I still remember my first day in Sterile Processing.  I had just finished my 400 training hours, passed my certification test, and was hired by the facility that I had been volunteering at.  After a brief tour of the SPD & Operating Room, I was left with an O.R. nurse and taken into one of the operating rooms.  They briefed me on the sterile field and aseptic technique and I stood quietly in the corner trying not to touch anything.

Then they started opening a Laparoscopic Instrument Set, and pointed out that it was my initials on the label.  My heart dropped and I started trying to remember when I had done the set.  Maybe a week ago?  Or two?  Did I include all my indicators?  Did I perform the insulation testing on all the sheaths?  Did I test the sharpness of the scissors?  Did I remember to check the bipolar tip?  My heart was pounding and I wiped sweat from my forehead.  This was a real human being on the table.  He had smiled at me nervously as he was wheeled into the operating room.  And I couldn’t remember doing the set & whether I had done a good job.

I would later find out that this was a test from my new boss.  Every new SPD tech was taken into an O.R. on their first day and had one of their sets opened on a case.  The reason was to demonstrate the impact that our job can have on a real person.

Lesson learned.

I did fine.  No mistakes with the tray, and the case went smoothly.  But I never forgot that feeling of questioning myself.  My perspective had shifted.  And in the 12 years I've been in Sterile Processing, I have never felt that level of uncertainty on a tray again.  In SPD, it is always Quality First.

I was lucky.  I had a boss who was well versed in Sterile Processing and knew how to teach us the importance of what we do.  I had an experienced educator who had guided me through the certification test, and was a mentor and role model in this new career.  I knew the importance of quality in Sterile Processing, and what I did every day was connected to that patient on the table.

So when I accepted a position at another facility five years later, I did so because I wanted to move up into leadership and knew that I would have a better chance at a larger facility.  It was also closer to home and family, and I was excited about the move.

At first, things were amazing.  The department was fully staffed, and the relationship between the O.R. and SPD was collaborative and pro-active.  O.R. had absorbed the SPD staff and we had joint meetings and daily huddles.  Our Quality Assurance (Q/A) audits were always in the 97% or above range, and with the thousands of sets being processed per month, that was an impressive feat.

When our Manager stepped down (a former O.R. nurse who was well versed and trained in Sterile Processing), we were saddened, but didn’t fully realize what was to come.

Our new Manager took over a couple months later.  He had a business degree and was experienced in the Warehouse/Shipping world.  His initial job was as a Materials Manager, but as part of a hospital restructuring, Materials Management took over control of SPD from the O.R. and he was promoted to Director.

Nothing too much changed at first.  He sent some memos about the tardiness and absence policy.  Typical new Director stuff.

Then came the budget cuts, and his agenda became clear.

One of his first major mandates was to cut SPD staff hours from 8 hours per day, to 7.5 (from 80 to 75 hours per pay period).  He eliminated overtime, unless approved by a supervisor.  Our paychecks got lighter.

This caused a few techs to leave the department.

He decided not to re-hire their open positions.

A few months of short-staffing started causing burnout among the staff.  Several more quit.

He decided not to re-hire their positions either.

Within 2 years of him taking over the SPD, the number of certified techs dropped from 23 to 15.

So how were things getting done?  There were 8 fewer people to process all these instruments, scopes, and sets.  Well, our boss had a solution.

Increase productivity.

He posted a list of our department productivity separated by shift.  He encouraged us to push ourselves to process 8 trays per hour, as that number would get us closer to 100% as a department.  Some techs found a loophole in this “8 trays per hour” suggestion, and started processing the smaller, easier sets.  Which would then leave the larger, more complicated trays for the rest of the staff.  The shifts started fighting with each other, pointing to their productivity numbers as proof that they were working harder than the other shifts.

More techs left.  Their positions were not replaced.

