Forging a Patient Safety Alliance
By Kris Ellis
Central service (CS) and operating room (OR) personnelshare a common goal: the provision of excellent patient care and positive outcomes. Technologicalinnovation and scientific advancements have produced extensive change andevolution in both of these departments in recent years, to the benefit of each.For many facilities, however, communication and teamwork between them has becomestagnant. In these situations, leadership and commitment to change can make asignificant impact.
One of the biggest things I see in terms of communication issues is thatin ORs there have been so many changes procedures, instrumentation, you nameit, and I think sometimes they think that sterilization stays the same and hasthe same level of knowledge that it did 10, 20, 30 years ago, says NatalieLind, CRCST, CHL, educational director for the International Association ofHealthcare Central Service Materiel Management (IAHCSMM). We have made hugeadvances in not only our understanding of the sterilization process and thescience of sterilization, but weve also been challenged with instrumentationthat is a lot more complex, so I think sometimes theres a communicationbreakdown because what used to be an acceptable practice is not acceptable anymore, and that can be a real source of frustration for both departments.
Nancy Chobin, RN, CSPDM, SPD/CS educator for Saint Barnabas Health CareSystem in New Jersey, says lack of effective communication is an unfortunateissue that has developed in many facilities, but it must not be ignored. We have to work so closely together, we impact so dramatically on theoutcomes of patients that when we consider the amount of time that we spendnitpicking and finger pointing, we could really be using that to do somethingconstructive. You have to look at the root of it how did it get started? Inmy opinion, we have a problem because theres a misunderstanding of thecultures.
OR personnel have high expectations of sterile processing department (SPD)staff in terms of their ability to provide correct and complete instrumentation.Theyre in a high-stress environment, they need things done, and if theyredone wrong, theyre in the firing line, Chobin continues. They have totake it out on somebody, and oftentimes its the person in CS. Why didntthe CS person do it correctly? There are a number of reasons; what I find firstand foremost is that people lack proper training and education. If we dontaddress this issue, this problem is never going to go away.
ORs have a perioperative training program you dont work in the ORunless youve gone through that program. Why dont we do that in the CS?Chobin questions. I have good intentions when I hire you I start you in decontam with mybest person, and then third day on the job, two people call out sick, I havenobody to put with you, and youre on your own. Thats not only scary, butits dangerous.
Rose Seavey, RN, MBA, CNOR, ACSP, past president of ASHCSP, and director ofthe SPD at the Childrens Hospital in Denver, also accentuates the importanceof 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 thesesessions as well. For example, we recently had the bronch nurses come downand do a presentation on bronch instruments. We just figure out what the currentneeds are and try to get as many people involved as possible.
Efforts such as these have led to a good working relationship between the twodepartments at Seaveys facility. Theres a whole list of things that wedo and most of it involves meeting together on a routine basis and gettingpeople involved and not having everybody do instruments, just specific people inthe SPD, and then having each one assigned to a service.
One of the great things that we do here is were getting ready to have ourninth annual OR and SPD workshop. Its a one- or two-day conference and wehave 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 wecall a combined staff meeting, and you get OR and SPD personnel in there.
Barbara Trattler, RN, MPA, CNOR, administrative director of perioperativeservices at Long Branch, N.J.-based Monmouth Medical Center, which is also partof the Saint Barnabas system, notes that work groups can help in opening thelines of communication. For example, setting up a process improvementcommittee between the OR and SPD so that you have key players involved, and notthe managers. Managers need to be facilitators of discussion in planning theagenda and ensuring that the meetings take place, but the people who actuallyperform the work, so the SPD techs along with the OR staff, need to be at themeeting. What you do is you say, OK, were not going to point fingers, werejust going to discuss the issues. So if the issue is missing instruments, youcan talk about the process why are they missing, and how we go aboutreplacement, understanding why theyre missing whats our process? Canpeople look at each others work to determine how instruments could bemissing? Thats an example.
