A Southern academic medical center contracted Compass Clinical Consulting for assistance with three pressing needs in the Sterile Processing Department: inefficient processes, poor quality practices, and a lack of strong leadership. The Interim was originally contracted to provide consulting feedback and expertise in the Sterile Processing Department, but the scope of this engagement was expanded to an interim leadership role once the Compass SPD expert arrived at the medical center and conducted an assessment of the situation.

Lack of Strong Leadership

Initial observation of the department revealed to the Interim that the Sterile Processing Department’s manager’s leadership style was not effective; a department of that size created many challenges that he did not have the capacity to solve. The Compass Interim provided daily feedback, including observations and best practices, to the manager, and provided a written report a couple of times a week to senior level management of perioperative services. The Interim expressed these hindrances within the department to leadership, and leadership decided to pursue new candidates to fill this OR manager role. The Interim temporarily filled this vacancy, and coached and mentored the newly appointed manager over the course of his engagement.

Leadership in the department were much more resistant to change. Standard work had not been created for the critical SPD functions. SPD leadership failed to fully engage with OR leadership for process improvement activities due to the perception that the OR leadership would be unwilling to assist in process change. As a result, SPD leadership were aware of industry standards and best practices but failed to implement them. These difficulties in communication and the different expectations of the leaders and the Interim presented initial barriers to change within the organization when the Interim arrived.

Inefficient Processes

This clear lack in leadership oversight included the failure to hold staff accountable to following processes. The Interim identified inefficiencies using the following:

  • Thorough capacity assessment
  • Leadership assessment
  • Instrument set utilization evaluation
  • Assessment compliance to best practice

There were numerous issues regarding quality in the instrument completion process. The Sterile Processing Department was not able to provide surgical instruments to the Operating Room in an efficient manner. Many instrument sets were completed and sent to the OR with missing instruments, or sets were assembled incorrectly. Staff were not assigned to specific work functions appropriately, and there were no adjustments made to address changes in work throughout the day.

Poor Quality Practices

Through observations, feedback from the OR, and data collection, the Interim identified the main issues in quality practices such as a lack of compliance with industry best practice, failure to follow AAMI and AORN standards, no regularly scheduled training/education for the staff, and lack of vendor compliance with best practices. He then made recommendations and put new processes in place to improve quality and monitor improvements.

Encouragement of Staff Drives Change

Surprisingly, the staff were very interested in process improvements. One of the tactics the Interim used with the staff was to have all the SPD staff rotate through the Operating Room. This action demonstrated to the staff the importance of their work related to patient care. Staff members’ engagement increased significantly once they realized they had a direct impact on patient care. In addition, shift huddles were implemented to provide education and feedback over their performance to staff in a timely manner. Prior to this, staff were only provided feedback at staff meetings once or twice a month. This change a positive atmosphere.


The Interim SPD Director identified barriers to the medical center’s current processes and made appropriate recommendations to tackle these problems. He developed a mechanism for data collection to identify opportunities for improvement.

The Interim’s expert assessment, open communication with staff, and diligent implementation of practices led to a multitude of positive results in the Sterile Processing Department such as:

  • Improved efficiency of the decontamination process
  • Decreased errors in instrument set completion
  • Restructured SPD leadership organization and accountability
  • Institution of training program for SPD staff
  • Institution of recruitment and retention program
  • Development of work flow redesign
  • Institution of standard work and shift huddles
  • Implementation of a tool to evaluate the number of errors made by staff

Additionally, quality standards and metrics were put in place and are being measured on a daily or weekly basis, with some recommendations by the Interim still ongoing. Although the Interim was originally contracted for consulting assistance, his expertise and guidance went further to make a more lasting impact on the academic medical center as an interim leader. The Interim initiated and led SPD leadership restructuring, which enabled the medical center to regain its stability and implement smooth, efficient processes in the Sterile Processing Department.

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