Back to Basics in the SPD

Why is getting back to the basics so challenging in the SPD?

When asked why standard practices in the SPD may be overlooked, Nancy Fellows, MSN, MPA, RN, CNOR, senior clinical education consultant, ASP, cited the following factors:

“Staffing shortages have plagued healthcare since the COVID-19 pandemic. Fewer staff members means less productivity. Additionally, the complexity of the SPD employee’s roles and responsibilities has increased due to the intricacy of today’s surgical instruments as well as interpreting manufacturers’ instructions for use (IFU).”

Fellows also cited poor quality training as a factor for noncompliance. She noted how “training is often provided from one employee to another without the behavioral understanding of the task, resulting in skipped critical steps being replaced by reasonable habits on how things should be done.”¹

Fellows summed up the overall importance of addressing what could be considered minor compliance issues:

“Small breaches in standard practice may not have an overall significant impact, such as eating in the department, brushing under water and not over it, placing chemical indicators in the wrong places, and sticking things like count sheets in the folds of wrapped trays; however, a strong, skilled, competent SPD staff performing essential invasive surgical device reprocessing is critical to quality patient care and safe patient outcomes.”

Basic best practices throughout the SPD

Some of the most common basic best practice breaches cited by SP professionals for this article were those that can occur anywhere in the department.

With more than 50,000 members and certification holders worldwide, the Healthcare Sterile Processing Association (HSPA) routinely field questions from its members and other SP professionals on standard practices in the SPD, according to HSPA Vice President of Strategic Initiatives, Damien Berg, BA, BS, CRCST, AAMIF.

When asked to provide his insights for this article, Berg stressed the importance of addressing the basics of infection prevention and employee safety before launching into more specific basic requirements for the core SPD areas. 

Microbiology understanding

“All who perform any SP-related duties should have received education (ideally, with at least annual and as-needed refresher courses) about microbiology basics and how to control microbial contamination,” said Berg. “Unfortunately, some facilities fail to provide a level of meaningful education in that regard, which can jeopardize employees’ own safety and lead to cross-contamination of environmental and equipment surfaces and other devices.”

IFU and standards

Berg noted how facilities must understand that safe, effective processing hinges on the availability (and employees’ understanding of) the latest IFUs for all equipment, instruments, chemicals, and supplies. 

“Many facilities fail to update their standards and guidelines libraries as revisions are made, and it’s not uncommon for IFU to be difficult for employees to access and understand,” he commented. “IFU and standards/guidelines should be well organized and maintained and placed in a dedicated location that is readily accessible to all technicians. If IFU are missing, vague or confusing, it is vital that the manufacturer be contacted directly for clarification and, if necessary, additional training.”

Proper, consistent use (and discarding) of PPE

“This is among the most vital safety and infection prevention requirements that must always be followed,” said Berg. “In countless social media posts from SP technicians - and even during some in-person SPD visits over the years - we have seen inappropriate use of PPE or instances where it is not providing adequate coverage.”

“It’s not uncommon to see hair uncontained by head and beard coverings, masks slipping below the nose, and face shields failing to provide proper coverage and protection from splashes and aerosolization in the decontamination area,” Berg continued. 

Consuming food and beverages

In both my interview with her and in her recent webinar, Nightmare of SPD Street, Healthmark Clinical Education Specialist Malinda Elammari, CST, CSPM, CSPDT, CFER, CSIS, CRCST, CIS, CHL, CER, CLSSGB, cited the problem of SP professionals eating in the department. She stated:

“We have found everything from candy wrappers in decontam to three-course meals, including food and drinks, in departments. Beyond eating and drinking, SP professionals must remember not to put anything on their lips or in their mouths in the SPD. This includes oral medications, such as Tylenol, and the application of lip balm or lip gloss/lip stick.”

Berg commented on the common “misstep” of hiding snacks and beverages in the department, stating:

“Some individuals have shared online photos depicting how they managed to sneak and hide food and opened cans of soda into various work areas of the department, unbeknownst to their managers. These are very dangerous, risky, and unprofessional practices, and employees must understand why it’s vital to follow standards and policies and alert their departmental leaders if they witness it in action.”

Wearing street apparel, jewelry, and other fashion items

When posting a request for SP topics to cover in 2025, Carol Malone, AAB, CSPDT, CRCST, CIS, CHL, CER, director of marketing, Clinical Education & Implementation for Turbett Surgical, was one of the first SP professionals to respond, emphasizing the importance of basic practices in the SPD. 

