At Markham Stouffville Hospital the Sterile Processing Department is responsible for the decontamination, cleaning, reprocessing and sterilization of instruments and equipment for the entire hospital. The Sterile Processing Department follows stringent criteria, best practice guidelines and standards to ensure the delivery of quality safe services to stakeholders such as the Operating Room and the Emergency Department. The department’s commitment to safety and quality aligns with the hospital’s belief statement “we must deliver safe, high quality care”. Although the department strives to exceed standards of practice, frontline staff identified the following two gaps: 1. Audit results such as instrument set error rate, missing chemical indicators, sterilization record accuracy and the frequency of sharps being found on used/soiled trays were inconsistently tracked and shared with frontline staff. 2. The lack of a systematic process such as a weekly audit tool to capture all reprocessing volume/activities including: thermal and high level disinfection, sterilization, weekly testing and maintenance and descaling of reprocessing equipment such as instrument, ultrasonic and cart washers. Simultaneously, while the Sterile Processing Department was exploring solutions to the above concerns, some of the acute inpatient units were implementing Releasing Time to Care. Releasing Time to Care is a process used to capture and report quality outcome indicators such as falls and pressure ulcer rates. The Sterile Processing Department, after visiting these acute inpatient units, adopted the Safety Crosses as a format to capture and disseminate the audits results as outlined above in Gap 1. The team also developed a weekly departmental audit tool to monitor and report their various departmental reprocessing volumes and activities as noted above in Gap 2. After many months of hard work, the department now boasts a quality board that proudly displays their four Safety Crosses: instrument/set errors, missing chemical indicators (internal and external), sterilization completion and accuracy rates and sharps sent to the Sterile Processing Department by end users. The quality board also serves as a mode to track and report the department’s weekly reprocessing activities and volume. Staff now has immediate access to reports and audits results. They are also a part of the process, because they actively complete the Safety Crosses on a daily basis. Through education, completion of iReports and direct follow ups with sending departments, the team has noticed a decline in the frequency in which sharps are returned to Sterile Processing Department.

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