Beyond the Surface: How a Simple Audit Transformed Sterile Processing Across a Health System

When a Joint Commission visit revealed opportunities for improvement in instrument care, sterile processing educators Anna Castillo-Gutierrez, CRCST, CSPDT, CHL, CIS, CFER, and Maya Luera, CRCST, CIS, CER, CHL, sterile processing educators for Texas Children’s Hospital responded with a comprehensive audit—and uncovered far more than expected.

What began as a tool to reduce staining, scratching, and instrument damage evolved into a systemwide initiative that exposed hidden mechanical issues, product failures, and overlooked educational needs across multiple campuses. Their findings not only strengthened processes and equipment reliability but also highlighted the critical value of education, communication, and systemwide accountability in sterile processing.

To learn more, Infection Control Today^® (ICT^®) spoke with Castillo-Gutierrez and Luera about their presentation at the conference.

Anna Castillo-Gutierrez, CRCST, CSPDT, CHL, CIS, CFER:Our poster presentation is about an audit we created after our Joint Commission visit. They identified a couple of things that were necessary findings, but there are things that we could improve upon and mitigate, and so we implemented the audit to help reduce some of the things, such as scratching, hitting, staining on instruments, and wretched instruments.

Maya Luera, CRCST, CIS, CER, CHL: With the audit, the data was able to identify what areas needed the education and what kind of education they needed. We also were able to identify underlying issues that you know staff and end users don't have control over, and we're able to improve on those and act on them faster.

AC-G: So things such as just mechanical issues on the washer, disinfectors or maybe the chemical dosing wasn't set or adjusted correctly, we were able to identify those pain points in the audit to help streamline the processes for the rest of our staff, things that they couldn't control.

ML: Another thing was we had some products that were available for staff that were just failing them, and so we were able to remove those from the inventory and find a better product for them.

AC-G: So, ultimately, the audit was to find things we could improve upon and help us mitigate concerns we were seeing trends in as well.

ML: With the audit, we could also identify the responsible parties and let them know. We all have eyes on instruments, so everyone should know how an instrument is so critical. Finding what education we should give them.

AC-G: That was for the entire facility of [Texas] Children’s, not just that one location, but all the locations.

ICT: What are the key takeaways from your presentation?

AC-G: For me, one of the key takeaways was that the audit was initiated us to mitigate the issues that we already had. Still, the audit helped us identify even deeper issues, for example, our water quality and chemistries we're using. They were either imbalanced or ineffective, or maybe damaging other instruments that we weren't aware of. The audit started to help streamline processes and things like that. What we did in time for it to do was identify deeper pain points that we could then mitigate. And that was just the awesome results of the audit.

ML: I think for me, one of the great things that I took from it was [that] we started to see a trend, like, we get education. We saw that our audit compliance went up. And so for me, I think that was the biggest thing that I got out of it. We were able to identify that education is so important, and that's our role, our heart. So, to get that out to the industry, you need to open those positions for educators.

ICT: What is currently the biggest challenge for sterile processing departments?

AC-G: The biggest pain point that I saw in the audit is the uncontrolled things. For example, many times when we do these audits or even when we get called into the operating room and they're telling us, “Hey, there's, there's some hole in here,” I think there's a lot of finger pointing that happens initially, and this audit helped us to identify things that were not in the control of our staff. And we're seeing that there's an elevated, there's a higher number in those concerns that are out of the control, that educators our leaders can help mitigate so that we stop the finger pointing to the staff because often times it's not things that are in their control. It's more of the chemistries, the sterilizers, the washer disinfectors, things that are not working in sync with our staff. There are staff who try to do the right thing [oftentimes], but it's just the equipment that fail us. So that was my biggest thing that I saw as a pain point: we are seeing trends in more of the equipment and the products we use than in user errors that we see.

ML: The biggest pain [point] for me is having the other areas understand the criticalness of instruments they rely solely on SPD; we're human. We make mistakes, and there are some things that we don't have control over, that we're identifying. So, we need to have them understand that the the instrument gets to us before it gets to the patient, and we need to take responsibility for it. Then, as a medical staff, they need to understand the importance of critical care for critical instruments.

ICT: What is the best part about attending the HSPA Annual Conference?

AC-G: I love the atmosphere. I love the collaboration and the camaraderie. I just, you know, we come to these events, we're able to refocus, we seek ourselves. We leave that energy back to going back to our facilities, and we just have that aura back, that we were looking for because we know that it's a hard job to continue doing, so this is kind of a refreshment for us.

We go back and put 100%, 120% back into our facilities, and we're ready to get going again.

ML: What I like the most is hearing the updates and what HSPA is doing for us. They get to hear our voice here. Throughout the year as well, they send out surveys to see what we need help with, but it's touching to me when I can walk up to this president and say, “Hey, I love what you're doing with this industry. I love how you're aiming it, or this is what we need.” And so, for me, having that one-on-one, that face-to-face, is important. If you haven't been, I would welcome you to come. It's a great opportunity. They also have the Expo. You get to meet vendors, and you can find, if [there are] products that are not working for you, they're here. Then, I also met new people and networked. You can find the resources that you need. It's a good opportunity.

This interview has been edited for clarity and length.