Malone emphasized that there are certain essential skills every SP technician should have regardless of their shift. These include the ability to properly execute and document all machine testing. She also outlined general guidelines for SP professionals: they should wear only hospital-laundered scrubs in the department, avoid fake nails, refrain from wearing open-backed shoes, and not wear street clothes under their scrubs or in the department.

Berg pointed out how long, polished, or artificial nails “pose an infection risk because they can harbor bacteria or chip or fall off into instrument trays.” He noted how “nails should be clean, natural, unlacquered, and well-maintained, with a length that does not extend beyond the fingertips.”

“Additionally, personal bags and backpacks, electronics such as cell phones or other mobile devices, and other outside items should not be brought from home and into any SPD work areas because these, too, harbor microorganisms that can contribute to cross-contamination,” Berg added. 

Berg also highlighted the pervasiveness of jewelry in the SPD, which goes against written standards like ANSI/AAMI ST79. He stated: “Some technicians - and even those in leadership positions - continue to wear jewelry, such as earrings, necklaces, rings, facial piercings, and watches (including Apple-type watches). It’s imperative that managers teach by example and remain vigilant about these missteps among their employees.” 

Basic best practices in each area of the SPD

Many of the back to basics insights provided by SP professionals for this article focused on practices specific to an area of the department and, in some cases, areas outside of the department. 

Point of use (POU) basics

To drive best practices, Fellows stressed the importance of the SPD and OR teams developing a “symbiotic relationship.” She stated:

“Because the OR may not understand the responsibilities of the SPD, they may not appreciate the challenges faced by those employees. While it may take some coordination between the two departments, SPD staff should have an opportunity to observe a surgical procedure to see how instruments are used. This will provide the knowledge and importance of tray assembly, inspection of surgical devices for accurate functionality, and patient safety.”

John Kimsey, VP, Processing Optimization and Customer Success, STERIS, acknowledged how “Back to basics wouldn’t be complete without reaffirming the impact the operating room’s (OR) back table instrument handling and point of use compliance has on sterile processing performance. The better the OR can return the correct instruments to the correct tray, remove gross bioburden, and apply point of use processing gel to keep the instruments from drying, the better SPD will be able to clean and complete trays.”

Speaking specifically to the importance of point-of-use (POU) treatment compliance, Berg stated:

“Removing the debris and keeping instruments moist (either with a solution developed for this purpose or at least covering instruments with a water-moistened towel) helps prevent debris from drying and hardening on the devices and making it difficult to remove in the SPD’s decontamination area. It’s important to note that saline should never be used for this purpose because it can corrode and otherwise damage instruments.”

“Another critical factor for effective decontamination is ensuring that instruments are transported to the SPD for proper cleaning as quickly as possible (ideally within an hour of the end of the procedure),” Berg added. “The longer it takes, the more likely biofilm can form and create cleaning challenges that can then affect sterilization outcomes.”

Kimsey cited two other back to basics best practices related to communication and collaboration between OR and SP teams:

• Maintaining accurate preference cards to ensure the surgeon receives what they need, while minimizing waste of picked and unused items or missing items from the case requiring OR and SPD to scramble at the last minute.
• Measuring how well SPD meets their customer’s requirements, which he says often relies on the customer, or OR staff, to timely report all quality issues so SPD can track and follow up appropriately. 

“Far too often, we hear the OR complain that SPD under reports quality issues, yet the OR fails to notify SPD when there is a quality issue,” Kimsey commented. “Back to basics includes a cooperation from our customers to report and notify us of SPD quality and service issues in a timely fashion.”

Decontamination and cleaning basics

“Perhaps the best back to basics reminder for decontamination is to follow the instrument IFUs,” said Kimsey. “SPDs will need to leverage technology at the sink to provide technicians with the cleaning instructions they need to follow in real time instead of relying on memory.”

Many back to basics best practices in decontamination revolved around the sink, including soak time, as Kimsey explained:

“SPDs invest in the best enzymatic and detergent chemistries to breakdown bioburden and dislodge it from the instruments, but chemistries only work if we allow the instruments to soak at the correct temperature and dosage. We need to ensure staff understand the chemistry’s IFU as well as the instrument’s IFU and allow the appropriate soak time before starting the manual brushing and cleaning process.”