Chobin explains that an initiative to make SPD improvements in her systembegan last year with a paper she wrote for upper administration called ExtremeMakeover SPD. I did this because we have this OR initiatives project,where theyre making the ORs as efficient as possible theyre looking atroom turnover, personnel utilization, supply utilization, etc., and I sit onthat committee, and one day I said, You know, this is really great, but ifyou dont fix the CS piece, youre wasting your time. A secondcommittee was subsequently formed, with Chobin serving as co-chair withTrattler. The recommendations that I had made were that we, No. 1, revise allof our job descriptions, and upgrade all the positions to the same level assurgical technician, because if were ever going to get out of this, we needto attract a different caliber of people, and I dont mean that in aderogatory sense, but the people that we have been attracting for the past 40years 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 manufacturersinstructions, how do I change sterilizer settings, is this compatible itsa whole different world.
In addition to changing the job classifications, a career ladder was alsoproposed. In this model, when a new hire comes into the St. Barnabas system, he or she would begin as an attendant. When mastery ofcompetencies is demonstrated, the attendant would get promoted to the next step,technician, which includes a pay increase. Youre still not certified [asis required in New Jersey], and that means that you could be in that group for ayear and a half, or as long as it takes, Chobin explains.
After the technician passes the certification exam, he or she becomes aspecialist, which encompasses new responsibilities such as the ability to trainnew people and work independently. The next step is a lead technician, and this is someone who will assignwork and ensure accountability. We want 24/7 accountability in our department sothat on weekends and holidays when we might not have a manager, there still hasto be accountability were a manufacturing center, Chobin continues. With a lead technician, that person assumes that accountability but theydont have to get into the managerial things like hiring, firing, discipline,etc., they just write down what the problems are and the manager deals withthem. The fourth step is a supervisor because we do have some of our hospitals thatare large enough to have both a manger and a supervisor. We actually will have five steps in that career ladder, so well offerpeople a tremendous amount of personal and professional growth, and theres apayback for that because look at the time that were going to spend to trainthem we dont want to lose them.
To reinforce this point, Chobin describes a study she conducted in 1997 onthe 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 recommendsusing that money on training and salary increases. Youre going to savemoney, she concludes. Chobin also emphasizes that the training process shouldbe able to accommodate different learning styles. You can really lose out onsome good people by forcing them into a certain mold. You need to work with theindividual and meet their individual training needs.
Seavey contends that SPD managers should make the effort to empower theiremployees 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 onceevery six months or so to actually see a surgery case, and hopefully its onewhere theyve picked the case cart or done the instruments. We also require new OR staff to spend a week in the SPD where they work withcase carts, instruments, and decontam.
Whats imperative for a good relationship is that both departments needto understand what the other does, Trattler says. So the OR personnel, aspart 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 needto be in the room observing the procedures, learning how the instruments areused, so that they understand why the surgeon gets upset when the forceps dontline up, or when the scissors are dull. Then they can understand how thatfrustration filters down to the SPD.
Seavey also points to the importance of the perioperative services operationsteam (PSOT) at her facility, which includes herself as the SPD representative,as well as administrative staff, surgeons, nurses, anesthesia personnel, and abusiness manager. A lot of things are taken care of at that level, shesays. Having a voice at that level really helps. I think many places donthave that; I hear a lot of SPD supervisors saying the OR doesnt listen. Youhave to make it happen you need to be visible. You cant sit back andexpect them to do it.
I think a lot of hospitals are really trying to bridge that divide andthey do it in a lot of different ways, Lind says. I know some hospitalshave specialty teams in their OR an ortho team or a neuro team, and theywill have CS technicians who work with the team, not in the OR, but in helpingto get things set up and work on problems with instrument sets, things likethat. Simple things, Lind adds, can go a long way toward strengthening thesense of community and camaraderie between the two departments. I think thebest 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 otherdepartment to stop over during their coffee break just so they can put the facewith the name, she says. We talk on the phone all of the time butoftentimes we dont know who that person really is. Something as basic as thatcan 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 facilitatesunderstanding of whats needed in the OR and what needs to be turned over tofacilitate the schedule. Amongst the employees of the department shellidentify that the instruments from the first case need to be turned over for the fourth case, for example, sothe staff downstairs know that as soon as those instruments come down, they haveto go through the decontamination process and then get assembled and put in thesterilizer.
