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By Kent A. Pedersen
How do you recognize when it is time to take a hard look at your sterileprocessing department (SPD)s productivity? There are three big indicatorsthat your SPD may be in trouble. The No. 1 indicator that problems are on therise coincides with an increase in physician complaints. The second is an apparent uncontrollable increase in repair/replacement costsof instrumentation. The third significant development is an obvious increase in stressedrelations between operating room (OR) personnel and SPD personnel. This can beespecially pronounced when the two departments report to different departmentheads.
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 ofinstrumentation. However, surgeon complaints can serve as a barometer ofpotential problems. Late surgical starts and delays during surgery, either dueto missing or inoperative instrumentation, will almost certainly insure visitsto senior administration by the operating surgeon.
Regardless of the root cause of these problems, which are most often processrelated and involving multiple sources, it is the SPD that it is looked upon toprovide the controls necessary to prevent these problems from occurring. It isimportant for the hospital administration to have a clear understanding of thedemands that are placed on the SPD. According to Bryant C. Broder, formerpresident of the American Society for Healthcare Central Service Professionals(ASHCSP), Even though sterile processing departments are instrumental inrunning an effective and efficient surgical department, they are often the mostoverlooked area of the surgical theatre both in surgical centers and in hospitals.1
Instrumentation reprocessing and delivery is a complex service requiringefficiencies throughout the cycle of use of instrumentation to deliver qualitycomplete sets to surgery. Each stakeholder in the process shares a responsibility and a role in thedelivery of instrumentation for surgery. If surgery nurses returninstrumentation to the SPD with heavy instruments on top of delicateinstruments, sets jumbled without organization, and identified damagedinstruments mixed with functional instruments, the result will most likely bedelayed 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 criticalneed to have all stakeholders managing with one consistent set of expectationsof performance. If the surgeons expectation is that every instrument must be available forevery case each time a case is scheduled, regardless of surgical volume, thenthe 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. theperformance expectations of the SPD, are not aligned. Sometimes the expectationsdo not align simply because the two parties never discussed the needs vs. theachievable deliverability (see Table 2).
There are few sterile processing departments that simply do not want todeliver the level of service required to optimize patient care. Instead, it ismore typically a situation where either organizationally or financially thesurgeon expectation cannot be met without changing either cross-functionalresources or the investment in instrumentation or both.
Cross-Functional Roles and Responsibilities
An uncontrollable repair/replacement budget for instrumentation often pointsto significant process control issues. Rather than effectively addressing rootinstrumentation issues, the quick solution is to simply buy more instrumentationor increase repair budgets to try to keep instrumentation functional. Anout-of-control repair/replacement budget should be an immediate signal that theprocesses throughout the cycle of use of instrumentation are broken and requireimmediate attention. To be effective, these processes may require significantretraining in the OR and SPD to instill lasting positive change.
The delivery of accurate functional instrumentation for optimal patient careis not the responsibility of a single department. All surgical servicespersonnel must participate to have a reproducible model providing the rightinstrumentation, at the right time, in the right quantities. Stakeholderownership begins at the site of use by the surgeon. The surgeons preferencecard identifying the specific needs for the procedure has a tremendous bearingon instrumentation availability. Surgeons who request more than is necessary fora procedure both increase instrumentation inventory needs and increase theburden on the system for reprocessing of unused instrumentation. OR nurses whodo not restring instrumentation and/or fail to place instrumentation back intothe pans in which they arrived, add significantly to the reprocessing time in boththe decontamination and prep and pack departments. Decontamination and prep andpack departments that fail to follow manufacturers recommended reprocessinginstructions can cause unnecessary damage to instrumentation, thus reducing itsavailability for scheduled cases. The cycle of use of instrumentation canperform very effectively when all stakeholders assume ownership andresponsibility.
Finger-Pointing is Evidence that a Real Problem Exists
Stressed relations between OR and SPD personnel is the result of directors ofeach area permitting finger-pointing when issues arise. Once this practice ispermitted to occur, the working relationship between these departments quicklydeteriorates. Surgeons lose their temper and call senior administration, demanding thatinstrumentation problems be resolved. OR nursing staff blames the condition ofthe instrumentation sets on the SPD. In turn, the SPD contends that largepercentages of instrumentation are being returned to decontam unused (indicatingprocedures are being over-instrumented) and those instruments that have beenused are jumbled together without concern for proper handling or reassembly. Itmust be recognized by both departments, and enforced by the departmentdirectors, that operational issues cannot be departmentalized and must betreated as opportunities to increase productivity. The root source of the issuemust be identified, and when necessary, policies or procedures developed toresolve the problem.
No lasting solution will be found to increase the productivity of surgery ifthe relationship between the OR and SPD is not sharing a common goal to ensuresuperior patient care.
When the instrument delivery process gets to this level of disarray, emotionsare 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. Toachieve this level of unbiased issue identification and recommended processchange, it will typically require the assistance of a qualified outsideconsultant reporting directly to the senior administrator charged with resolvingthe reprocessing issues. The senior administrator selected must have theauthority to deal with issues throughout surgical services with surgeons, ORpersonnel, and sterile processing personnel.
Solving the Problem
The first step is to recognize that instrumentation reprocessing is a processthat involves a number of critical steps throughout a cycle that begins and endsat the point of use in surgery (see Table 3).
Each department and every individual that handles the instrumentationthroughout this cycle must strive to achieve the same expected level of service.This level of service must be supported by senior administration and must bemanaged at each level of the reprocessing and use cycle. Often this does notmean throwing more money at the purchase of additional instrumentation; instead, it can often mean that the processes that are currently in placesimply do not support an efficient utilization of the available resources.Mapping out the proper processes to facilitate higher utilization and developingpolicies that promote efficiencies can significantly improve instrumentationdelivery. SPD personnel and OR staff must be trained in the proper handling andcare of instrumentation. Proper handling can significantly reduce instrumentation damage that in turnreduces repair/replacement costs, and more importantly, increasesinstrumentation availability.
Finally, automation of tray contents and tray tracking can eliminate numeroushuman errors and provide a higher degree of consistency in the handling ofinstrumentation. In a case study conducted by Computerworld in 2005,2 theeffects of an instrument management tray tracking system were measured for oneyear in a 325-bed teaching hospital. The results of adding automation were veryimpressive:
Automation, however, regardless of the system selected, is not magic. As withany data processing system, total integration into the daily processes isessential to obtaining system benefits. Some of todays systems that have been designed specifically for thisapplication do an excellent job both in integrating into daily processes andachieving a high level of usage compliance.
1. Broder BC. Sterile processing: the wheels that keep surgery centersmoving. todays surgicenter. October 2002. Accessed at www.surgicenteronline.com.
2. 2005 Computerworld Honors Case Study: Surgical Instrument ManagementReduces Surgery Delays and Drives Staff Productivity.