Case study

Beyond the assessment: Building lasting operational confidence in surgical services

We helped a multi-campus hospital uncover critical gaps across three sterile processing sites. Within 26 weeks, we rebuilt their quality systems, cut error rates, and restored surgical confidence.

Challenge
Approach
Findings
Solution
Impact
Menu

Overview

Facing persistent quality and compliance issues across three campuses, a multi-site hospital in the Southeastern U.S. partnered with ASSI.

In just 26 weeks, ASSI reduced tray error rates from 16.3% to under 1%, improved team productivity from 47% to 96%, and fully trained 17 staff members. A new quality program, leadership structure, and cross-department collaboration model were introduced, restoring operational confidence and positioning the system for long-term success.

Client

Multi-campus hospital

  • 3 locations
  • 3 SPDs, 1 endoscope reprocessing area
Year

2020

Region
Southeastern U.S.
Solutions provided
  • Clinical assessment
  • Departmental leadership
  • Quality program development
  • Education
  • Staffing

”ASSI brought structure and clarity to a department under strain. Their consultants led daily briefings and provided in-depth site visits, always delivering tangible solutions. They didn't just assess; they trained our Surgical Services Leaders and built a path to sustainable compliance. Their leadership and expertise were instrumental in restoring operational confidence.

VP of Surgical Services

The challenge

The facility faced persistent issues within its three Sterile Processing Departments (SPDs), including limited staff training, inadequate quality assurance measures, and compliance risks across multiple critical areas.

Leadership identified deficiencies in decontamination practices, instrument inspection protocols, documentation processes, and interdisciplinary communication. These gaps posed a risk to surgical integrity, patient safety, and regulatory compliance, prompting the facility to engage Advantage Support Services, Inc. (ASSI) for a comprehensive remediation strategy.  

Our approach

Clinical assessment

ASSI conducted a five-day onsite assessment, followed by a 26-week engagement to stabilize operations, train staff, and establish sustainable quality practices. The team embedded with SPD and OR leadership to align workflows, elevate performance, and build cross-department collaboration.

Findings

The findings revealed issues across six key domains:

Documentation and standards
  • Missing or outdated policies and IFUs in decontamination and assembly areas.
  • No protocol for IUSS validation or annual competencies related to high-risk sterilization practices.
  • Inadequate use of sterilization indicators and improper labeling practices for peel pouches and trays.
Training and competency
  • No formal SPD education program or annual competencies; orientation handled solely by OR educator.
  • Absence of a dedicated Superuser or Subject Matter Expert for training and quality oversight.
  • Low certification rates and no structured training pathway for new or existing staff.
Quality and compliance
  • Lack of a Quality Assurance Program with no tracking of KPIs or quality audits.
  • Tray error rates and bioburden issues impacting OR start times and surgical readiness.
  • Inconsistent decontamination practices with no periodic ATP testing or validated airflow monitoring.
Communication and leadership
  • No structured interdisciplinary communication platform between SPD, OR, and EVS.
  • Lack of scheduled leadership rounding, KPI review meetings, or shared accountability protocols.
  • Absence of a multidisciplinary team to oversee infection prevention, EVS compliance, and process improvement.
Infrastructure and equipment
  • Insufficient workstation setup and lighting; no access to magnification for inspection.
  • No tracking system in place, preventing tray-level traceability and quality metrics.
  • Ergonomic and functional deficits in decontamination areas, including improperly used sinks and insufficient PPE.
Environmental services
  • No dedicated EVS checklist or training program for SPD-specific cleaning.
  • Infrequent deep cleaning, absence of documented cleaning schedules, and no collaborative review between SPD and EVS.

Assessment results

Satisfaction survey scores (1–4 scale)

Instrument quality
2.3
Tray accuracy
2.1
Bioburden frequency
1.9
Instrument availability
1.9
Case cart quality
2.8
Case cart completion
1.9
Tray turnover efficiency
2.1

Assessment outcomes

5
Compliance dangers
196
Improvement opportunities
211
Meets standards
12
Best practices

Performance grades across 4 departments

Lowest
63.4
Average
74.7
Highest
81.3

Solution

ASSI implemented a focused, 26-week improvement program to stabilize sterile processing performance, raise compliance standards, and strengthen cross-department collaboration.

The following interventions were implemented:

Standardization and training

  • Delivered the SPD Standardization 101 program to all SPD staff.

  • Designated Superusers to support ongoing training, competencies, and quality improvement.

  • Fully competency-checked 17 employees to meet compliance and performance standards.

Quality and compliance

  • Implemented a comprehensive SPD Quality Program, including audit quotas and tracking systems.

  • Trained and deployed Quality Technicians to conduct pre- and post-sterilization audits.

  • Achieved CMS-recognized improvements in quality oversight and documentation practices.

  • Reduced tray error rates from 16.3% to under 1%.

Infrastructure and equipment

  • Established a Multidisciplinary Team including SPD, OR, Infection Control, EVS, Materials, and Risk Management.

  • Aligned SPD and OR operations through leader rounding, shared KPIs, and structured communication.

  • Established productivity standards that raised performance from 47% to 96%.

Team performance and collaboration

  • Secured capital investments for borescopes and compliant decontamination sink upgrades.
  • Introduced water and steam quality testing to identify environmental bioburden risks.

Impact

ASSI’s targeted interventions delivered measurable improvements across the organization.

By the end of the 26-week engagement:

Tray error rates dropped from

16.3

to under

1
Significantly reducing surgical delays and patient risk.

Staff competency improved with

17

employees fully validated and prepared for compliance audits

Productivity increased from

47

to

96
With clearly defined standards sustaining team performance.

The newly implemented Quality Program received commendation during the final CMS visit, boosting leadership confidence.

Cross-department collaboration between SPD, OR, and Infection Control was established for the first time, improving communication and accountability.

Leadership now operates with improved data visibility, enhanced training infrastructure, and systems in place for continuous quality tracking.

These changes not only addressed immediate compliance gaps but laid the foundation for long-term operational resilience.