Successful performance improvement - Clinical Innovations

AORN Journal, April, 2002 by Donna L. Baker

The first step in performance improvement is to find opportunities so you know what needs to be improved. As in many areas of health care, opportunities for improvement can be subtle or glaringly obvious. At our facility, Christiana Care Health Services in Newark, Del, 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 OR 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 the 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 integrators versus indicators, 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 about 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 in the integrator or 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 improve the process.

As recommended by the vendor, our 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, and contents of the load on the sterilizer tape or on a daily log 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 pretest 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 efforts through email 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 model.

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.