Chemical considerations

Proper management, handling, and preparation of cleaning and disinfection chemicals is a back-to-basics best practice on top of the list for Berg. He offered the following insights and recommendations:

• Cleaning and disinfection chemicals must be prepared properly, in strict compliance with the manufacturer’s IFU. 
• Expiration dates must always be checked.
• Chemical/solution concentrations should never be adjusted outside of the manufacturers’ recommendations (improper dilution or too much product). Just as too little chemical can negatively affect process outcomes, too much can damage devices and leave residues that make removal difficult.
• The correct temperature of each solution must  always be followed, along with water quality and pH requirements.
• Chemicals require the correct contact (coverage) and exposure time. This is an area that must always be stressed to all SP employees because if a chemical solution is not allowed adequate “wet contact,” it will be rendered ineffective. 
• If a disinfectant or other chemical solution evaporates or otherwise dries before the manufacturer’s stated contact exposure time in the IFU, the solution must be reapplied, and the exposure time must begin again.

Brushing

Improper brushing of instruments in the decontamination sink was a common back to basics failure cited among those providing commentary for this article. 

“Brushing underwater and not brushing over the water is definitely one of the  basics,” said Elammari. “When you brush over water, you're spreading contaminants through the air. You're aerosolizing them, which can put you at risk of possibly contaminating yourself and maybe breathing them in but also cross contaminating other surfaces and possibly putting patients at risk.” 

“It’s also critical to utilize the appropriate type and size of brush for manual cleaning to ensure effective removal of bioburden,” said Kimsey. “Basic options such as bristle diameter, material, overall length, and handle style all play an important role to proper cleaning. New brush styles in endoscopy include a combination nylon brush on the leading end and a series of squeegees on the trailing end to remove debris.”

Washer/disinfectors

Proper loading, use, and testing of washer/disinfectors, as well as regular monitoring of water quality, were cited as other best practices where compliance failures occur. 

“One thing we see all the time is SP teams leaving finger mats at the bottom of trays and sending them through the washer in this manner,” said Elammari. “Finger mats can go through the washer, but they must be taken out of the tray.”

“Failure to separate trays with multiple layers before placing them into the washer is another common issue,” she added. “Another problem I see is improper positioning of items, such as placing items in a way where they block the spray arms from spinning and placing the lid for a tray underneath the tray in the washer, blocking the water and detergents.”

Speaking on the importance of correct positioning of hinged instruments for effective automated washing, Kimsey stated, “Positioning the instruments in an open position with working tips facing up towards the washer spray arms allows for direct washing spray contact and cleaning of the box lock hinges.”

Jonathan A. Wilder, Ph.D., managing director, Quality Processing Resource Group, suggested SP teams ask the following questions to determine if they are in alignment with back to basic best practices in disinfection and cleaning:

• Are you making sure the washer/disinfectors are doing what they should be doing by noting if the spray arms are moving as they should?
• Are cleaning indicators run daily in more than one location in the washer rack and are they coming out spotless?
• Are you testing each washer rack that is used, especially the lumen racks?
• Are you even using the lumen racks?
• Do you make sure that detergent is being dosed to the washer/disinfectors by marking the soap bottles with a Sharpie on a daily basis?
• Are you checking daily that the spray arms do not have any debris sticking out of the holes in them and that the screen in the floor of the washer chamber has no obstructions?
• Does the water suddenly have a color or smell to it?
• Can you smell blood/decaying bioburden in the washer/disinfector?
• Are you processing each layer of the trays separately to ensure that they get cleaned and the washer sprays are not obstructed? If not separated, they won’t be cleaned.
• Are you removing filters from container lids?
• Are you placing container lids and containers in the washer separately and not stacked? If stacked, they won’t be cleaned.

“If a washer/disinfector is kept running at its best, it saves you time and labor and makes the load safe to handle on the clean side,” said Wilder. “If it is not, you have to process the instruments again.”

Equipment and supplies

SP professionals underscored the importance of adequate engineering controls, equipment, and supplies in decontamination that support SP teams in adhering to best practices.

