Apr 26, 2017 | Sterile Processing

Improve the Quality of Surgical Instrument Set Assembly in CSSD

Looking back at my experience managing a Central Sterile Supply Department (CSSD), many of the errors found by the OR were simple errors that could have been caught prior to sterilization with a Quality Audit checkpoint in place. Quality Audits give management insight into problem areas so that proactive improvements can be made and tracked.

A current Censis client, who annually serves over 50,000 surgical patients and processes nearly 8 million instruments, recently reported an impressive defect rate decrease. In less than two years, their performance improved tremendously and dropped a defect rate of more than 15% to less than 3% per patient with the addition of Quality Audits.1

Let’s take a look at the key components you need to set up a Quality Audit process in your own facility and begin decreasing errors and defect rates.

Quality Audit Workstation

  • The Quality Audit workstation is typically stationed between assembly and sterilization
  • Assign a Certified Sterile Processing technician to perform instrument set audits from each shift.

Define an Assembly Quality Audit Checklist (example below)

Container Sets

  • Verify/inspect each instrument on the count sheet (accuracy, functionality, cleanliness)
  • Inspect container for defects (gasket, dents, retention plate)
  • Inspect filter for defects (hold filter up to light to verify)
  • Secure the retention plate (retention plate must not be loose)
  • Verify chemical indicators are in the instrument set
  • Verify/inspect locks to ensure they are secure on container

Wrapped Sets

  • Verify/inspect each instrument on the count sheet (accuracy, functionality, cleanliness)
  • Select appropriate wrap size
  • Place towel under set and place corner protectors on corners (steam only)
  • Verify indicators are in the instrument set
  • Wrap using envelope technique
  • Secure wrap with appropriate tape

Monitor Quality/Data Collection

  • Conduct daily Quality Audits on assembled sets
  • Document results of the Quality Audits and take pictures if necessary
  • Quantify the severity of the defect
  • Document how you resolved the defect

Continuous Feedback

  • Hold daily meetings with the team to discuss audit results and defects
  • Discuss weekly targets with the team and administration
  • Keep staff engaged and informed
  • Maintain continuous staff education

Data Collection/Reporting

Quality Audit results can be collected via a manual process, but if you are a current CensiTrac user, you can save valuable time by entering your Quality Audit results directly into the CensiTrac Quality Feedback module. The Quality Feedback module provides any stakeholder involved in the reprocessing of instruments an electronic means to capture comments and/or images regarding the condition of trays, instruments, or other assets when it is convenient for them. Once a defect is resolved, the status of the Quality event can be changed to “closed.”

Key Features of the CensiTrac Quality Feedback Module:

  • Easy access to the module from any PC workstation for stakeholders with system privileges
  • The ability to capture pictures or images when documenting a situation
  • The ability to pull reports based on multiple parameters for analysis:
    • Type of event
    • Tally
    • Updated Date
    • Reported By
    • Responsible Party
    • Asset Name
    • Event Date
    • Comments
    • Case Reference
    • Event Time Delay
    • Event Time Period
    • Facility
    • Last Updated By
    • Status
    • Status Updated By
    • Updated Time Period

The Quality Feedback report is just one of many reports you can utilize in CensiTrac for valuable information on set audits. Contact us today to learn more about CensiTrac and the Quality Feedback module!

Author: Michelle Gallagher, Manager of Clinical Services