Training, pride play big role in staff turnaround
QI team eliminates central sterile delays
In September 1995, the administration at Children’s Medical Center of Dallas faced a major challenge in the central sterile (CS) processing department: Morale was low, absenteeism high, and performance was below average. Numerous errors in tray assembly were causing delays in the operating room. Compounding the problem was antiquated equipment that was failing regularly.
But just a year later, that same group of employees, now certified and motivated, stood before a hospitalwide leadership group to receive T-shirts that proclaimed: "Life in CS is the Best."
What happened here?
"It was simple but not easy," says Judy DeMario, RN, director of perioperative services at the 322-bed facility. "We focused on the employee as well as on his or her education."
The resulting quality initiative not only reduced the processing time for surgical instruments from eight hours to 4.5 hours, cut two full-time equivalents, and saved about 15% on instrument expenditures, but increased employee morale, she says.
DeMario was part of the improvement team that included the operating room materials manager, CS clinical manager, CS technicians, and a nurse consultant from Jarit Surgical Instruments in Hawthorne, NY. The team reversed physical work flow in the department, implemented flexible scheduling, and developed training, certification, and quality assurance programs.
To identify the challenges, Michele Kettwig, RN, RCST, CCSM, CSPDT, the Jarit nurse consultant, observed operations in the operating room as well as CS.
"By observing OR staff during turnover of suites, she was able to follow the process from the pickup of carts housing the contaminated instruments to the process through CS," says DeMario.
She identified these problems:
- Poor instrument process flow.
"There was no documented process for transporting instruments to and from the operating room," Kettwig says. "Plus the work area itself created bottlenecks, thus preventing timely processing."
- Lack of knowledge regarding instrument care and handling.
"Although stainless steel instruments don’t have to be gas sterilized, many of them were," Kettwig says. "This also created a 15-hour turnaround time."
Improper use of the small washer/disinfector was pitting and corroding instruments, she adds.
- Inexperienced CS management.
"Without a structured orientation plan and high competency-based training, the staff morale was low and absenteeism high," DeMario notes.
After identifying the challenges, the team met with the staff often. "We knew we were building a positive environment both physically and interpersonally, so we had to have buy-in and feedback," DeMario says.
First, the team made some changes that the technicians felt needed immediate attention. "We relieved the staff from blood transport duties and begin offering inservices right away," she says.
Second, the more experienced staff members were partnered with those less experienced. "We also discovered that two of the more experienced staff members worked together on the evening shift, so we moved one of them to day shift," DeMario says.
Next, they devised the following plan for delivering a quality product to the operating room.
- Change physical setup of CS department.
"We realigned how the instruments flowed from dirty to clean by relocating the assembly stations away from the decontamination area," DeMario says. "New lighted workstations replaced old tables."
Gas sterilizer replaced
Capital investments cost about $250,000: The old washer/disinfector that processed about four trays at a time was replaced with a tunnel washer that processes 12 to 14 trays simultaneously. The air handling system was upgraded and the ethylene oxide sterilizer (ETO) was replaced with an Abtox Plazlyte sterilizer. "Regulations regarding the use of the ETO sterilizer are stringent due to the toxic nature of the gas," DeMario explains. "But the new sterilizer uses a different technology and poses no danger to health care staff."
- Introduce flexible schedules.
Although the majority of the staff worked the early shift, the highest volume of sets to be processed came into CS during the evening shift. "So we changed the technician hours to stage the heaviest support from noon to 10 p.m.," DeMario says.
- Create OR/CS liaison.
This position supports the operating staff by organizing locations of instruments and acts as a resource for problem-solving. "I’ve worked in both departments, so I understand how important it is to have good communication between the two," Kettwig says.
- Define job description.
Outlining the job also helped staff to concentrate on the task at hand. "Previously, staff would have to stop assembling instrument trays when they were beeped for blood transport, and go pick up and deliver blood," DeMario says. "Then they’d have to come back to the set to remember where they left off. Now the stat delivery function has been removed entirely from this department."
The job description was also upgraded to require mandatory certification from the International Association of Healthcare Central Services Materials Management in Chicago. The training includes courses on microbiology, anatomy and physiology, reusables vs. disposable, quality assurance, distribution, sterilization, and inventory control.
- Provide an educational blitz.
Kettwig created an orientation manual and helped the team develop a competency checklist. "She also conducted multiple inservices that required return demonstration of complex trays," DeMario says.
A certified instructor from Houston provided a 12-week course on Saturdays. The national exam soon followed. "There was only one staff member certified before the course began, and now there are 10 certified technicians working in the department," DeMario says.
- Develop performance improvement program.
Lead technicians now collect and tally count sheets to identify any potential problem areas. Tray assembly productivity how many trays are assembled and sterilized and by whom is recorded on a log. "By comparing the number of trays per month, the staff productivity has increased by 50%, and accuracy has improved by 80%," DeMario says.
Lesson learned: Ask the expert
DeMario credits Kettwig for spearheading the effort. "When I saw her resume, I realized her experience enabled her to design effective strategies that would completely change how work was done in the department."
Her advice to others? "If you’re out of your league or overstretched, pursue help from outside the hospital," she says.
And last, but not least, invest in and recognize your staff constantly.
[For more information, contact Judy DeMario, Director of Perioperative Services, Children’s Medical Center of Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 640-8001.]
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