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Prove it & Improve it: Building Sterile Processing Policies that Actually Work

Updated: Jul 28, 2022

Recently we conducted an interview with Ken Pichulo BSN, RN, CRCST, CER, CHL, Senior Manager of Sterile Processing at Advent Health | Orlando on the topic of building department policies that are not only good on paper -- but actually work in real life. His interview transcript below highlights many of the challenges frontline Sterile Processing technicians and leaders encounter in their daily mission to #FightDirty. We welcome your feedback and insights on what our industry can do to build better department policies which hardwire excellence and compliance in the name of patient safety.

1) (Beyond Clean) In your mind, what are the components of a great Sterile Processing policy?

(Ken Pichulo) A number of years ago, the facility I work at moved away from the Joint Commission and engaged DNV as their accreditation body for CMS. DNV utilizes ISO9001 quality management systems standards as their survey basis. In a nutshell, ISO9001 says “do what you say, say what you do, prove it, improve it”. As such, I’ve integrated this philosophy into my own practice when developing process and procedures, policies, and standard workflow elements into the department.

For me, a good SPD policy or procedure is one that is very clear in what it addresses. Education- both for how and why, is key. ISO’s “do what you say” refers to practicing what the written policy outlines and “Say what you do” is that clearly written standard or instruction. Both should be easy to understand and implement. Frontline leaders should be familiar with change management strategies, especially when the policy represents a significant diversion from a previous practice.

2) (Beyond Clean) Why is engaging frontline staff so critical for developing and maintaining high-quality policies?

(Ken Pichulo) In my mind, the single biggest stumbling block to the successful implementation of new policy or procedure is the lack of “buy-in” from the people that will be expected to incorporate the policy guidance into daily practice. “Buy-in” can be achieved in multiple ways but I’ve found that the quickest way to promote ownership to department policy and procedure is to invite the frontline teams to have a part in its development. These individuals will have to live with the subsequent workflow and frankly, they likely already know what works and what needs remediation better than leadership anyway. Harness the human resources that are right within the department walls for successful policy development and implementation.

3) (Beyond Clean) What are some common examples (or results) of policy/procedure disconnects in the Sterile Processing context?

(Ken Pichulo) In my department, we have established a number of protocols that we felt were important enough to build a policy around. One of these is the procedure used for processing items with lumens and the policy focuses on validating cleaning efficacy by utilizing a borescope to directly visualize the lumen prior to placing the item into the washer disinfector. We spent 6 figures on borescopes. We trained the team on the use of borescopes and when they should be used. The policy was presented in the form of an in-service and an “official” start date was set.

That date came and went, and after some time, I audited compliance to this policy and was surprised to discover that there had been no change in practice and that the borescopes were largely un-utilized. After further investigation, I found that this wasn’t the only process that wasn’t being followed as prescribed. I realized at that time that both myself and my front-line leaders did not follow up the education with implementation. We assumed that by telling the team to add this practice to their routine that it would just happen. We learned a lot about clear communication and the art of accountability through this exercise.

4) (Beyond Clean) What advice would you give to leaders to help them identify when these kinds of communication/application breakdowns are happening in their departments?

(Ken Pichulo) Again, ISO9001 provides very good guidance on this matter. The elements “prove it” and “improve it” suggest that it’s not enough to write and then implement a good policy or procedure, but that you must also actively “prove it”, meaning getting up from your desk and auditing routinely for compliance. Non-conforming behaviors must be addressed in the form of coaching, and when coaching isn’t effective, then discipline may be considered. In short, without personal accountability, new habits will not be created, and your awesome policy will never see the light of day. Auditing also impacts “improve it” as it is through auditing that elements of the procedure may be determined to require tweaking. You won’t know this unless you look and talk to your teams about how it’s going.

5) (Beyond Clean) What advice would you give to frontline technicians who struggle to get access to or remember the various policies & procedures they are responsible for in their facility?

(Ken Pichulo) The SPD arena requires an extensive knowledge base. As such, SPD leaders must make every effort to support their teams with the ability to retrieve policy and procedure information easily, and not rely on memory for this important information. In our department, the frontline technicians are encouraged to ask for assistance anytime that they need it. Asking for help should be celebrated and our leaders are tasked with being the subject matter experts on “our way” of doing things. Our techs are also encouraged to routinely engage with our hospital website and demonstrate the ability to pull up policies independently.

6) (Beyond Clean) Why is the "doing" of great policies just as important as the "knowing"? (In other words, why is this conversation worth having in the industry?)

(Ken Pichulo) If we come from a common mindset that policies are necessary from a standards perspective, then having a written standard makes no difference if it is not put into practice. In fact, departments that have policies that are not followed open themselves and their facilities to risk, when non-conforming practices lead to suboptimal outcomes.


Thanks for reading this interview. If you have more ideas for frontline Sterile Processing interviews or have your own story to tell, please email us at We'd love to talk! Until next time, keep #FightingDirty!

Beyond Clean © 2021


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