Infection Control Today - 10/2003: OR Topics

Fostering Teamwork Between Sterile Processing and the OR

By Tina Brooks

The friction that sometimes exists between the sterile processing department (SPD) and the operating room (OR) is a historical phenomenon, ubiquitous in the healthcare industry.¹ Fostering teamwork, however, can be instrumental in bridging the gap that often exists between these two departments.

SPD and the OR

Although the SPD and the OR have a special relationship that directly relates to patient safety and the success of surgical procedures, their responsibilities are quite different.²

Today, it is recommended that the operating room deal with the patient and do surgery and central sterile deal with all of the cleaning, decontamination and sterilization, says Nancy Chobin, RN, CSPDM, CS/SPD educator for the Saint Barnabas Healthcare System in New Jersey.

Chobin notes, however, that this arrangement often causes what she affectionately calls the Hatfields and the McCoys. The cultures are very different, she says. The operating room deals with people. We deal with widgets. And, thats a big gap. A truly chaotic atmosphere and disparate goals in the SPD and the OR are often further spurred on by misconstrued notions on both sides.³

Both departments often dont appreciate or have a full perspective of what the other departments responsibilities are, for the organization, the patients and the physicians, says Barbara Trattler, RN, MPA, CNOR, CNA, director of orthopedic services at Atlantic Health System and director of surgical services at Mountainside Hospital in Mountclair, N.J. That creates turmoil. The OR is usually a demanding, high-volume, quick-paced environment. So, if they need something, they expect to have it.

On the other hand, Trattler says SPD tries its best to perform its job responsibilities, meeting all of the regulatory requirements for the proper cleaning, decontamination and sterilization of surgical instruments.

Trattler and Chobin both worked with the department of health in New Jersey, bringing together perioperative and sterile processing directors to develop guidelines for instrument processing which were eventually taught throughout the state. New Jersey has put forth a regulation that all SPD workers need to become certified.

Teamwork

The dynamics of the healthcare environment today are such that it puts pressure on every department in the hospital in terms of the quality of service and the timeliness of service so each hospital can be competitive, deliver the highest quality of care and have the best possible outcomes, Trattler says. So, the OR and SPD working together is really critical to the success of an organization at being able to do just that.

Teamwork means caring for and about people. Intelligent caring takes enormous energy and the ability to share knowledge, communicate effectively and monitor performance.⁴

Teamwork can be viewed as a strategy by which both departments benefit, but more importantly their organization.

Through the evolution of quality improvement work in healthcare systems, it is increasingly apparent that coordination of care is a far more common source of errors or poor quality care, than are actual knowledge deficits, says Jane Brock, MD, MSPH, associate medical director at Colorado Foundation for Medical Care (CFMC) in Aurora. It is rare that poor care results from the carelessness or inadequate knowledge of a single individual. A hospital is a very complex environment that depends on the timely interaction of many persons and departments.

During the past year, CFMC, a quality improvement organization, has become increasingly interested in understanding and promoting teamwork functioning in the multidisciplinary interactions of hospital departments. CFMC is contracted by the Centers for Medicare and Medicaid Services to assist medical providers in supplying ideal care to Medicare beneficiaries.

Brock says, In healthcare, we have a long history of segmenting job responsibility, both by provider type, nurses vs. doctors vs. respiratory therapists, etc., as well as by department. But you cant have quality care without coordination of care. So although different members of the healthcare team will always have different job responsibilities, no one individual or department can really deliver quality care without effective teamwork with all the other providers involved in the patients care. The patients experiences of the entire continuum of care is the only real measure of quality, and every player, even the attending surgeon, is a cog in the wheel. Some cogs are clearly bigger than others, but if they dont mesh together, there will always be problems. Most hospital workers really have the same goal in mind: ideal patient care and patient satisfaction. Every department has a part in that. In promoting the teamwork concept we are taking all the lessons we can from the very impressive improvements in aviation safety, where teamwork training is required for all members of the aviation team.

For example, if there is a delay during a surgical case while someone gets the right instrument or re-sterilizes something, the patient may experience an unnecessary prolongation of anesthesia, which increases her risk of an adverse event and prolonged post-operative recovery. The next scheduled patient, who is waiting for his procedure NPO, waits longer. The natural course is for people and departments to start blaming each other. The surgical team may feel central supply is putting them in the position of delivering substandard care by making them wait for instruments. The SPD team may feel that the OR team springs surprises on them way too often, which puts them in the position of appearing to deliver substandard performance.

Brock continues, But what everybody should be thinking about is how to change the interaction between the OR and SPD to prevent this problem from happening again. Even more to the point, the departments should look together at whether or not there is an unacceptable risk of OR delays built into their usual system of delivering operative services through the acceptance of poor communication between these two departments. The focus needs to be on figuring out how to foster teamwork between departments so that everybody looks good, rather that figuring out who did what well, or who may have made a mistake.

Creative Approaches to Teambuilding

Any investment in teambuilding must be linked to the goals and objectives of the two departments to be truly successful. There are many different team-building strategies to select from, however, Brock has found these to be beneficial:

• Stop the culture of blame and get everyone to start being part of the solution.

• Raise awareness of the other departments pieces of the continuum of care, and how to reduce barriers to ideal performance.

• Construct some type of formal process that includes formal proscribed communication modes, to do future work.

• Train all participants to appropriately assert themselves when they detect problems. An important part of assertion is to train those at the top of the hierarchy to listen when they hear concerns expressed.

• Track near misses, which are errors without obvious consequences, involving both departments.

• Conduct a formal teamwork training program that addresses all these components, such as what the Human Performance Training Institute (HPTI) in Englewood, Colo. offers. HPTI CEO Scott Shutack says, HPTIs mission is to provide clinicians with skills that will detect, prioritize and manage threats and errors in a team-based environment. These skill sets have been derived from the successful Crew Resource Management (CRM) model employed by the U.S. commercial aviation industry. CRM is mandated by the FAA, and is a key component to the Six Sigma safety record in the industry.

Brock mentions further that one problem SPD has is its lack of visibility when things go right, which is most of the time.

I would guess that most surgeons rarely think about the role of central supply in their average successful case, she says. Probably the nursing staff has a much better idea, but any strategy which can make more visible the good work of sterile central supply should be explored. In quality improvement activities, much research shows that the most successful strategies are multidisciplinary and I would try to incorporate SPD in QI multidisciplinary teams.

Another strategy to raise SPD personnels visibility is by including the SPD manager and staff in regularly held OR staff meetings, so that they feel like theyre part of the team and not a department that just has to provide these vital services to the functioning of the operating room, Trattler says. What SPD provides in terms of service is critical to the functioning of the OR and the success of the surgical procedure.

For both departments to better understand each other, Trattler and Chobin recommend that employees, including nurses, experience working in the other department for a day or a half day.

I always find it is important to walk a mile in somebody elses shoes, Chobin says.

Chobin has observed that OR staff are often amazed at what the SPD does, the extent of not only handling the demands of the OR but the rest of the hospital. Conversely, SPD staff can observe surgery and see what happens when an item is packaged wrong or is missing. Why did the surgeon become upset? How did it impact the case? If the situation is such that SPD and the OR can not work through their differences, Chobin suggests forming a process and improvement committee.

You get risk management involved, infection control, quality assurance in addition the operating room and sterile processing, Chobin says. When you have those other departments involved it now becomes a committee decision and not a OR versus SPD. It really takes away the finger-pointing.