Infection Prevention: 10 Sterile Processing Benchmarks

Infection Prevention

By: Weston "Hank" Balch

Published: 8/12/2019

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Measure your department's performance with these key indicators.


Besides the occasional complaint about incomplete sets or late-arriving trays, how can an OR manager grade the sterile processing department’s performance? We’ve got you covered with 10 simple-to-measure benchmarks your SPD should hit.

1 Total cycle times
There’s no better way to measure the speed and productivity of SPD workflow than total cycle times. This metric tracks the time it takes a surgical tray to go from the first scan into the decontamination area, through the cleaning, inspection, assembly, packaging, sterilization and cooling process. While some of this time is equipment-dependent — such as a 32-minute washer cycle versus one that’s 1 hour and 15 minutes — this measurement also captures the speed of your manual cleaning, inspection and assembly process to give you a good sense of the true speed of flow through your department.

2Unprocessed trays at 7 a.m.
This indicator will cue you into potential volume versus staffing misalignments, as it measures the number of trays from the previous surgical day that are still sitting unprocessed at 7 a.m. While a high number of trays left over in the morning does not necessarily mean staffing is insufficient — especially if you have an overnight shift— it might signal you to take a closer look at your overall process.

3Missing instruments & incomplete trays
Measuring the ongoing completeness of your surgical inventory is another key indicator of reprocessing quality. Most instrument-tracking systems allow for simple reports for this metric on a daily, weekly or monthly basis to identify trends in the types of instruments going missing, and how often trays are being reprocessed without all the requested instrumentation. Some larger facilities can be missing thousands of instruments at any given time.

4Request & delivery times
This compares your expected delivery times for a requested instrument from an OR to the time it takes your staff to locate and deliver the item to the customer. If your SPD is located in the sterile core on the same floor as the OR, this might only be a 2-minute target. But if your SPD is 2 floors below in the basement, it could be closer to 5 or 7 minutes to allow for stairs or elevator transport. Missing this target could mean that your inventory storage is not well organized or that staff need more training on search functions in your tracking system.

5Customer satisfaction
While one of the more difficult metrics to measure, customer satisfaction from your users is a critical marker for overall success in your department. Emailing your OR team and surgeons a survey at various intervals. “On a scale of 1-10, how satisfied are you with the service you received from our sterile processing department?” can be enough to establish a baseline grade.

STARTS IN SURGERY Removing bioburden begins during and immediately after surgical procedures in the precleaning process.   |  Pamela Bevelhymer, RN, BSN, CNOR

6Rejection rates &missing indicators
Measuring your department’s packaging rejection rates and missing indicators will give you insight into potential care and handling issues during sterilization, storage, case picking and transport, as well as possible assembly workflow interruptions or distractions that could cause staff to forget to insert chemical indicators in their trays. We all know that a surgical tray cannot be used if the sterile packaging is compromised in any way — such as a rip, tear, puncture, moisture invasion or other contamination. These devices are “rejected” and must go back to the very beginning of the reprocessing workflow. The same is true for sterilized surgical trays that don’t contain an internal chemical sterilization indicator to confirm the contents were exposed to the appropriate sterilant.

7Contaminated trays
One of the most significant and highly publicized quality metrics to benchmark is the incidence of bioburden and other contamination you identify in your sterilized trays. Evaluate any event that involves retained bioburden on a surgical instrument from all aspects of the instrument use and reprocessing workflow. This should be a shared metric between the OR and SPD teams. Remember, removing bioburden begins during and immediately after surgery in the precleaning process that takes place in the OR.

8Surgical case delays
Case delays is another collaborative metric between perioperative teams. The reprocessing department should document specific reasons for a sterile processing-related case delay — such as “tray not available,” “incorrect preference card pulled” or “missing critical instrument” — to enable appropriate root-cause analysis and follow-up by department leadership. You’ll find that you can track many of these types of case delays back to dirty data as often as a broken process.

9Employee injuries
Track employee injuries in the decontamination area, particularly sharps exposures. Because of the substantial risk associated with exposure in this area of the workflow, you should document, report and track all events in a transparent fashion across perioperative teams, infection control, risk and administration.

10On-time loaner deliveries
A final benchmark to consider captures the critical delivery windows for your external vendor-owned implant loaner trays. Depending on the volume of orthopedic or neuro loaner instruments your facility requires, late deliveries can have a dramatic impact on your team’s ability to compliantly process these trays in time for their scheduled surgical procedures. Industry delivery expectations range anywhere from 24 to 72 hours before the start of the case to ensure your department is adequately staffed to safely and compliantly support this additional reprocessing volume.

Time to measure metrics

Hopefully, we’ve given you some practical benchmarks you can use to measure success and position your reprocessing teams for ongoing improvements that are measurable, realistic and transparent. While there are many different measurements available to gauge your current state and overall department progress, these 10 will give you the clearest picture of your reprocessing quality. OSM

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