A Success Story
By Donna Baker

The first step in Performance Improvement is to find the opportunity so you know what needs to be improved. As in many areas of healthcare, opportunities for improvement can be subtle or glaringly obvious. At our facility, Christiana Care Health Services in Newark, DE, we encountered the latter situation.

Christiana Care Health Services is a suburban hospital with a 20-suite OR. The department has nine sterilizers within the three cores, which are designated as A, B, and C. In the fall of 1999, the operating room had approximately 12 closed containers for flash sterilization. The purpose of the closed container system is to provide sterile transport from the sterilizer to the sterile field. Staff members, however, reported that they used the containers without the lids because the chemical indicators placed inside the containers did not indicate they were safe and fully sterilized. Staff members were violating the principle of closed transport by not using the container lid.

Within the first month of my employment as Clinical Specialist for Surgical Services I was asked to determine why our closed container flash sterilizer system was not working properly. I used the FOCUS-PDCA model for Performance Improvement (Table 1).1 This model is used frequently in health care to identify and address areas that can be improved.

IMPLEMENTING THE MODEL
As a first step, I investigated the function and use of this product (ie. F in the model) which took my research in many directions. To determine why the chemical integrator failed in the container, I explored the area of integrators vs. indicators and how each functions, their sensitivity and specificity, and their cost. I also questioned whether there was a sterilizer dysfunction.

I read all the information I could find on sterilizers and their function, which led me to the recommendations of AORN and the Association for the Advancement of Medical Instrumentation) (AAMI). I spoke with clinicians employed by our sterilizer manufacturer, as well as experts employed by the container vendor on the physics of the closed flash system. After reading monographs, researching the literature and conducting personal interviews I concluded that the failure was in the flash container and not the integrator or the sterilizer.

To pursue this idea, I organized a team whose members included the clinical specialist and key staff members. We researched the subject to clarify our information. This exploration helped us better understand where our process was inefficient so we could decide how to improved the process.

As recommended by the vendor, the facility set up a preventative maintenance program for our container system. This maintenance program was planned and implemented in cooperation with the vendor. In addition to replacing the valves and seals twice per year, nursing staff members began a daily inspection for cracks and loose screws and cleaned and vented the valves. The development of this documented maintenance program has been successful in preventing failure of the container system. A very unreliable system has become a high-quality tool for the surgical team.

As is common, one opportunity for improvement quickly revealed another. AORN's "Recommended practices for sterilization in the practice setting" state that sterilizer loads should be traceable.2 This tracking mechanism can be implemented through a sterilizer log. Documenting the time, date, contents of load on the sterilizer tape fulfills this recommendation. Although the sterilizer log was posted daily on each sterilizer, it was apparent that not all loads were documented. A discrepancy occurred daily between the number of loads sterilized and the number of loads documented. Clearly, education on the subject of sterilization was necessary in our unit.

We quickly organized a staff meeting devoted to flash sterilization, the flash container system, and sterilizer monitoring. The meeting consisted of a pre-test and a short slide presentation on the principles of sterilization. To reinforce the material, the unit educator and clinical nurse specialist, who were costumed as a game show host and spokesmodel respectively, presented a fun game of "Sterilization Jeopardy." We awarded candy bars for correct answers, and the noisemakers we handed out, coupled with team spirit made this presentation an event to remember. The posttest scores showed a 60% improvement over the pretest scores.

RESULTS
A new awareness and understanding among staff members about all aspects of sterilization resulted in improved compliance. Documentation on the sterilizer log improved approximately 60% as well. Documentation was monitored daily, and staff members were encouraged to continue their improvement through e-mail messages and posters highlighting their success. When our compliance reached 100%, they were rewarded with a celebration party. Posttests and monitoring of documentation fulfilled the C of the PDCA.

In cooperation with the sterile processing department, we instituted improved sterilizer monitoring systems that met or exceeded AORN and AAMI guidelines. Staff members learned about the efficacy and necessity for adequate sterilizer monitoring and expressed an increased trust in our sterilization process.

In the technological world of the operating room, change is a constant. Staff member turnovers, the influx of residents and medical students, new equipment, techniques and procedures, as well as organizational modifications contribute to this culture of alteration, revision and adaptation. Expecting staff members to also change their longstanding, hard coded behaviors and practices can result in great resistance. Involving staff members in decisions to change and, especially, how to implement those changes, greatly reduces resistance, reluctance and mistrust in doing things the new way. Although the decision to comply with standards and policies cannot be negotiated, encouraging staff to plan and carry out the details achieves their buy-in and ownership of the project. Author W. Edwards Deming says, "Put everybody in the company to work to accomplish the transformation. The transformation is everybody's job."3 Every activity and detail is a part of the process.

Involving staff in performance improvement continues to challenge and motivate my practice. Their enthusiasm and commitment to quality care and positive patient outcomes continually encourage me. Whenever quality sags and processes breakdown, education continues to be the key to improvement as we act to hold the gain we have achieved. Understanding and knowledge are inseparable improvement partners. In our success story, staff members were able to accomplish dramatic improvement in process and practice through education, encouragement and participation.

Table 1:

References
1. Joint Commission on Accreditation of Healthcare Organizations, "FOCUS-PDCA model" in 2001 Comprehensive Accreditation Manual for Hospitals (Oakbrook Terrace, Ill; Joint Commission on Accreditation of Healthcare Organizations, 2001)

2. "Recommended practices for sterilization in the practice setting, " in Standards, Recommended Practices and Guidelines (Denver: AORN, Inc, 2002) 333.

3. Deming, W. Edwards. Out of the Crisis. (Cambridge, Mass: Massachusetts Institute of Technology Center for Advanced Engineering Study, 1986). 24.