CS and OR

CS and OR
Forging a Patient Safety Alliance

Central service (CS) and operating room (OR) personnel share a common goal: the provision of excellent patient care and positive outcomes. Technological innovation and scientific advancements have produced extensive change and evolution in both of these departments in recent years, to the benefit of each. For many facilities, however, communication and teamwork between them has become stagnant. In these situations, leadership and commitment to change can make a significant impact.

“One of the biggest things I see in terms of communication issues is that in ORs there have been so many changes — procedures, instrumentation, you name it, and I think sometimes they think that sterilization stays the same and has the same level of knowledge that it did 10, 20, 30 years ago,” says Natalie Lind, CRCST, CHL, educational director for the International Association of Healthcare Central Service Materiel Management (IAHCSMM). “We have made huge advances in not only our understanding of the sterilization process and the science of sterilization, but we’ve also been challenged with instrumentation that is a lot more complex, so I think sometimes there’s a communication breakdown because what used to be an acceptable practice is not acceptable any more, and that can be a real source of frustration for both departments.”

Nancy Chobin, RN, CSPDM, SPD/CS educator for Saint Barnabas Health Care System in New Jersey, says lack of effective communication is an unfortunate issue that has developed in many facilities, but it must not be ignored. “We have to work so closely together, we impact so dramatically on the outcomes of patients that when we consider the amount of time that we spend nitpicking and finger pointing, we could really be using that to do something constructive. You have to look at the root of it — how did it get started? In my opinion, we have a problem because there’s a misunderstanding of the cultures.”

OR personnel have high expectations of sterile processing department (SPD) staff in terms of their ability to provide correct and complete instrumentation. “They’re in a high-stress environment, they need things done, and if they’re done wrong, they’re in the firing line,” Chobin continues. “They have to take it out on somebody, and oftentimes it’s the person in CS. Why didn’t the CS person do it correctly? There are a number of reasons; what I find first and foremost is that people lack proper training and education. If we don’t address this issue, this problem is never going to go away.

“ORs have a perioperative training program — you don’t work in the OR unless you’ve gone through that program. Why don’t we do that in the CS?” Chobin questions. “I have good intentions when I hire you — I start you in decontam with my best person, and then third day on the job, two people call out sick, I have nobody to put with you, and you’re on your own. That’s not only scary, but it’s dangerous.”

Rose Seavey, RN, MBA, CNOR, ACSP, past president of ASHCSP, and director of the SPD at the Children’s Hospital in Denver, also accentuates the importance of continual education. “We make sure that we have at least one inservice every month, if not more,” she says. Members of the OR staff are frequently invited to participate in these sessions as well. “For example, we recently had the bronch nurses come down and do a presentation on bronch instruments. We just figure out what the current needs are and try to get as many people involved as possible.”

Efforts such as these have led to a good working relationship between the two departments at Seavey’s facility. “There’s a whole list of things that we do and most of it involves meeting together on a routine basis and getting people involved and not having everybody do instruments, just specific people in the SPD, and then having each one assigned to a service.

One of the great things that we do here is we’re getting ready to have our ninth annual OR and SPD workshop. It’s a one- or two-day conference and we have vendors there and educational sessions and so on. That works really well. Keeping the lines of communication open is important, as is face-to-face meeting — not just with the supervisors and managers, but we have a monthly meeting we call a combined staff meeting, and you get OR and SPD personnel in there.”

Barbara Trattler, RN, MPA, CNOR, administrative director of perioperative services at Long Branch, N.J.-based Monmouth Medical Center, which is also part of the Saint Barnabas system, notes that work groups can help in opening the lines of communication. “For example, setting up a process improvement committee between the OR and SPD so that you have key players involved, and not the managers. Managers need to be facilitators of discussion in planning the agenda and ensuring that the meetings take place, but the people who actually perform the work, so the SPD techs along with the OR staff, need to be at the meeting. What you do is you say, ‘OK, we’re not going to point fingers, we’re just going to discuss the issues.’ So if the issue is missing instruments, you can talk about the process — why are they missing, and how we go about replacement, understanding why they’re missing — what’s our process? Can people look at each other’s work to determine how instruments could be missing? That’s an example.”

