Oct 10, 2023 | Sterile Processing

Instrument Management Standardization in Multiple Facilities

The sterile processing industry seems to be getting more complex and technical every month. Is your instrument tracking process able to keep pace? If you’re still tracking your instrument reprocessing with paper documentation, you’re probably running into problems staying consistent and, well, documented. There are numerous issues surrounding paper instrument tracking, from wet documents to incomplete information, and let’s not get started on the amount of space required to store those boxes of reports, folders, and sterilization logs.

Recently, we sat down with Robby Miller, Sterile Processing Department (SPD) manager and Subject Matter Expert (SME) at St. John’s Hospital and Medical Center on our ConCensis podcast to discuss transitioning from paper tracking to CensiTrac’s electronic tracking system. He breaks down the struggles and triumphs, the teamwork and process changes, and the goals for the Common Spirit Health network he is part of, which spans 142 hospitals across 28 states.


Difficulties with Outdated Tracking Methods


Many sterile processing departments (SPDs) still use paper methods to track the sterilization of surgical instruments. Unfortunately, that means they’re missing a lot of reprocessing information that could be critical to patient safety in the perioperative loop. There can be several reasons for maintaining this method, including:

  • Small facilities with minimal workload don’t see the need
  • Facilities don’t have the budget to purchase a surgical asset management system

There are a multitude of difficulties with paper tracking. One of the biggest is storing boxes upon boxes of documents for the required amount of time. AAMI ST79 section 13.3.4 mentions that this can vary between facilities depending on policies, but typically records must be maintained for 3-6 years at a minimum. Not only does this take up space, but it can make pulling data time-consuming and tedious.

Another issue that many SPDs run into is that it’s impossible to standardize from one technician to another in a single department, never mind across multiple facilities. Even with a process guide, technicians will annotate the paperwork in different ways:

  • Some will use military time, others will not, which may cause confusion
  • Some will write out the specific names of each tray in a load, others may put “11 Synthes loaners” on the line
  • “241 dental peel packs” aren’t easy to trace if the load needs to be recalled
  • Your colleague’s handwriting could be mistaken for a doctor’s, it’s so illegible

With discrepancies in documentation, also comes an added strain on instrument tracking. And if the facility has limited staff, training is inconsistent because each person will show how they do it, versus the standardized way everyone should do it. These issues are the tip of the iceberg when it comes to using paper to track instrument reprocessing.


Transitioning to Digital Instrument Tracking System 


Robby Miller knows the pain of tracking with paper documentation. He remarks that there are 5 key components that electronic instrument management does for sterile processing professionals:

  1. Asset management: What resources do they have? When have they been used? How to track repairs and realize cost savings.
  2. Electronic documentation: Count sheets are consistent, sterilizer and HLD documents are clean, and quality assurance programs can be efficiently monitored. There are no more piles of boxes in a warehouse—information can be accessed in minutes.
  3. Structured processes: The ability to design a structured reprocessing process that drives patient safety and regulatory compliance in the department.
  4. Data reporting: Productivity and asset usage are reported objectively as technicians utilize the system.
  5. Instrument traceability: The ability to track individual instruments through the reprocessing cycle, directly to the patient, and back to the sterile processing department.

During the upgrades across his enterprise, Robby had the challenge of some facilities still using paper tracking, and others using an outdated electronic management system that was going away. When looking at the available options, CensiTrac’s capabilities and potential stuck with him as the best tool for their needs. He stated that transitioning from one system to another wasn’t too difficult for those technicians because they understood how the tracking system would work and what it would accomplish for them. He praised the phenomenal data transfer, especially considering the large number of conversions that took place in what he feels was a short amount of time.


Implementation Across Multiple Facilities



Implementing change in one facility is difficult but multiplying that to over 100 hospitals is quite the challenge. Robby gave us a few great tips to help smooth that process out:

  • Put together a collaboration group that communicates with all stakeholders across all facilities.
  • Create a task force with people in specific regions or divisions to keep the process moving appropriately.
  • Have the sponsorship and buy-in of executive members of your facility or enterprise because this will cost time and money.
  • Work with Censis professionals to utilize their expertise to achieve objectives.

Another big process implementation step is to make the tracking system universal across all departments. Have consistent naming and formatting, access levels, workstation groups, and documentation expectations, just to name a few. If you have technicians who float from one facility or department to another, having the layout and expectations the same everywhere will make for less confusion and fewer mistakes.

A struggle that Robby and his team faced was that SPDs were siloed from each other, and they weren’t communicating well. They had to work to get all areas involved and give them a voice that mattered so that they were invested in the process changes.


Into the Future



Robby states that one of the benefits of implementing a healthcare asset management system is that multiple processes and practices can be consistently applied. Standard Operating Procedures (SOPs), regulatory compliance, quality monitoring, and staff training are some of the areas where advancements are most keenly felt and witnessed. Knowing that inspectors will see the same practices and policies no matter what facility they are visiting across the enterprise gives an added sense of relief and security.

Implementing a tracking system in your sterile processing department means reconfiguring some of your department goals and Key Performance Indicators (KPIs). You will now be able to track turnaround times, case cart error rates, and bioburden events more accurately. You will also be able to assess if assets (instruments or flexible scopes) are being underutilized at one location and would be put to better use at another location.

Education can be streamlined and tracked to ensure your whole team is being given the knowledge and skills they need to succeed. This is a complex environment, and they must make high-risk decisions every day. Utilizing a tracking system can take some of that stress away when it comes to decision-making, like having set task lists or priorities in place.


Censis Can Help


Tracking instrument reprocessing in a sterile processing department can be exhausting and frustrating. Utilizing an instrument tracking system can relieve a lot of the burden through automated processes and updates.

Robby Miller spoke to the ConCensis podcast team about his experiences implementing CensiTrac across over 100 hospitals in his enterprise and how he kept the changes on track. If you’d like to hear more of what he has to say and learn how Censis can help, watch the video here.