Lisa Huber, CRCST, sterile processing director at Maryville, Ill.-basedAnderson Hospital, explains that a busy orthopedic practice with only one groupof surgeons at her facility prompted a new and effective approach from CS. Whatwe 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 teardown the cases so that instrumentation goes to her and then comes to us, shesays. Sales reps also communicate directly with her, so if something breaksduring a case and they have to take it out or if theyre expecting loanerinstrumentation for a case, she is the gatekeeper for all of that. If theorthopedic surgeons are happy or unhappy about anything the way aninstrument 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 notonly increased visibility, but also a better reputation. Were there aspart of the orthopedic team, and we make fewer mistakes because we have betterinformation. Thats our big push to improve the relationship, and we knewit fell on us to do it. Its really been successful for us.
How did the pieces fall in place to facilitate this accomplishment? Hubersays 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 theprocess back rather than move it forward, Huber explains. I have to admit it was just sheer luck that someone becameavailable with a great deal of experience, an impeccable work ethic and workrecord, and she really has taken the job and made it her own and has reallyforged this alliance. We talked about it for a long time and we did interviewseveral people. There were questions about whether or not each of them wouldwork; we would have one person with the right temperament but not the rightexperience, or someone with the right experience but couldnt work the rightflexible hours they all had just a piece of the puzzle, so we were willingto wait until we found the right person.
Trattler maintains that a good first step toward improving relations is totry and find one person from each department who can be a champion. Themanager would have to say I really need your help on this, would you try tobring the group together. They can talk about what the problems with therespective departments are.
Identifying the right people is critical. You want to find a person who ispositive, who has support; the managers have to support it, otherwise it willfall through the cracks, Trattler continues. The staff usually cant dothings 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 andanticipate what the issues are. In each department youre going to have acouple key people who are very positive and those are the people who youregoing to want to tap into to be your champions.
Trattler underscores the fact that change doesnt happen overnight, andthat relatively basic issues should be tackled initially. For example, saythe SPD doesnt get the schedule until very late in the day, so maybe the ORcan give them a draft schedule earlier so they can begin to anticipate whatsneeded for the next day, she offers. If the two departments are reallyheated and cant talk to each other, then you need to find a facilitatorinternally. Youd look for a resource who can bring the managers together andassist 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 trackingsystem has been a key component in the effort to repair and optimize SPD/ORrelationships and processes. Effective tracking systems offer the potential toestablish 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 youve got accuratecontents trays, case carts, and so on, Myers says. So were ensuringaccuracy on the front end in sterile processing, which carries over into assuredaccessibility in the OR.
This means OR personnel are also able to locate a cart or instrument at anytime. Thats where it helps the communication SPD personnel start to getcredit for the good job theyre doing, or alternatively if theres an issue,it can be identified and addressed appropriately, Myers continues. In theOR, once things are accurate and accessible, that trust factor is established,so when they are looking for something, they know that it can be locatedquickly.
Myers notes that this type of system can also be valuable in the trainingprocess for SPD staff. Its a tremendous training tool. Techniciansnavigate with touch-screen monitors you have images of the instruments, andif youre managing all the way down to the instrument level, unique bar codeson the instruments allow you to scan and electronically confirm that its thecorrect instrument.
While using a tracking system may seem like a drastic departure from somehospitals standard procedures, it can be implemented with a simple, phasedapproach, Myers explains. Our approach is really a phased and scalable one.We have facilities using our system at various levels of detail. We havecustomers who start by just managing their count sheets. From there, its aneasy transition to tracking and managing at the tray level, and finally we havethe customers who manage their instruments on an individual basis with uniquebar codes. Implementation and training can last from two weeks to two monthsdepending on the scope of the install.
Once successfully instituted, a good tracking system can demonstrate itsvalue in many other areas as well. Our system isnt just for sterileprocessing, Myers says. We refer to it as a comprehensive solution that can be deployed anddeliver benefit in sterile processing, the surgical services suite, materialsmanagement, and the area of infection control. There is value in using our system in all of thoseareas.