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Rhonda P. Estok, CRCST, RN, BSN, MPH – Nurse Educator, Sterile Processing Services (SPS) Laura D. Webb, CRCST, RN, BSN, MRP – Quality Coordinator, SPS CSI & INSPECTOR GADGET – Getting to Quality The Veterans Affairs Medical Center - Durham, North Carolina, USA SPS Tray Audit Results (based on 30 audits per month) • Compliance rate - 97% (Count sheets included in trays and no missing instruments). • Consistent improvement and sustained results for 18 month period. 0.00 20.00 40.00 60.00 80.00 100.00 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 April 2014 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 TOTAL TRAY AUDITS: Total Compliance - Count Sheets & Missing Instrumentation % with CS % w/o MI Rhonda P. Estok, CRCST, RN, BSN, MPH – Nurse Educator, Sterile Processing Services (SPS) Laura D. Webb, CRCST, RN, BSN, MRP – Quality Coordinator, SPS CSI & INSPECTOR GADGET – Getting to Quality The Veterans Affairs Medical Center - Durham, North Carolina, USA SPS Focus on Quality • SPS has one bi-monthly “Focus on Quality” session. • Session is led by SPS QI Coordinator and Nurse Educator. • Results of tray audits and other quality monitors are reviewed with staff and any quality-related issues are discussed. • Goal was to figure out a “not so boring” way to emphasize the importance of delivering QUALITY. Rhonda P. Estok, CRCST, RN, BSN, MPH – Nurse Educator, Sterile Processing Services (SPS) Laura D. Webb, CRCST, RN, BSN, MRP – Quality Coordinator, SPS CSI & INSPECTOR GADGET – Getting to Quality The Veterans Affairs Medical Center - Durham, North Carolina, USA CSI –“Certified Sterile Processing Inspection Team THE SCENE • Four (4) Stations – each with 1 tray, the tray list/count sheet for that tray, a CSI list (to record the evidence), and CSI Evidence Cards (number of cards = number of items to identify. • Nonconforming instruments identified from prior tray audits, or by repair service were collected over a 3 month period in preparation for the inservice. • Several of these nonconforming instruments were “planted” in the trays for identification by SPS Investigators. • Each of the 4 trays had between 4 and 10 nonconforming instrumentation or tray issues that Investigators needed to identify. Rhonda P. Estok, CRCST, RN, BSN, MPH – Nurse Educator, Sterile Processing Services (SPS) Laura D. Webb, CRCST, RN, BSN, MRP – Quality Coordinator, SPS CSI & INSPECTOR GADGET – Getting to Quality The Veterans Affairs Medical Center - Durham, North Carolina, USA Evidence Markers Count Sheet Tray CSI List CSI STATION SET UP (1 OF 4 STATIONS) Rhonda P. Estok, CRCST, RN, BSN, MPH – Nurse Educator, Sterile Processing Services (SPS) Laura D. Webb, CRCST, RN, BSN, MRP – Quality Coordinator, SPS CSI & INSPECTOR GADGET – Getting to Quality The Veterans Affairs Medical Center - Durham, North Carolina, USA “YOU CAN’T EXPECT WHAT YOU DON’T INSPECT.” (W. Edwards Deming) EXAMPLES OF NONCONFORMING ISSUES AT CRIME SCENE: • Cracked box locks • Broken tips or tips that don’t meet (forceps, scissors, clamps) • Bent instruments • Mismatched pairs of instruments (3:1 instead of 2:2 or 3L:1R instead of 2L:2R) • Barcode mismatch (Basket/container) • Sprung needle holders – ratchet doesn’t lock or won’t hold needle • Stain/discoloration • Additional or missing instruments • Incorrect sizes of instruments • Grossly damaged metal (rongeurs, suction tips, etc.) Rhonda P. Estok, CRCST, RN, BSN, MPH – Nurse Educator, Sterile Processing Services (SPS) Laura D. Webb, CRCST, RN, BSN, MRP – Quality Coordinator, SPS CSI & INSPECTOR GADGET – Getting to Quality The Veterans Affairs Medical Center - Durham, North Carolina, USA EXAMPLES OF THE EVIDENCE: Rhonda P. Estok, CRCST, RN, BSN, MPH – Nurse Educator, Sterile Processing Services (SPS) Laura D. Webb, CRCST, RN, BSN, MRP – Quality Coordinator, SPS CSI & INSPECTOR GADGET – Getting to Quality The Veterans Affairs Medical Center - Durham, North Carolina, USA THE EVIDENCE Most Often Identified Most Often Missed Broken or bent instruments/tips Cracked box locks Additional instruments Barcode mismatch Missing instruments Mismatched pairs Grossly damaged metal Stain/discoloration (if subtle) Wrong sizes of instruments Scissors not sharp Needle holder won’t hold needle Rhonda P. Estok, CRCST, RN, BSN, MPH – Nurse Educator, Sterile Processing Services (SPS) Laura D. Webb, CRCST, RN, BSN, MRP – Quality Coordinator, SPS CSI & INSPECTOR GADGET – Getting to Quality The Veterans Affairs Medical Center - Durham, North Carolina, USA FACTS 1. Requires lots of preparation and thoughtful organization. 2. Trays selected for stations are dependent on OR needs of the day. 3. Time consuming – best to have staff pair up for detective work. In their own words…what the inspectors had to say… …best inservice ever! …didn’t get to all 4 stations, wish we’d had more time. …that was really fun, and I learned a lot! …can we do this again? …we should do this more often! Rhonda P. Estok, CRCST, RN, BSN, MPH – Nurse Educator, Sterile Processing Services (SPS) Laura D. Webb, CRCST, RN, BSN, MRP – Quality Coordinator, SPS CSI & INSPECTOR GADGET – Getting to Quality The Veterans Affairs Medical Center - Durham, North Carolina, USA BACKGROUND MUSIC TO INVESTIGATE BY…