Chobin explains that an initiative to make SPD improvements in her system began last year with a paper she wrote for upper administration called “Extreme Makeover SPD.” “I did this because we have this OR initiatives project, where they’re making the ORs as efficient as possible — they’re looking at room turnover, personnel utilization, supply utilization, etc., and I sit on that committee, and one day I said, ‘You know, this is really great, but if you don’t fix the CS piece, you’re wasting your time.’” A second committee was subsequently formed, with Chobin serving as co-chair with Trattler. “The recommendations that I had made were that we, No. 1, revise all of our job descriptions, and upgrade all the positions to the same level as surgical technician, because if we’re ever going to get out of this, we need to attract a different caliber of people, and I don’t mean that in a derogatory sense, but the people that we have been attracting for the past 40 years only had to do manual tasks — there was no critical thinking. Now you have to know, is this steam, is this gas, can I read manufacturers’ instructions, how do I change sterilizer settings, is this compatible — it’s a whole different world.”

In addition to changing the job classifications, a career ladder was also proposed. In this model, when a new hire comes into the St. Barnabas system, he or she would begin as an attendant. When mastery of competencies is demonstrated, the attendant would get promoted to the next step, technician, which includes a pay increase. “You’re still not certified [as is required in New Jersey], and that means that you could be in that group for a year and a half, or as long as it takes,” Chobin explains.

After the technician passes the certification exam, he or she becomes a specialist, which encompasses new responsibilities such as the ability to train new people and work independently. “The next step is a lead technician, and this is someone who will assign work and ensure accountability. We want 24/7 accountability in our department so that on weekends and holidays when we might not have a manager, there still has to be accountability — we’re a manufacturing center,” Chobin continues. “With a lead technician, that person assumes that accountability but they don’t have to get into the managerial things like hiring, firing, discipline, etc., they just write down what the problems are and the manager deals with them. The fourth step is a supervisor because we do have some of our hospitals that are large enough to have both a manger and a supervisor. We actually will have five steps in that career ladder, so we’ll offer people a tremendous amount of personal and professional growth, and there’s a payback for that because look at the time that we’re going to spend to train them — we don’t want to lose them.”

To reinforce this point, Chobin describes a study she conducted in 1997 on the cost for training a CS worker. At that time, the cost was just under $30,000. Considering the turnover rate in many CS departments, she recommends using that money on training and salary increases. “You’re going to save money,” she concludes. Chobin also emphasizes that the training process should be able to accommodate different learning styles. “You can really lose out on some good people by forcing them into a certain mold. You need to work with the individual and meet their individual training needs.”

Seavey contends that SPD managers should make the effort to empower their employees and promote self confidence. “You can do that by introducing them,” she says. “The other thing we do is send our staff up there at least once every six months or so to actually see a surgery case, and hopefully it’s one where they’ve picked the case cart or done the instruments. We also require new OR staff to spend a week in the SPD where they work with case carts, instruments, and decontam.”

“What’s imperative for a good relationship is that both departments need to understand what the other does,” Trattler says. “So the OR personnel, as part of their orientation, need to spend time in SPD, all of our staff members, and SPD staff need to be up in the OR as part of their orientation — they need to be in the room observing the procedures, learning how the instruments are used, so that they understand why the surgeon gets upset when the forceps don’t line up, or when the scissors are dull. Then they can understand how that frustration filters down to the SPD.”

Seavey also points to the importance of the perioperative services operations team (PSOT) at her facility, which includes herself as the SPD representative, as well as administrative staff, surgeons, nurses, anesthesia personnel, and a business manager. “A lot of things are taken care of at that level,” she says. “Having a voice at that level really helps. I think many places don’t have that; I hear a lot of SPD supervisors saying the OR doesn’t listen. You have to make it happen — you need to be visible. You can’t sit back and expect them to do it.”

“I think a lot of hospitals are really trying to bridge that divide and they do it in a lot of different ways,” Lind says. “I know some hospitals have specialty teams in their OR — an ortho team or a neuro team, and they will have CS technicians who work with the team, not in the OR, but in helping to get things set up and work on problems with instrument sets, things like that.” Simple things, Lind adds, can go a long way toward strengthening the sense of community and camaraderie between the two departments. “I think the best way to get two departments together is to throw some food into the mix, something as simple as having something in the break room and inviting the other department to stop over during their coffee break just so they can put the face with the name,” she says. “We talk on the phone all of the time but oftentimes we don’t know who that person really is. Something as basic as that can go a long way.”

At Monmouth Medical Center, an SPD lead tech acts as a liaison to the OR, which has had a significant impact, as Trattler explains. “She facilitates understanding of what’s needed in the OR and what needs to be turned over to facilitate the schedule. Amongst the employees of the department she’ll identify that the instruments from the first case need to be turned over for the fourth case, for example, so the staff downstairs know that as soon as those instruments come down, they have to go through the decontamination process and then get assembled and put in the sterilizer.”