Commenting on this topic, Berg cited the following:

• PPE that is properly fit tested for each technician to ensure correct coverage and protection from splashes, spills, and aerosolization. 
• Decontamination sinks that can raise or lower to accommodate employees of different heights, which can greatly reduce splash and aerosolization.
• Ready access to the proper supplies and training on how to use them safely and correctly. (e.g., brushes should be long enough to clean the length of lumens and of correct diameter to ensure adequate contact of the lumen interior.)
• Lighting should also be prioritized in all areas of the SPD to allow technicians to closely inspect devices for cleanliness and damage. 

Vendor trays

Noting how “vendor trays frequently have the highest percentage of quality and bioburden incidents in the OR due to improper basic inspection and cleaning in decontamination,” Kimsey offered these best practice recommendations:

• Picking up and manually inspecting each item in the vendor tray during the cleaning process. 
• Adhering to vendor IFUs that often call for washing the instruments in a wash basket and not in the vendor tray where the instruments have specific location holders. 
• Washing the tray in a sonic washer, which is usually listed in the IFU as a requirement. “Unfortunately, many SPDs do not have the adequate sonic capacity required for the volume of vendor trays requiring justifiable capital investment to meet the clinical requirements,” said Kimsey.
• Separating multiple tray levels onto the washer manifold for effective automated cleaning. 

Preparation, packing, and assembly basics

“Assembly back to basics includes three points: prioritize, follow the count sheet, and inspect,” said Kimsey. “First, assembly technicians should be working on trays that are needed or prioritized. If you have a backlog of trays, this could be critical to ensure you meet the OR needs and timely case cart completion. If you don’t have a backlog, good for you, and you can then assemble by first in first out.”

Count sheets

Kimsey emphasized the importance of SP team members following count sheets instead of their memory. “As hard as it is to check off each instrument in the tracking system or paper count sheet as you place it into the tray, it is the best way to avoid a mistake and stick to the basics,” he explained. 

Berg commented on how technicians must be provided count sheets that are clearly written, standardized, and available to all SP employees across all shifts. While the pack content information can be collected and stored manually or in a computer system, according to Berg, he noted how either approach should include these basic yet essential details for the assembly technician:

• Complete, accurate name of the tray.
• Detailed list of tray contents, including quantities, sizes, and catalog or reference numbers.
• Critical steps for preparation and inspection such as how they should be assembled and disassembled according to their IFU.
• Detailed instructions for proper placement of items in the tray.
• Type and size of packaging to be used.
• Type and placement of internal and external process indicators.
• The destination or storage location for the tray.

Chemical indicators

Multiple SP professionals cited correct chemical indicator placement depending upon the sterile barrier being used as a back to basics best practice that must be followed. 

“Remembering how our customer, the OR, opens and inspects instrument trays for sterility reminds us to place a chemical integrating indicator in visible sight upon opening the tray,” said Kimsey. “This may mean you place indicators in the bottom corners as the most challenging position but another indicator on the top for immediate visual confirmation by the OR staff.”

According to Elammari, it is not just where chemical indicators are placed but the manner of placement and quantity of indicators. She stated, “When you are wrapping a tray or placing instruments in a container do you know how many indicators to place and where? Are you putting the indicators in bags and not taping indicators inside a tray?” CIs should be placed in the most resistant area of the sterile barrier system being used.”

“Another back to basic is the ability to properly read printouts, she added. “So, understanding the numbers, what they mean and how to read that the cycle parameters were met via the numbers during each phase.”

Inspection and testing

Thoroughly inspecting instruments and devices for cleanliness, dryness and functionality before they are placed in trays is another back to basics best practice area SP professionals called out as critical but not always performed. 

“Back to the basics means standardizing how your technicians are expected to inspect instruments and could include visual inspection, magnification, borescope inspection, cleanliness verification tests, and testing for functionality,” Kimsey commented. “As we ‘rush’ to complete our work or find ourselves understaffed, inspection and testing is one of the first areas to cut corners on and skip. Let’s stick to the basics and ensure our patients and surgeons have clean, sterilized and functioning instruments!”

“One specific problem I have come across is failure to test scissors every time they come through assembly,” said Elammari. “Oftentimes when we go into facilities, they don’t even have scissor testing material at their stations, or they have only one size testing material and not the two different thicknesses needed to test different size scissors.”

“And it's not just failure to test basic instrumentation, but laparoscopic instruments as well,” she added. “So many times SP teams will tell me that they test every lap tray but upon observation they are not testing critical components of these devices to ensure they are working properly, such as insulated shafts and handles, as well as monopolar and bipolar cords.”