By this point, I had moved up into management.  I was in charge of our computer tracking system, purchasing, repair, and instrument budget for the department.  Because our department had eliminated the educator position, I did as much as I could in that area as well.  After researching our Quality Audit data, I noted that over a 6 month period as we were losing staff, our Quality Audit numbers had been steadily dropping:

December: 97%

January: 96%

February: 93%

March: 81%

April: 77%

May: 64%

The drop was drastic and frightening to me.  We had consistently been at 97% or above for so long, that to see 64% was shocking.  We were opening fewer sets for our audit program because everyone was trying to keep up with the workload, so the mistakes were piling up in the O.R.  Nobody could afford to spend valuable productivity time on the audit program anymore.  There were hundreds of sets per day in the department, and 1/3 fewer people to process them.

O.R. satisfaction tanked.  The relationship between the two departments became contentious because the trust was broken.  We were missing turnover deadlines, and the errors in our trays caused case delays.

And patients suffered.

I kind of understand where our Director was coming from.  Even though his employee satisfaction scores dropped, his bosses were constantly rewarding him for his quick and decisive actions to lower costs in the department.  He was praised by the C-Suite as being a shining example for lowering costs and improving productivity.  At a leadership meeting I remember he touted that our department was being used as a fiscal example to all the other SP departments throughout our health system.  We were saving millions of dollars doing things his way, and they were using his plans as the bluprint to run dozens of other departments.

I decided it was time to take action.  Despite my concerns, I had been waiting to see how this new Director would acclimate to Sterile Processing.  He told us that he was going to get certified.  Two years later, he never did.  I stayed through the lean years of staffing, the increased workload, and out paychecks getting smaller.  And on a personal level, I liked the guy.  He was a brilliant businessman and I learned a lot about the business side of our industry from him.  I still use some of the Excel tricks he taught me.

I sent him an email showing him the chart of our declining quality numbers.  I showed him the schedule of staff from 6 months previous and how the drop in quality was in direct response to the drop in staff.  Fewer techs = Lesser quality.  I told him that the posting of productivity was having a negative impact on both our Quality Audit numbers and employee satisfaction.  I could easily process 12 Circumcision trays per hour, or I could do 1 Maxillofacial tray.  My time was full either way, the Maxillofacial tray had hundreds of difficult to identify instruments in it.  But giving techs a benchmark of 8 trays per hour was not realistic.  It would depend solely on the individual trays that were needed.  I was professional and respectful in my disagreement with his policies.  I requested a meeting to discuss how we could start making positive changes.

He wasn’t happy.  He did not respond to my email, but sat me down for a chat in his office.  He told me that you can have increased productivity and increased quality.  The two were not mutually exclusive. 

I brought in my Quality Audit data.  I showed that cutting staff and increasing productivity had a direct negative correlation on our quality numbers.

He disagreed.  He said that our department was more than fully staffed.  If you compared our staffing to other departments in the health system, we had more than any other hospital.

I asked for clarification.  How was he measuring this?

Total hospital patient discharges.  In other words, the number of patients discharged from the facility on a daily basis.

He was not basing our staffing on the number of sets we processed per hour, or per day.  Not basing even on the O.R. case schedule.  Hospital patient discharges.

I asked him to reconsider, but his mind was made up.  His bosses were happy with him, and he didnt see the need to divert from his current course.  Not when he was doing such a good job that he was promoted from Manager to Director and given extra departments to manage.  Not when his department was being used as an example of fiscal responsibility throughout an entire health system.

After the meeting, I reached out via email to the SPD and O.R. leadership teams and shared my data and concerns with them.  There was very little response.  Mostly meetings and empty words of wanting things to get better.

My relationship with the Director was never the same after that.  He did end up removing the productivity numbers from the wall, but he also discontinued the Quality Audit program entirely.  He could not be blamed for poor quality data, if there was no quality data.

Eventually, I took a job at another facility.  After 12 years in Sterile Processing, it is the only department I ever left in a worse place than when I found it.

From time to time, I think about that situation.  I wonder if there was more I could have, or should have, done.  I wonder if my boss feels that he did the right thing.

From time to time, I think about the man on the gurney who smiled at me as they wheeled him into the Operating Room.  I think about how vulnerable, exposed, and dependant a person is when they are put under anesthesia.  How they rely on surgeons, nurses, techs, and SPD professionals to all have done their jobs with 100% confidence.

And I wonder if the fundamental difference between a good SPD manager and a bad one, is that perspective.