Putting the 'Process' in Sterile Processing

March 20, 2012
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Sterile processing department workflow "after." Courtesy of St. Joseph Medical Center. Sterile processing department workflow "before." Courtesy of St. Joseph Medical Center. Sterile processing assembly workspace "before." Courtesy of St. Joseph Medical Center. Sterile processing assembly workspace "after." Courtesy of St. Joseph Medical Center. Dave Norton, MSIE, MBA Jim Albert, AIA, ACHA, LEED AP Sterile processing floor plan, Phase 1. Courtesy of Hord Coplan Macht. Sterile processing floor plan, Phase 2. Courtesy of Hord Coplan Macht.
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When it came time to renovate the existing sterile processing department at St. Joseph Medical Center (SJMC) in Towson, Maryland, the project goals were twofold—to take the limited space available and make it more efficient while also applying a wholesale change to the department’s processes.

The design team at Hord Coplan Macht teamed up with SJMC’s very own Lean expert, Dave Norton, MSIE, MBA.

Norton, system process improvement facilitator for the hospital, joined SJMC in 2007, after working in the automotive parts industry for 37 years. He’s transitioned that knowledge base into a healthcare environment to improve patient flow and bring the Lean spirit of “Kaizen” —a focus on continuous improvement—to the table.

In terms of the sterile processing department, because the facility needed to purchase a new autoclave, Norton says an opportunity was identified to replace it and at the same time work to streamline inefficient processes.

“To understand the cycle time we have to understand that pretty much that cycle time took long enough that if we used an instrument today, without some level of heroics, we could not use it tomorrow. It would take us into tomorrow to get it cleaned and sterilized. Our goal was to be able to use it today and have it ready tomorrow,” he says.

Jim Albert, AIA, ACHA, LEED AP, principal and vice president at Hord Coplan Macht, says there were additional layers to the project, as well.

“In parallel to reducing cycle time, they really wanted to reduce errors in the case cart picking,” Norton says. “The third part was the area was actually slated to be completely remade in the next major expansion from the hospital in five or six years. They wanted to do this as a renovation focused on flow and throughput accuracy, without expansion and without major cost.”

Phase 1 of the project was completed in summer 2010, with Phase 2 expected to begin in spring 2013.

Recognizing flaws
Norton says he came onto the scene at SJMC just as planning was getting underway for the sterile processing project, so it was a natural fit for him to use his knowledge of process improvement as it proceeded.

“Walking into a hospital after running, designing, and being in factories for 37 years, it felt like going home, actually,” he says.

And immediately flaws in the department became obvious to his trained eyes.

“It was a logical way to run and apparently many sterile processing departments are run this way, but the process had basically been to clean the instruments and process them the rest of the way with assembly and sterilization on an as-needed basis,” Norton says.

What resulted is the instruments waiting for assembly would lead to congestion that came with its own risks outside of the inefficiency created due to stocking them in the middle of the process.

“Damage could occur, mixing of stock could occur, and—I don’t know for certain—but I was nervous that in a warm human environment, instruments come out warm, wet, and humid and sit for three or four days before processed. I’d rather get it sterilized and on the shelf dry, and be happy with that. From that standpoint, we basically focused on flowing the instruments as quickly and efficiently as possible,” Norton says.

Going Lean
“While the project inspired process changes, the physical space itself not only needed to be altered to permit those changes, but it also needed to be renovated within the existing space.

“One of my goals was understanding that this department is completely landlocked with no room for expansion in its current location,” Albert says. “I wanted to make sure we could design the space as well as possible so the individuals in the department have the workspaces they need.”

To that end, team meetings with staff members were held at the beginning of the design process to discuss errors and cycle times, and to brainstorm ideas on how to improve the space. Several of those same staff members remained involved throughout construction. Staff was also taken through a physical mock-up of the space prior to it being built, which also resulted in tweaks being made.

The renovated layout includes the addition of gravity feed conveyors between work areas with the goal of not letting the conveyors get backed up. “That’s one of the key Lean principles is being able to see your process,” Norton says. “It’s called visual control, and just having a simpler roller conveyor you try to keep clear allows the staff to self-direct themselves.”

This linear process means that instruments begin the sterilization process at one end of the department and never circle back around for any reason. “The space is open—you can see from one end to the other—and you can see where all the work is at each step of the way from any point in the space,” Albert says.

Another Lean principle incorporated is workplace organization through the design of four identical assembly stations. “The emphasis was on identical. They have the exact workspace organization that allowed us to get a standard of work that’s done the exact same way every time,” Norton says. 

However, with that standardization also was built flexibility in the layout and utilities to allow, for example, a work bench to move a few feet one way or another without the need for major rework.

“I found in my manufacturing plants that in some cases, we went with very flexible air connections, power connections, etc., which allows you to adjust the process to fit inevitable changes that happen,” Norton says.

Working together
Albert and Norton say they each had to understand the limitations each other faced in the space and how Lean principles would be introduced and supported.

“Jim, in some cases, had to suspend belief, because we’re all taught in our MBA schools that bigger is better and the bigger batches you can run, the better. In Lean, the concept is flow the product and don’t have big batches,” Norton says.

For example, the two realized the need for smaller autoclaves to allow more flexibility to staff. However, the equipment industry itself doesn’t quite yet support this need, resulting in the department purchasing two large autoclaves instead of the intended four small autoclaves. The resolution to the challenge was found in introducing extra carts where staff can preload instruments to approximate a smaller lot size.

It’s processes like this that Albert says had to be recognized and then achieved despite space constraints.

“From those limits, we would work the space however we needed to around what the process required,” he says.

Even construction itself took plenty of coordination since the department had to be shut down for the renovation. To prepare for the three-week delivery schedule, sterile processing was outsourced while all the materials needed, from HVAC equipment to plumbing, was preordered and available to subcontractors immediately.

Efforts were successful, with SJMC meeting its goal of reducing cycle time by 50%, while also seeing a 30% improvement in quality, Norton says. “The challenge now is to both sustain our gains and to continue finding small incremental ways to improve," he adds.

Another accomplishment, though not previously identified as a goal, was an improvement in productivity, as well.

“From my perspective, I’m very pleased with it. It met the staff’s goals, and the space has made their jobs a lot easier,” Albert says.

For more information on St. Joseph Medical Center, please visit www.sjmcmd.org. For more information on Hord Coplan Macht, please visit www.hcm2.com.