Transforming a Siloed Reprocessing Center into a System Asset
Case study
Rebuilding a Regional SPD Network
Overview
April 2024, ASSI conducted a comprehensive Clinical Assessment aligned with CMS standards, resulting in interim leadership for a Southern Virginia hospital system. The engagement included 9 hospitals, 9 endoscope suites, 28 clinics, and an off-site reprocessing center, focusing on compliance, communication breakdowns, and operational stabilization.
Client
Large Hospital System
Year
April 2024
Region
Southern Virginia Hospital System
Solutions provided
- Clinical Assessment
- Interim Director
”“Partnering with ASSI was a turning point for our Sterile Processing Department. Their clinical assessment provided an honest, data-driven view of our operational gaps, backed by national standards and actionable insights. The transition to having an on-site Director of Sterile Processing from Advantage brought immediate structure, consistency, and accountability to our department. Their leadership not only stabilized daily operations but also improved staff engagement and cross-functional trust with the OR. We've seen measurable gains in quality, compliance, and team
Chief Operating Officer of Southern Virginia Healthcare System Market
performance."
The challenge
A centralized Offsite Reprocessing Center (ORC) responsible for sterilization services across a multi-hospital system was experiencing significant operational and communication challenges that were directly impacting surgical performance.
Key Operational Issues
Several hospitals within the system were routinely experiencing:
- First-case delays caused by late tray delivery
- Instruments left unprocessed overnight
- Torn wrappers on surgical sets
- Visible bioburden found on instruments
Despite these recurring issues, there was no formal audit process in place to identify root causes, measure trends, or support corrective action planning.
Workflow & Capacity Challenges
The original purpose of the ORC was no longer being fully realized due to:
- Growing trust concerns between facilities and the ORC
- Strict processing cut-off times
- Hospitals processing more volume internally than through the ORC
- Ongoing staffing conflicts between facilities
At the same time, Immediate-Use Steam Sterilization (IUSS) rates were exceeding national benchmarks without documented clinical justification.
Workforce & Communication Gaps
Additional challenges included:
- Perceived staffing shortages
- Inconsistent technician practices
- Limited standardization across workflows
- Breakdowns in communication between the ORC and perioperative teams
The ORC was operating in a siloed environment with limited visibility into the dynamic needs of the operating rooms it served. This disconnect contributed to growing dissatisfaction among surgical staff and ongoing complaints from surgeons across the health system.
The Need
The situation highlighted the need for:
- Workforce development
- Certification readiness
- Process standardization
- Structured communication pathways
- Stronger alignment between sterile processing and perioperative services
A system-wide approach was needed to rebuild trust, improve operational reliability, and strengthen surgical support across the organization.
Our approach
We conducted a comprehensive multi site assessment of the Offsite Reprocessing Center (ORC) and affiliated hospital and clinic-based sterile processing departments within the health system.
Key actions included:
- Workflow Observation and Gap Analysis: We performed on-site observations across
several facilities, identifying workflow inefficiencies, equipment utilization issues,
and breakdowns in sterile processing best practices. - Assessment of Compliance and Standards: We evaluated adherence to industry guidelines (e.g., AAMI, AORN, CDC) and identified deviations in decontamination, sterilization, and storage processes.
- Staffing and Training Review: We assessed staffing levels, certification status, and
role clarity among SPD staff. Gaps in competency, orientation, and continuing education were documented. - Performance Metrics and Data Review: We analyzed IUSS rates, bioburden incidents, tray quality issues, and turnaround times, comparing them to our proprietary internal benchmarks.
- Communication and Leadership Evaluation: We examined cross-departmental communication between the ORC, OR teams, and leadership, identifying a siloed structure and a lack of real-time feedback mechanism
The findings were compiled into a detailed report with actionable recommendations, addressing systemic challenges, workforce development, workflow redesign, and leadership accountability. This assessment laid the foundation for future process improvement and quality stabilization efforts across the system, and we were selected to provide long-term leadership of enterprise Sterile Processing Activities.
Findings
Assessment results
Client satisfaction survey results
Instrument quality
1.2
Bioburden Frequency
2.8
Tray Accuracy
1.8
Instrument availability
1.9
Case cart quality
1.7
Case cart completion
1.8
Tray turnover efficiency
1.9
Assessment outcomes
285
Compliance dangers
160
Improvement opportunities
59
Meets standards
12
Best practices
Average department grade
Lowest
61
Average
67.8
Highest
72
Impact
- Advantage was selected to provide an Interim Director of Sterile Processing.
Helping services with integrity and care
25
Years of expertise
100
Facility assessments
1000
Staff ready
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