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Master Inventory Lists: The Key to Mastering Sterile Processing Compliance

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Imagine a hospital where staff would occasionally lose track of their patients, where they sometimes forgot to administer the proper medication, or even treated patients for illnesses they didn’t actually have.

Frightening, eh?

Not the kind of hospital any of us would want to be admitted into or have one of our family members be treated in.

Now imagine if those patients were surgical instrument trays or processing equipment. Let’s be honest for a moment: Does your department know how many trays you actually own? Do you know where they are, how they are to supposed to be cleaned and sterilized according to validated manufacturer parameters, how often they are used, and when they should be repaired? Are you sure all your processing equipment is being properly serviced and maintained according to the original manufacturer’s instructions for use (IFUs)? Let’s take a look at the current state of many of our departments regarding these things, and talk about one tool that can help us rein in the common chaos of instrument inventories and equipment maintenance.

Who really knows what we own? If you’re one of those lucky departments in the sterile processing industry that uses an instrument tracking system, you may think you’ve already taken care of this first informational need. After all, you just have to run a simple report to see all the trays you have in inventory, right? Well, kind of. The truth is these standard reports and inventory lists from most tracking systems can only give you part of the puzzle. While your software may tell you how many tray titles you have in your database, it won’t necessarily tell you how many sterilized peel packs you have scattered to the four corners of your hospital or hiding in clinics and doctor offices around your city. These systems may be able to tell you how much inventory came through your sterilizers, but they typically have zero accounting for any backup or replacement inventory you have on pegboards, bins, or drawers.

In the real world of sterile processing, most of us actually don’t have, and couldn’t supply, a true accounting of what we realistically own at any given time. The closest many of us can come is showing what and when we purchased an instrument, but even that can be difficult to keep track of if multiple departments or cost centers can purchase instrumentation in a single facility. We often struggle with bridging the practical divide between what we’ve bought, what we’ve tracked, what we can find, and what we can’t.

Ambiguous count sheets and invisible instructions One of the many causes of this lack of inventory transparency can be tied back to ambiguous instrument count sheets and tray recipes. Whether or not you use an instrument tracking system, dirty and incomplete data can doom you from the start. Without manufacturer product numbers on your count sheets, you have no real means to accurately cross-reference the pertinent instructions for use for each particular device in your trays. The more ambiguous the product description, the more danger your team may be in for incorrectly processing instrumentation. Simply listing “Maryland Dissector” on a lap chole tray count sheet without also listing the instrument catalog number assumes all instructions for processing Maryland Dissector instruments are the same, which is simply not true. It is not uncommon for similar instruments from different manufacturers to have measurable differences for how they are to be manually cleaned, inspected, disassembled, packaged, etc. Without clear count sheets, real processing instructions become inaccessible.

Equipment in limbo Instruments, however, are not the only aspect of department life where real potential for serious compliance breakdowns can be found due to the lack of transparency into our existing inventories. Seemingly invisible processing equipment can sometimes be just as problematic. Granted, an ultrasonic washer is a little harder to misplace than a #3 knife handle, but what happens when your biomedical team forgets about it? Or when that monthly cleaning of your autoclave chambers drops off without anyone noticing? Even though these devices are big, bulky, and constantly emitting some kind of buzzing, beeping, and alarms, it is still not uncommon for various teams to lose track of their required cleaning, testing, and preventive maintenance needs.

One reason for these equipment oversights has to do with the fact that multiple teams are often responsible for multiple aspects of a single unit. For instance, sterile processing technicians may perform the daily testing and cleaning of their ultrasonic cleaners, but their biomedical teams may do minor repairs, and the equipment vendor may come in to complete annual preventive maintenance work. There is no one person or team who knows what and when all of these duties need to be performed, so if the ball is dropped, there’s no one standing there to raise a flag.

Master inventory lists: a compliance must-have Simply put, our sterile processing teams cannot even begin to process or maintain our equipment or instruments properly unless we know what they are, how many we own, and how they are to be cared for and handled according to the manufacturer. Instead of solely focusing on the importance of IFUs, our departments have to first give proper attention to creating master inventory lists of all our medical and processing devices. These lists should include everything from Allis to Zenker clamps for inventory master lists, and from autoclaves to ultrasonics for our equipment lists.

The fundamental purpose of these master inventories is to provide sterile processing teams the ability to holistically validate and monitor their true department compliance. Not a guess. Not an assumption that someone else at some point in the distant past must have checked this, but a real, present, up-to-date record of compliance today for every square inch of your SPD.

If your hospital owns 2,500 different types of medical devices, with individual IFUs distilled down to a combined total of 12 different manufacturer validated cleaning protocols, sterilization parameters, and processing modalities, then you should be able to demonstrate an ability to support all 12 of those processing workflows in your department. If your hospital owns 20 different pieces of processing equipment, from instrument washers to peel pack sealers, which require a combined total of seven daily quality monitoring tests, 14 daily or monthly cleaning duties, and various other quarterly and annual preventive maintenance checks, then you need to know what all those responsibilities are and be able to prove they are being done regularly. Total compliance transparency into every device that plugs into or is processed by our departments is the ultimate goal.

In the same way that hospitals couldn’t properly treat patients they haven’t admitted or assigned a room, sterile processing departments are unable to demonstrate true compliance unless we are able to prove what we own, and that we can and do meet every requirement that ownership brings with it. Anything less is just a dangerous guess, and that’s no way to run a hospital or an SPD.

Decide today to master the art of fighting dirty with a master inventory.

What say you?


Hank Balch is the Founder & President of Beyond Clean. He began his career in instrument reprocessing as a frontline technician in 2009, and has served as an Instrument Database Specialist, Department Manager, and System Director for various SPD departments across the country. Hank is an award winning Sterile Processing leader (2016 Healthcare Purchasing News "CS/SPD Department of the Year"), twice nominated for IAHCSMM President (now HSPA), founder of two state-wide IAHCSMM chapters, conference speaker, and well-known industry writer, blogger, and social media connoisseur. He has written over 150 Sterile Processing articles, with his work being published in Becker's Hospital Review, Infection Control Today, Healthcare Purchasing News, Communique, Outpatient Surgery Magazine, AAMI BI&T Journal, SteriWorld, and other publications across the globe. His passion is seeing frontline Sterile Processing professionals equipped to #FightDirty, every instrument, every time.


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