Streamlining the Process for Instrument Sterilization Compliance to Improve Patient Safety and Efficiency

Problem/background: The Centers for Disease Control and Prevention guideline for disinfection and sterilization in healthcare facilities outlines the requirements for monitoring of sterilizers to ensure effective and safe reprocessing practices. Reprocessing compliance is determined by the submission of documents related to monitoring autoclave maintenance, as well as biological, chemical, and mechanical indicators. Patient safety depends on properly reprocessed and well-maintained instruments in accordance with manufacturer’s instructions; therefore, best practices should be applied. In April 2021, the reprocessing compliance rate was ~65%. This was due to an inefficient process that included ~5-10 forms that were completed manually and submitted in person. In 2022, an electronic process was implemented to improve efficiency. However, it did not allow for multiple forms to be submitted simultaneously, which led to the implementation of a new platform, REDCap. This platform not only enables the submission of multiple data entries at once but also supports data export. Lengthy data analysis and limited viewing access remained a challenge for monitoring compliance. In March 2024, a Tableau dashboard was established to pull data directly from REDCap for easy analysis and reporting.
Smart aim: To increase the reprocessing compliance rate to >95% as evidenced by monthly compliance reports by end of FY24.
Methods/implementation: In April 2021, infection prevention nurse collected baseline data that revealed an average reprocessing compliance rate ~65%. Issues that contributed to low compliance included missing or late submissions and repeated or incorrect dates of submission. Beginning April 2022 to April 2024, in collaboration with enterprise information system (EIS) and operations teams, new processes and platforms were implemented for improvement. Established REDcap platform in March 2022 allowing for multiple data submissions and ability to export data to Excel. Collaborated with EIS team to design a Tableau dashboard in January 2024 specific for reprocessing. Implemented Tableau dashboard in April 2024: directly pulled data from REDcap, filter option to view data for specific clinics and forms, and accessibility for operations team to monitor compliance. Increased site visits and conducted trainings to ensure understanding of reprocessing compliance and document submission processes. Incorporated reprocessing compliance education and document submission process into new and annual employee competency training. Targeted education to clinics identified as non-compliant with missing data for reinforcement.
Results: In April 2021, the average monthly compliance was 65%. One year later, it slightly improved to 70%. In April 2023 and 2024, it further increased to 92% and 95% respectively.
Discussion/conclusion/implications: Goal was met, as evidenced by average monthly compliance rates increasing by 30% over 3 years. Improvement was noted in number of reports submitted, accuracy in data, and timely submissions. Implementation of electronic platforms improved efficiency in the process for monitoring compliance. Recordkeeping of reprocessing documentation is an important practice for maintaining process integrity and contributes to quality and patient safety. This project can be implemented in any ambulatory care clinic setting performing instrument reprocessing.