For departments with newer staff or vendor tray quality issues, Kimsey said a great back to basics practice is to have an experienced and higher-level technician perform quality assurance checks on high-risk trays and trays assembled by newer less experienced employees.

“Back to basics in assembly also means an organized supply of single back-up instruments,” Kimsey added. “Let’s stop piling up instruments like junkyards and instead create organized, labeled, and routinely cleaned and managed back-up instrument inventories that represent the most used and missing instruments.”

Containers

In Berg’s experience, some technicians who carefully inspect each instrument “make the mistake of not giving the same attention to the containers and all their components.”

“This can have a direct and negative impact on sterilization outcomes,” he explained. “Rigid containers, for example, must be cleaned according to the IFU, interior backets must be removed and cleaned, and dividers and pins may need to be removed if they interfere with cleaning. The containers should also be carefully inspected to identify damage or wear that could affect the sterilization process or sterility maintenance.”

Berg provided these examples of important container inspection points:

• The filter retention plate should be intact and not bent, allowing it to be seated properly over the filter and secured in place.
• The container and lid (including the edges) should be inspected for dents, chips, and other damage, and the retention post must be secure, with no movement present.
• Handles should also be checked to ensure proper movement and function, and latches and springs should function properly to ensure a proper seal.  

Packaging

According to Elammari, proper sealing of peel pouches is another area to revisit when it comes to back to basics in the SPD. She stated:

“Whether you're using a heat sealer or self-seal, are you doing the process correctly? When you seal it with the heat seal, is it a flat, even seal? Do you have any creases or wrinkles? Or if you're using a self-seal, are you using the right technique?”

With regards to sterilization wrap, Berg emphasized how it is critical that technicians only use tape created specifically to withstand sterilization and never use safety pins, staples, paper clips and other items for packaging closure. “Punctures, creases or other damaged caused by their use can allow contaminants to penetrate the packaging,” said Berg. “Using too much tape that was approved for sterilization can also prevent an effective process.”

Elammari stressed how technicians should not use steam tape, filters, blue wrap, and peel pouches outside of their attended purpose (e.g., using blue wrap as liners for workstations, shelves or tables). 

“I’ve seen departments where technicians use steam tape to hang up peel pouches and use peel pouches to separate extra instruments in drawers,” she noted. “Nothing used for sterility should be used in any other manner. Tape [MM1] on instruments is another big issue and a big focus for The Joint Commission (TJC).”

Sterilization basics

Kimsey referenced IFU compliance when it comes to sterilization back to basics, stating:

“Back to basics for sterilization should always include following the instrument sterilization cycle IFU requirements,” Kimsey added. “While many SPDs utilize instrument tracking systems for electronic sterilization records, it’s best practice to enter the instrument sterilization IFU cycle parameters into the tracking system and utilize built-in hard stops and warnings to ensure the correct cycle is selected.”

Equipment 

Berg offered this list of some of the “biggest mistakes” caused by improperly cleaned instruments or residues that impede the sterilization process:

• Packages packed too densely or positioned incorrectly, preventing effective steam or sterilant contact.
• Overcrowding loads in the sterilizer chamber.
• Clogged drain strainers.
• Mechanical or utility malfunctions.

“Technicians should be shown the correct way to position and pack sets for proper sterilization, and they should notify a qualified service professional any time defects or suspected mechanical or utility issues occur,” Berg commented. 

Auditing

“Back to basics for sterilization reminds me that we used to audit our sterilization records, paper or electronic, every day to ensure we caught any mistakes and were compliant,” said Kimsey. “Keeping the daily audit routine is a best practice to ensure our instruments are sterilized, documentation correct, and mistakes caught as quickly as possible.”

Sterile storage basics

“Even the best cleaning and sterilization processes and outcomes can result in contamination and damage if packages aren’t handled, stored, and transported properly,” said Berg. “Technicians must understand that sterile storage begins the moment the sterilizer door opens at the end of cycle.”

Environment

SP professionals agree that maintaining the integrity of a sterile storage area is the first step in maintaining the sterility of the instruments, devices and supplies stored in that space.

