Secrets to perfection - the perfect central sterile services department

3 November 2016

Practical Patient Care explores how to make the perfect central sterile services department (CSSD) in a hospital. We talk to Courtney Mace-Davis – who recently won a prestigious award for her work at University of Iowa Hospitals and Clinics – about her profession, its place in hospital management and her personal tips on building a successful and effective team in the CSSD.

“I cover the operating room CSS department, which supports house-wide clinics as well as 32 operating rooms,” Courtney Mace-Davis tells us from her base in Iowa City, where she works for the University of Iowa Hospitals and Clinics as departmental manager for its 732-bed site. “I also have direct oversight of our new centralised endoscope reprocessing centre. Our team consists of over a hundred people. Last year we processed over eight million items, and supported over 20,000 cases for the main operating theatre.” In other words, she’s pretty busy.

Mace-Davis’s background is not in medicine, but in quality control of manufacturing processes, before she moved into logistics for medical device companies, and eventually to hospitals. “My role has focused around compliance and improving quality. In the past two years, we have made many improvements in the areas of people, methods, machines, material and the environment, with the goal of building a strong foundation for quality systems.”

The International Association of Healthcare Central Service Materiel recently awarded Mace-Davis and her department for being “a team that is building confidence within their organisation with programmes that empower the team and the hospital to deliver the best in patient outcomes”. We ask Mace-Davis how one would go about that, and what steps her team take to facilitate this positive environment.

Responding to feedback

“We had, and continue to have, many opportunities for development – both individually and as a team,” she says, highlighting the theme of employee engagement and training. Encouragement and making sure that the team is able to work together harmoniously is imperative, Mace-Davis continues. “Measuring the right things and celebrating even the smallest of wins keeps us moving in the right direction.”

“We have made a conscious effort to make the connection to our patients by sending our staff to the operating room to observe surgeries, and we have invited patients to our department meetings to share their experiences.”

Engaging with feedback to find out if a patient has any particular qualms with their level of care and why this is the case is vital. CSS staff are not directly caring for the patient, but their role can make a huge difference. Medical negligence, human error and healthcare-associated infections are the third most common cause of death in the US, and a large chunk of those could be down to faulty equipment, insubstantial hygiene standards and other issues that come under a CSSD’s remit; it is no wonder they want to know where they are going right or wrong.

So when Practical Patient Care puts the question of what makes the best CSSD to her, Mace-Davis is somewhat daunted: “Wow,” she begins, “there are so many things that contribute to making a great sterile processing department. For us, education and department structure have been critical to our success. It is one thing to train someone on a task, but it is another for them to understand why each step is important, and the ramifications of an error. We have encouraged education, and our assistant manager teaches Certified Registered Central Service Technician (CRCST) preparation classes. As a result, the number of certified technicians in the department has increased over 400% in the past couple of years.”

“This is a rapidly changing profession,” she continues, “and one that involves many factors. Because of this, we have been very fortunate to have the support of our administrators in restructuring the department, including hiring additional staff. While there are certainly challenges with assimilating so many new people at once, the rewards have outweighed these challenges. We have hired an educator, a quality engineer, a lean coordinator,” Mace-Davis says, referring to the quality assurance discipline known as lean management that relates to root-source analysis of why things are not as productive as they should be or why the same faults and mistakes keep happening. The system stretches back to post-war Japan, which was keen to be as productive and cost-effective as possible to kickstart its manufacturing rebirth. It has since spread globally and moved from factory production lines to hospitals. The system has been a great way of using data analysis to show where and why certain elements of hospitals are going wrong.

Mace-Davis doesn’t linger on it though, with many more things to add to her list of changes: “We are creating systems for document control, risk assessment, product realisation, and equipment management, just to name a few.”

The right tools

When it comes to what Mace-Davis would advise for other CSS professionals and departments around the world, she looks once more to her background in lean management as an inspiration for how to achieve better results.

“My advice for others who are struggling with workload is to focus on data and fact-based decision-making. There are many great quality and process-improvement tools out there,” she tells us. “We use Pareto charts to help us prioritise.” Her team also uses Ishikawa diagrams to help consider what the potential root causes of issues are, and check sheets in cases where data is lacking. This style of diagram is also called a cause and effect diagram, as it shows the causes of a specific event and highlights trigger points in hospital processes where things continuously go wrong.

Mace-Davis believes in many other aspects of the so-called lean toolbox, such as ‘5 whys’ to challenge thinking and flow charts to better understand processes. “We also follow ‘plan-do-study-act’ (PDSA) as well as ‘define-measure-analyse-improve-control’ (DMAIC) to experiment with potential solutions and drive change. Using these tools and strategies helps to define what’s working and what’s not, as well as where to focus our time.”

She also recommends working closely with compliance and infection-prevention departments to learn more about what should be done, rather than having it relayed back to them in a meeting weeks, or even months, later.

Finishing off her advice for the perfect CSSD, Mace-Davis notes the growing appreciation for diversity. “Because there are so many valuable characteristics of a good CSS department, we are realising that we can learn a lot from other industries. Of course, we need clinical experts on our team, but we also need those with strong people management skills from any background,” she adds. “We can learn a lot about customer service from the hospitality industry, and manufacturing can provide great examples of process improvement and quality management systems. For the organisations that are adapting to this way of thinking and managing it correctly, this is a very positive move that will result in a stronger team and, ultimately, better patient care.”

An underrated department

Mace-Davis believes that CSSDs are the front line of patient safety, but that, as a profession, they have been misunderstood and underappreciated. “We hire mainly entry-level people into a complex environment with little or no training or experience, and expect perfection each and every time. Because of this, it is our responsibility to work with our teams to analyse our processes as much as possible. Focusing on processes instead of blame ultimately leads to fewer errors and a happier workforce.”

As an industry, things are getting better – but there is still a long way to go in terms of accurately reflecting the importance of this department in patient care and safety. Hopefully, with people like Mace-Davis sharing her expertise and hopes for the future, the situation for CSSDs will continue to improve.

Courtney Mace-Davis joined the University of Iowa Hospitals and Clinics as a lean management engineer in 2011 and, since 2014, has served as the manager of CSSD, where she oversees the centralised flexible endoscope reprocessing centre and sterile processing for the OR.

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