Lisa Huber, CRCST, sterile processing director at Maryville, Ill.-based Anderson Hospital, explains that a busy orthopedic practice with only one group of surgeons at her facility prompted a new and effective approach from CS. “What we did was fill an open position with someone who is our orthopedic specialist, and she communicates and travels back and forth between CS and OR, helps tear down the cases so that instrumentation goes to her and then comes to us,” she says. “Sales reps also communicate directly with her, so if something breaks during a case and they have to take it out or if they’re expecting loaner instrumentation for a case, she is the gatekeeper for all of that. If the orthopedic surgeons are happy or unhappy about anything — the way an instrument works, the sharpness, the quality of something, the nursing staff — everything goes through her.”

Huber says this has changed everything for her department, giving them not only increased visibility, but also a better reputation. “We’re there as part of the orthopedic team, and we make fewer mistakes because we have better information. That’s our big push — to improve the relationship, and we knew it fell on us to do it. It’s really been successful for us.”

How did the pieces fall in place to facilitate this accomplishment? Huber says timing and good fortune were key. “We refused to hire the wrong person, because knowing that everything hinged on this, the wrong person would set the process back rather than move it forward,” Huber explains. “I have to admit it was just sheer luck that someone became available with a great deal of experience, an impeccable work ethic and work record, and she really has taken the job and made it her own and has really forged this alliance. We talked about it for a long time and we did interview several people. There were questions about whether or not each of them would work; we would have one person with the right temperament but not the right experience, or someone with the right experience but couldn’t work the right flexible hours — they all had just a piece of the puzzle, so we were willing to wait until we found the right person.”

Trattler maintains that a good first step toward improving relations is to try and find one person from each department who can be a champion. “The manager would have to say ‘I really need your help on this, would you try to bring the group together.’ They can talk about what the problems with the respective departments are.”

Identifying the right people is critical. “You want to find a person who is positive, who has support; the managers have to support it, otherwise it will fall through the cracks,” Trattler continues. “The staff usually can’t do things like that on their own — they need to be empowered. The managers from each department need to recognize that there are issues, and even though they might not always agree, they need to problem solve and anticipate what the issues are. In each department you’re going to have a couple key people who are very positive and those are the people who you’re going to want to tap into to be your champions.”

Trattler underscores the fact that change doesn’t happen overnight, and that relatively basic issues should be tackled initially. “For example, say the SPD doesn’t get the schedule until very late in the day, so maybe the OR can give them a draft schedule earlier so they can begin to anticipate what’s needed for the next day,” she offers. “If the two departments are really heated and can’t talk to each other, then you need to find a facilitator internally. You’d look for a resource who can bring the managers together and assist the staff in identifying and opening up — you want to begin discussion. The first step is to get people to the table and let them talk without accusations.”

For many facilities, implementation of an automated instrument tracking system has been a key component in the effort to repair and optimize SPD/OR relationships and processes. Effective tracking systems offer the potential to establish accuracy, accountability, and accessibility, according to Blair Myers, vice president of sales and marketing at Censis Technologies, Inc.

“Utilization of our system aids in making sure that you’ve got accurate contents — trays, case carts, and so on,” Myers says. “So we’re ensuring accuracy on the front end in sterile processing, which carries over into assured accessibility in the OR.”

This means OR personnel are also able to locate a cart or instrument at any time. “That’s where it helps the communication — SPD personnel start to get credit for the good job they’re doing, or alternatively if there’s an issue, it can be identified and addressed appropriately,” Myers continues. “In the OR, once things are accurate and accessible, that trust factor is established, so when they are looking for something, they know that it can be located quickly.”

Myers notes that this type of system can also be valuable in the training process for SPD staff. “It’s a tremendous training tool. Technicians navigate with touch-screen monitors — you have images of the instruments, and if you’re managing all the way down to the instrument level, unique bar codes on the instruments allow you to scan and electronically confirm that it’s the correct instrument.”

While using a tracking system may seem like a drastic departure from some hospitals’ standard procedures, it can be implemented with a simple, phased approach, Myers explains. “Our approach is really a phased and scalable one. We have facilities using our system at various levels of detail. We have customers who start by just managing their count sheets. From there, it’s an easy transition to tracking and managing at the tray level, and finally we have the customers who manage their instruments on an individual basis with unique bar codes. Implementation and training can last from two weeks to two months depending on the scope of the install.”

Once successfully instituted, a good tracking system can demonstrate its value in many other areas as well. “Our system isn’t just for sterile processing,” Myers says. “We refer to it as a comprehensive solution that can be deployed and deliver benefit in sterile processing, the surgical services suite, materials management, and the area of infection control. There is value in using our system in all of those areas.”