success.
And change isn’t easy in healthcare. DeGraw, Hadley, and Nicklas acknowledge how they have experienced push back from the various stakeholders impacted by the change, primarily the clinical and SPD teams.
As DeGraw noted in the first article in this series, clinicians worry that if they allow the SPD team to take over HLD, their equipment will get lost or damaged. As for proposals to switch to disposable items, questions around quality and cost will likely arise.
“Some clinicians like the quality and feel of reusable devices so it can be an uphill battle to make the change to disposables,” said Hadley.
“I’ve had pushback from clinicians on the cost of disposable items, with comments on how they are too expensive,” said DeGraw. “So, it is important to know going into it the financial impact of the proposed change.”
As for the SPD team, concerns around the idea of taking on the additional work of HLD are common, as DeGraw explained: “I’ve had SPD teams give me a hard ‘No’ when asked to take on HLD and that was a hard pill to swallow. If the directive is coming from senior leadership and centralization must happen, you have to come up with ideas on how to make it work for the SPD.”
Pro tip: Ask SPD what they need
When faced with SPD team pushback, DeGraw suggests advocating for an open dialogue to identify what resources—such as equipment, workspace, or staffing—would be needed to make a change feasible. By focusing on solutions, clear communication, and concrete metrics, DeGraw believes SPD and other departments can find mutually beneficial approaches that balance workloads and improve outcomes.
(Read the first article in this two-part series, “Taming the Beast: Best Practices for Managing HLD Inside and Outside the SPD,” for advice on key factors for consideration and metrics to measure and track when centralizing HLD).
Hadley added how SPD staff education and training is another important fact to consider. If an SPD team has only been performing HLD on a limited basis, or perhaps not at all, they can face a steep learning curve when HLD centralization is proposed. Beyond training and competencies, Hadley provides his team with easy access to valuable resources they can reference when a question on HLD arises. He stated:
“I have developed a unified, standardized format for cleaning procedures in decontamination. It is like a little library where, based on a reference number, a technician can find a laminated document with step-by-step instructions for that device. They simply put it up on the wall in front of them and have everything they need.”
Pro tip: Turn to a neutral project manager
DeGraw stressed that large-scale HLD process changes can be overwhelming for all departments involved—not just SPD—and often come with emotional and operational challenges.
She highlighted the value of having a neutral project manager or facilitator who is not tied to any one department. This dedicated resource can coordinate efforts, keep stakeholders focused, build business cases, and guide discussions toward shared goals.
DeGraw believes such leadership helps prevent projects from stalling and ensures forward momentum, particularly in larger facilities where the scope and complexity of changes can easily derail progress.
Step 7. Pilot before scaling
One way to help manage HLD reprocessing changes is to pilot the proposed model. That way, stakeholders can identify challenges—and work to overcome them—on a small scale.
“Sometimes no amount of preparedness can assure you will get everything right on day one of a transition,” said Hadley. “Therefore, take the time to simulate proposed workflows, perform test runs, and trace the entire life cycle of the impacted devices in advance. It’s extremely enlightening.”
“Start small,” said Nicklas. “Pilot a change with one department or one device at a time. Measure turnaround time, compliance, and staff feedback before expanding.”
Nicklas and DeGraw recounted an HLD centralization project that moved too fast, with the SPD team overwhelmed by higher instrument and device volumes. The result was a shift back to clinical departments performing HLD and the SPD and IP teams having to continuously monitor and address “bad practices.”
“SPD preparedness can make or break your whole project,” said Nicklas.
“It literally broke our project in one case,” DeGraw added.
Pro tip: Decide on transport in advance
A major challenge with centralizing HLD to the SPD is transporting devices to/from the clinical departments using them. As our experts point out, it is not only time and distance that must be taken into consideration, but also the labor involved.
“One of the things I typically encounter, whatever department is the end user, is that they're always too busy to deliver their devices to the SPD,” said Hadley. “They want SPD to start reprocessing their items as soon as possible but claim they don’t have the resources to get them into decontam. My advice is to establish clear rules for transport that are set in stone before any changes are initiated, and a process for ensuring compliance with the rules.”
“I’ve been in those conversations where clinical and SPD teams are going back and forth on who will bring the instruments into SPD and who will return them to the department,” said DeGraw. “Sometimes you just have to meet in the middle, and it becomes a shared responsibility. Perhaps the clinical department agrees to deliver soiled items to the SPD, and the SPD team agrees to return the clean and sterilized items back to the department.”
“In some cases, other resources need to be tapped,” she continued. “Maybe it is designating a runner who does the transport back and forth? Consider hospital volunteers who can help with tasks like this to take the burden off the clinical and SPD teams.”
Closing thoughts
There’s no one-size-fits-all answer for HLD. The right model—whether centralization, targeted improvements, or selective disposables—depends on each organization’s realities. What’s universal is the need for collaboration, clear communication, and shared ownership. When SPD, infection prevention, and clinical leaders align around patient safety, HLD processes can evolve to be safer, smarter, and more sustainable.
“My words for encouragement to SPD and IP teams leading the charge for change in HLD – this doesn’t happen overnight,” said Nicklas. “It is often a many years long process because healthcare doesn’t change quickly.”
“Take it in small bites,” said DeGraw. “This isn’t a sprint; it’s a marathon.”
Hadley reminded SPD and IP teams that they don’t have to go it alone, stating:
“We have some major stakeholders involved in our cross disciplinary group and that’s really been shown to work for us – not only to get the ball rolling with change but to enforce policies and procedures and sustain improvements.”
About the Author
Kara Nadeau
Senior Contributing Editor
Kara Nadeau is Sterile Processing Editor for Healthcare Purchasing News.