sterile processing
By David L . Taylor III , MSN , RN , CNOR
Peeling the Onion : How C-Suite Involvement , Consulting Can Spur Big Improvements in the SPD and Beyond
Without the
SP function , a hospital can become paralyzed ; therefore , it is vital that hospital administrators engage more readily with their SP professionals , so they can focus on improving processes and outcomes that impact the continuum of care .
the healthcare industry seeks answers to
As improve its “ system of care ,” an area often overlooked is sterile processing ( SP ). Far too often , administration fails to understand the importance of such a department , which supports and enables hospitals and health systems to focus on what they do best — delivering patient care . Without the SP function , a hospital can become paralyzed ; therefore , it is vital that hospital administrators engage more readily with their SP professionals , so they can focus on improving processes and outcomes that impact the continuum of care .
One CEO did just that by engaging a team of consultants to improve both the operating room ( OR ) and the sterile processing department ( SPD ) at two of his hospitals located in the Northeast — and the efforts were greatly rewarded . Initially , the SPD had been identified as a leading cause of the OR ’ s issues ; however , after an intense multi-week assessment , it became clear that was not the case . While the SPD certainly had some issues that needed addressing , the OR team could not get out of its own way to realize they were part of the problem . More specifically , bullying behaviors from some in the OR were causing a divide between the two departments , which proved to be the root of the problems . Compounding matters further , after decades of neglect , understaffing , poor instrumentation maintenance and instrument set shortages , the SPD could not keep up with the demands placed upon them by the OR .
The fallout was significant . The SPD ’ s manager resigned , and the department had just failed its survey from the Joint Commission ( TJC ), and the SP team bore staggering responsibilities that included not just meeting the needs of the busy OR , but also all procedural areas ( e . g ., the emergency department , intensive care unit , both onsite and offsite clinics , and an ambulatory surgery center ). Additionally , the SPD was responsible for the cleaning , maintenance , storage and distribution of durable medical equipment , crash , trauma and hemorrhage carts , and it also was largely responsible for resupplying all nursing units and ancillary support areas with patient-related supplies through a modified materials management support system . The entire hospital relied on the SPD for nearly every aspect of patient care and yet the department had 10 full-time equivalent ( FTE ) vacancies , which greatly exacerbated the challenges of effectively and efficiently meeting organization-wide demands .
The cause and affect due to the lack of staffing involved near-constant interruptions ( occurring six times an hour , on average ), staff burnout , errors and safety issues .
Through a collaborative effort with the hospital C-suite , a plan was implemented to address all issues identified during the assessment . First and foremost was addressing the TJC survey deficiencies that were levied against the SPD . To manage the improvement project , a new leadership team was needed . After an in-depth evaluation of the current staff , no one was identified who could step into a manager ’ s role . As a result , two interim managers and two supervisors were hired , one manager-supervisor set for each campus . Additionally , an interim SPD educator was employed to address educational needs at both campuses .
To address the survey deficiencies , an action plan was developed and each TJC issue was identified , prioritized and addressed . Areas identified included safety , cleanliness , clutter , employee skill level , and infection prevention issues . In conjunction , the leaders needed to evaluate and “ know ” their staff . Six-part folders were created for each employee , which allowed the interim leadership team to understand every employee ’ s employment history and better track their progress . Each folder contained :
● Hire date ( work anniversary ) and employee profile ( job description , roles and responsibilities )
● A competency skills checklist and validation for each area in the SPD
● Mandatory training ( BCLS , fire safety , etc .)
● Certifications held or in progress ( e . g ., CRCST , CIS , CER , CHL )
● Education and in-services , staff meetings , and continuing education credits ; and
● Employee development ( conference attendance , annual evaluations , counseling documents )
These efforts not only allowed the management team to create a feedback cycle ( which demonstrated to each employee how they were contributing to their own department ) but also allowed the SP team to more readily see how they and their department ’ s contributions impacted the organization . Put simply , it helped demonstrate their value to the organization — and showed that those in the C-suite also understood their importance . Further , the folders allowed the new management team to reconstruct every employee ’ s work history and have it at their fingertips . Some