“Sterile storage is more than the room where sterile instruments are stored, it’s the room that maintains the sterility of the instruments,” Kimsey explained. “That’s a small but important differentiating definition. To maintain sterility, we must go back to the basics of limited traffic flow, frequent air exchanges, ensure first in first out usage, protection of wrapped trays from tears, minimize stacking of wrapped items, shelf liners, dust avoidance, minimize handling, and routine cleaning.”

“No one should enter dedicated sterile storage areas without proper PPE, and these areas should not allow for pass-through traffic,” Berg commented. “The storage areas require clean, dust– and contaminant-free surfaces, proper air filtration, and adherence to ventilation and temperature and humidity recommendations per ANSI/ASHREA/ASHE I70 Ventilation of Health Care Facilities. Whenever possible, closed shelving should be used to allow for proper cleaning and protect sterile packages from contaminants.”

Closing thoughts

The SP professionals interviewed for this article provided back to basics for other areas of the SP department and additional advice for enhancing compliance, but there simply wasn’t enough space to cover everything in this one article (perhaps there is a Back to Basics in the SPD chapter two in the future?). 

Here are a few closing thoughts from the contributors:

Damien Berg, BA, BS, CRCST, AAMIF, VP of Strategic Initiatives, HSPA

It is no secret that many (perhaps most) SP professionals have experienced pressure to more rapidly reprocess instruments and devices, but as Berg asserted, “technicians must never rush or skip processes due to user expectations for rapid turnaround.”

“While it’s true that efficiency is required, that should never come at the sacrifice of safe, thorough, and consistent processes,” said Berg. “If unreasonable requests or demands are placed on the SP team, managers or other SP leaders should address those concerns with the user areas and explain why rushing steps is not an acceptable option (and provide standards for support).”

“Every patient deserves the same level of quality care, and adjustments must be made to the procedure schedule or instrument inventory if thorough, effective processing cannot be performed to accommodate procedural volume,” he added.

Malinda Elammari, CST, CSPM, CSPDT, CFER, CSIS, CRCST, CIS, CHL, CER, CLSSGB, clinical education specialist, Healthmark

“The only way I have found to keep staff members accountable is to set expectations from the beginning and reinforce them through audits and follow through. While most technicians are taught according to HSPA either in school or during their training, if the basics don’t get reinforced in the work field, they will wind up losing those concepts and converting to the department ways and shortcuts.” 

“I think from a leadership perspective, one of our biggest downfalls in SPD is that we teach but we don’t provide written expectations and reference points for staff in the way of standard operating procedures (SOP). My advice is to start by creating a comprehensive onboarding process according to industry standards and guidelines. Next, reinforce that with SOPs around each step where the procedures really define what the technician is supposed to be doing.”

“Lastly, have the technician sign off on the SOP acknowledging they understand it and audit that the process is being followed. You now have a way to standardize education and the ability to hold staff members accountable.”

Nancy Fellows, MSN, MPA, RN, CNOR, senior clinical education consultant, ASP

“As Wendall Willkie said, ‘Education is the mother of leadership.’ Sterile processing leaders must not only inspire and motivate their employees to reinforce basic practices among their staff, but also gain trust and respect while overseeing critical safety requirements.”

“SPD leaders must be subject matter experts and remain well informed on the latest work processes in accordance with the Association for the Advancement of Medical Instrumentation (AAMI), the Association of PeriOperative Registered Nurses (AORN), and the Healthcare Sterile Processing Association (HSPA). They must be able to identify employee mistakes readily, address them, and through education implement processes to eliminate mistakes in the future.”

John Kimsey, VP, Processing Optimization and Customer Success, STERIS

“To ensure staff retention and engagement to improve and sustain departmental performance, we can’t forget the basics of employee engagement. Maintain open and frequent communication, set clear expectations, follow-up and offer assistance, listen, make personal connections, create fun activities, be fair and hold all equally accountable, show them you care about them and about the department’s performance.

“A great back to basics employee engagement is recognition. Too often we find ourselves so focused on the daily business we forget to recognize the multiple  important efforts our staff make every day. Recognize frequently and often while learning how each person prefers to be recognized.”

Carol Malone, AAB, CSPDT, CRCST, CIS, CHL, CER, director marketing, Clinical Education & Implementation for Turbett Surgical

“My thoughts on reinforcing best practices revolve around three key elements: a clean, organized department, consistency in tasks, and unbiased accountability for all staff members. Consistency and accountability can be effectively monitored and tracked through regular audits.”