When Does Your SPD Need Help?
By Kent A. Pedersen
How do you recognize when it is time to take a hard look at your sterile processing department (SPD)s productivity? There are three big indicators that your SPD may be in trouble. The No. 1 indicator that problems are on the rise coincides with an increase in physician complaints. The second is an apparent uncontrollable increase in repair/replacement costs of instrumentation. The third significant development is an obvious increase in stressed relations between operating room (OR) personnel and SPD personnel. This can be especially pronounced when the two departments report to different department heads.
Instrumentation Reprocessing and Delivery/Physician Complaints
Physician complaints do not automatically indicate the efficiency of the SPD. There are a number of factors involved in the effective delivery of instrumentation. However, surgeon complaints can serve as a barometer of potential problems. Late surgical starts and delays during surgery, either due to missing or inoperative instrumentation, will almost certainly insure visits to senior administration by the operating surgeon.
Regardless of the root cause of these problems, which are most often process related and involving multiple sources, it is the SPD that it is looked upon to provide the controls necessary to prevent these problems from occurring. It is important for the hospital administration to have a clear understanding of the demands that are placed on the SPD. According to Bryant C. Broder, former president of the American Society for Healthcare Central Service Professionals (ASHCSP), Even though sterile processing departments are instrumental in running an effective and efficient surgical department, they are often the most overlooked area of the surgical theatre both in surgical centers and in hospitals.1
Instrumentation reprocessing and delivery is a complex service requiring efficiencies throughout the cycle of use of instrumentation to deliver quality complete sets to surgery. Each stakeholder in the process shares a responsibility and a role in the delivery of instrumentation for surgery. If surgery nurses return instrumentation to the SPD with heavy instruments on top of delicate instruments, sets jumbled without organization, and identified damaged instruments mixed with functional instruments, the result will most likely be delayed reprocessing and/or incomplete sets due to damaged or lost instruments (see Table 1).
Equally important, stakeholders must function as a team. There is a critical need to have all stakeholders managing with one consistent set of expectations of performance. If the surgeons expectation is that every instrument must be available for every case each time a case is scheduled, regardless of surgical volume, then the service expectation by the SPD must be that it can deliver every instrument for every case. Very often these two expectations, the performance expectation of the surgeon vs. the performance expectations of the SPD, are not aligned. Sometimes the expectations do not align simply because the two parties never discussed the needs vs. the achievable deliverability (see Table 2).
There are few sterile processing departments that simply do not want to deliver the level of service required to optimize patient care. Instead, it is more typically a situation where either organizationally or financially the surgeon expectation cannot be met without changing either cross-functional resources or the investment in instrumentation or both.
Cross-Functional Roles and Responsibilities
An uncontrollable repair/replacement budget for instrumentation often points to significant process control issues. Rather than effectively addressing root instrumentation issues, the quick solution is to simply buy more instrumentation or increase repair budgets to try to keep instrumentation functional. An out-of-control repair/replacement budget should be an immediate signal that the processes throughout the cycle of use of instrumentation are broken and require immediate attention. To be effective, these processes may require significant retraining in the OR and SPD to instill lasting positive change.
The delivery of accurate functional instrumentation for optimal patient care is not the responsibility of a single department. All surgical services personnel must participate to have a reproducible model providing the right instrumentation, at the right time, in the right quantities. Stakeholder ownership begins at the site of use by the surgeon. The surgeons preference card identifying the specific needs for the procedure has a tremendous bearing on instrumentation availability. Surgeons who request more than is necessary for a procedure both increase instrumentation inventory needs and increase the burden on the system for reprocessing of unused instrumentation. OR nurses who do not restring instrumentation and/or fail to place instrumentation back into the pans in which they arrived, add significantly to the reprocessing time in both the decontamination and prep and pack departments. Decontamination and prep and pack departments that fail to follow manufacturers recommended reprocessing instructions can cause unnecessary damage to instrumentation, thus reducing its availability for scheduled cases. The cycle of use of instrumentation can perform very effectively when all stakeholders assume ownership and responsibility.
Finger-Pointing is Evidence that a Real Problem Exists
Stressed relations between OR and SPD personnel is the result of directors of each area permitting finger-pointing when issues arise. Once this practice is permitted to occur, the working relationship between these departments quickly deteriorates. Surgeons lose their temper and call senior administration, demanding that instrumentation problems be resolved. OR nursing staff blames the condition of the instrumentation sets on the SPD. In turn, the SPD contends that large percentages of instrumentation are being returned to decontam unused (indicating procedures are being over-instrumented) and those instruments that have been used are jumbled together without concern for proper handling or reassembly. It must be recognized by both departments, and enforced by the department directors, that operational issues cannot be departmentalized and must be treated as opportunities to increase productivity. The root source of the issue must be identified, and when necessary, policies or procedures developed to resolve the problem.
No lasting solution will be found to increase the productivity of surgery if the relationship between the OR and SPD is not sharing a common goal to ensure superior patient care.
When the instrument delivery process gets to this level of disarray, emotions are running too high to resolve the issues without senior level involvement. Senior administration will need to decide that regardless of where the problems exist, they will be resolved. To achieve this level of unbiased issue identification and recommended process change, it will typically require the assistance of a qualified outside consultant reporting directly to the senior administrator charged with resolving the reprocessing issues. The senior administrator selected must have the authority to deal with issues throughout surgical services with surgeons, OR personnel, and sterile processing personnel.
Solving the Problem
The first step is to recognize that instrumentation reprocessing is a process that involves a number of critical steps throughout a cycle that begins and ends at the point of use in surgery (see Table 3).
Each department and every individual that handles the instrumentation throughout this cycle must strive to achieve the same expected level of service. This level of service must be supported by senior administration and must be managed at each level of the reprocessing and use cycle. Often this does not mean throwing more money at the purchase of additional instrumentation; instead, it can often mean that the processes that are currently in place simply do not support an efficient utilization of the available resources. Mapping out the proper processes to facilitate higher utilization and developing policies that promote efficiencies can significantly improve instrumentation delivery. SPD personnel and OR staff must be trained in the proper handling and care of instrumentation. Proper handling can significantly reduce instrumentation damage that in turn reduces repair/replacement costs, and more importantly, increases instrumentation availability.
Finally, automation of tray contents and tray tracking can eliminate numerous human errors and provide a higher degree of consistency in the handling of instrumentation. In a case study conducted by Computerworld in 2005,2 the effects of an instrument management tray tracking system were measured for one year in a 325-bed teaching hospital. The results of adding automation were very impressive:
- Incidence of incorrect and missing instruments reduced by 50 percent.
- Training time for new SPD staff was reduced from 30 percent to 60 percent.
- Reduced full time SPD staff by one person while realizing a 6 percent increase in caseload.
- Manual instrument sterilization logs were replaced with real-time updates via handhelds.
Automation, however, regardless of the system selected, is not magic. As with any data processing system, total integration into the daily processes is essential to obtaining system benefits. Some of todays systems that have been designed specifically for this application do an excellent job both in integrating into daily processes and achieving a high level of usage compliance.
1. Broder BC. Sterile processing: the wheels that keep surgery centers moving. todays surgicenter. October 2002. Accessed at www.surgicenteronline.com.
2. 2005 Computerworld Honors Case Study: Surgical Instrument Management Reduces Surgery Delays and Drives Staff Productivity.