Nov 4, 2021 | Article

How Quality Event Monitoring of the Small Things Can Have Big Rewards

  1. Understand the different categories of quality events.
  2. Learn how to implement successful quality event monitoring.
  3. Define how leveraging quality data can impact real change in your department or facility.

When something happens in your Sterile Processing workflow that could cause harm to the instrument/equipment, staff member, or patient, that is considered a “quality event.” Depending on your department and background, how you respond to these quality events can vary substantially. Not all quality events are created equal, and not all teams have the same expectations for how they are supposed to react to them. That being said, monitoring these quality events within Sterile Processing can be the impetus for tremendous improvement, both in your processes as well as the quality output of your department. Even the small things can have big rewards.

This article will cover different categories of quality events, provide strategies for successfully implementing quality event monitoring, and discuss ideas around leveraging quality data to impact real change in your department, facility, and even the entire industry. Whether you are a frontline technician, team leader, or upline manager, each of us has a critical part to play in making this process as simple, repeatable, and valuable as it can be for our mission of safe surgical care.

The Events We Don’t Enjoy, But Still Need to Plan For

Oftentimes in healthcare, an “event” is not something you want to happen. It’s not the fun type of events like family picnics and company retreats you may typically think of when you hear the word. The term “event” is used as a synonym for words like “process deviation,” “outlier,” and “error.” So when an event like this happens in our facility, it means that something happened (or almost happened) that could have caused harm. The process broke down somewhere and did not accomplish the thing which it was designed to accomplish. However, just because events like this are not enjoyable, the complexity of healthcare in general and Sterile Processing in particular means that events are likely to occur in many of our processes. Because quality events are likely, we should build proactive plans for what our teams should do when (not if) they encounter one.

In building a proactive quality event plan for your Sterile Processing department, it is important to know what kinds of things can qualify as quality as an event. Keep in mind that our definition of quality events from the article introduction is anything that could “cause harm to the instrument/equipment, staff member, or patient.” Here are just a few examples (below) broken down by area of your department:

  • Decontamination:
    • Retained sharp (scalpel blade not removed in the OR)
    • Improperly loaded case cart (rigid scope)
    • Improperly transported case cart (door not closed/unable to close)
    • Sink detergent dosing malfunction
  • Prep/Pack:
    • Instrument damage (forceps distal tip bent)
    • Gross debris (inside suction)
    • Instrument migration (large percentage of instruments missing from a tray)
    • Employee injury (lamina spreader pinch)
  • Sterilization:
    • Filter retention plate failure (dropped filter during sterilization phase)
    • Wet load
    • Employee injury (autoclave burn)
    • Container locks missing

As mentioned above, many of these things occur on a regular basis in our departments. But are they being documented anywhere? And if not, how are we learning from the events in order to improve our processes? Knowing the kinds of quality events like these to monitor is the first step. Now we will take a look at strategies to help you and your team implement a successful quality event monitoring program.

See it, Scan it, Solve it: Quality Monitoring in the Moment

Even though it is easy to see the impact quality events can have on your team and workflow, it is much harder developing a process for quickly and consistently capturing that information in a way that makes it valuable for real process improvement. There are two priorities that must be put front and center in order for any quality event monitoring program to succeed.

  • A culture of ownership: Frontline technicians in your Sterile Processing department must be empowered to own both the current and future processes in their day-to-day workflow. If they feel like they are a cog in the department wheel who are simply told what buttons to push, without any real insight or feedback from their perspective, quality monitoring will always end up on the sidelines of volume and productivity. Our technicians must become engaged as owners of the process itself. Are noncompliant case carts constantly a source of frustration? Work with your technicians to understand the problem from the ground level, and collaborate to identify what kinds of quality events in the process can be monitored to begin building a data-driven case.
  • Simple, immediate data capture: Once the culture of ownership is in place, our teams must have a quick, simple mechanism to capture quality event data in the moment. If it’s not quick, it just won’t happen. If it’s not simple, it won’t happen consistently the way that it must to give a holistic view of the quality of our department workflows. The best tool to accomplish this is an instrument management software with a quality monitoring module. These programs give frontline users the ability to immediately scan and document a quality event wherever they are in the department, without needing to stop what they are doing.

As more and more quality data is gathered through this kind of event reporting, your department will be able to visualize the real scope of process breakdowns at a high level. Are you seeing more employee injuries on the weekends? Do sharps come back to decontamination more often on certain shifts? Is gross debris making it to the clean side when devices go through a certain washer? The granularity of data available to you is nearly endless, if your team is willing to see it, scan it, and, most importantly, do something to solve it.

Quality Data that Does Something

You know what to monitor, you know how to monitor, but how do you get the most out of the quality data points that come in through a quality event monitoring program like this? In other words, how do you leverage your quality data to impact real change in your department, facility, and even the entire industry? Well, first things first. You must be transparent with the data that is gathered. As soon as your team members sense that leaders aren’t doing anything with or even looking at the quality data, they will most likely stop gathering it. This one point kills many quality event monitoring programs before they ever really get off the ground. Transparently reviewing quality events with your team on a regular basis sends clear signals that this information is 1) important, and 2) actionable. Examples of this transparency would be sharing quality trends during staff meetings and daily huddles, emailing monthly quality reports to the staff, posting particular quality metrics on the department bulletin board, etc. As your team sees and hears the data being discussed around them on a regular basis, they are that much more likely to contribute to it via quality event reporting.

However, quality event transparency is a double-edged sword. Sharing the data alone doesn’t change anything. Quality data is the thermometer that takes the temperature of the process, it’s not the medication which effects the cure. Where the real progress happens is when you begin to use this data to engage end users in the solution. Here is just one example to bring this concept to light from one of the quality events mentioned above:

  • Improperly loaded case carts (rigid scopes)
    • Monitoring over a six week period, your team captures 45 unique events of improperly loaded case carts related to rigid scopes.
    • During that same period, your rigid scope repair/replacement budget experienced a 70% increase in expenses.
    • You take these data points to the Executive Surgical Committee, engage your SPD, OR, Surgeons, and Supply Chain around a new scope containment solution & re-education program for OR staff on scope care & handling.
    • Over the following six week period, your team only captures 5 unique events of improperly located case carts related to rigid scopes, with no increase to your repair/replacement budget.

Keep in mind this is only one example of how monitoring a single quality event (improper case cart loading) can have a dramatic impact on multiple departments, budgets, and surgeon buy-in across the facility.

While quality event monitoring is obviously important at the department and facility level for all the reasons listed above, there is huge potential for similar data points to drive improvement on a national and even global scale. Even a quality event as complex as instrument migration, when data points are compared from facility to facility, can surface massive opportunities for the best and brightest in our industry to collaborate together around solutions that could change the way we manage missing and replacement inventory. And the same is true for countless other quality events we often ignore in our departments.

No matter how small the quality event may be, monitoring it can be the first step in massively improving your department’s ability to be the best-in-class Sterile Processing team that your patients deserve. One small scan, many big rewards.


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