A Multi-Faceted, Data-Driven Approach to Sterile Processing Transformation and Optimization

While some sterile processing departments (SPD) have demonstrated impressive improvements in specific areas of their operations, such as quality, productivity, or education, the UF Health Shands SPD team impacted all these areas in the past year. 

They embarked on the transformational change of centralizing instrument reprocessing to a 57,000 square foot Offsite Reprocessing Center (ORC), going live with all surgical services locations in just five months. 

Guided by a strategic vision and robust plan; enabled by digital technology solutions, optimized processes, and strong relationships; and informed by advanced data and analytics, the UF Health Shands SPD team didn’t just survive the transition – they shined with exceptional performance.

In 2024, the team of 137.8 full-time employees (FTEs) supported 79 operating rooms (OR), which performed 47,258 surgical cases. The ORC handled 70% of total instrument reprocessing, with 219,145 surgical trays and 7,010,227 surgical instruments sterilized.

Key performance metrics include:

• 6.5% increase in total instruments reprocessed from 2023 to 2024
  • 5.5% increase in total sets
  • 7.8% increase in loaner sets
• 30% increase in commonly used instrument assets
• 18% reduction in sets requiring rapid 24-hour turnover
• 66% reduction in sets overdue for repair
• 85% increase in scope processing electronic records 
• 71% increase in OR staff accessing quality events module
• 1.3% average defect rate per set
• 0.05% average defect rate per instrument

In September 2024, the team successfully completed a survey performed by The Joint Commission (TJC) with zero findings at the ORC.  

In her nomination for HPN’s 2025 SPD of the Year, UF Health Shands Sterile Processing Director Sara Vinson, MBA, CRCST, commented on the critical importance of the team’s data-driven and continuous improvement mindset, stating:

“What truly sets us apart is our dedication to innovation and investments in advanced analytics. With such a wealth of data at our fingertips we can focus on what truly will impact our operations in a positive and meaningful way. Establishing internal benchmarks and tracking ongoing performance ensures we are delivering our desired results. These robust analytical tools are essential to our successful performance.”

When asked to describe the success of the ORC, Vinson stressed the importance of a multi-faceted approach.

“Our success did not hinge on a single factor; rather, it was reliant on a multitude of elements. Our chosen areas of focus happened to align with the HPN SPD of the Year nomination criteria. This included a strategic plan, customer coordination, collaborative teamwork, productivity aimed at maintaining high quality, and education and training for a talented and sustainable workforce.”

In telling the story of UF Health Shands as the 2025 HPN SPD of the Year, HPN delves into each of these key components that together made for a winning team.

About UF Health Shands

University of Florida (UF) Health Shands is a private, not-for-profit healthcare system located in Gainesville, Florida. The health system includes the UF Health Shands teaching hospital, five specialty hospitals - UF Health Shands Cancer Hospital, UF Health Shands Children’s Hospital, UF Health Psychiatric Hospital, UF Health Heart & Vascular Hospital, and UF Health Neuromedicine Hospital - a network of surgical centers, outpatient rehabilitation centers, and a home health agency. UF Health Shands has been consistently recognized as the top hospital in Florida and among the best hospitals in the country.

About the UF Health Shands SPD

The UF Health Shands Sterile Processing Department (SPD) is responsible for the reprocessing of all reusable medical devices used in surgical, inpatient, and outpatient procedures. The team provides care for patients of all ages and for all specialties. Ancillary units supported include intensive care units (ICU), radiology, respiratory, endoscopy, the emergency department, labor and delivery, and many more.

The UF Health Shands SPD team’s reprocessing methods include steam sterilization, low temperature sterilization, and high-level disinfection (HLD). Their process begins when point of use ends. The team performs decontamination, inspection and assembly, and sterilization procedures. Their scope of work ends at the point of return to storage. From there, their surgical services and supply chain partners take over inventory management, case cart building, and delivery of surgical items to the required destinations.

Long-term strategy reflects projected surgical services growth

“Having a strategic plan to respond to rapid growth and the ability to adapt quickly is a must for surgical services,” Vinson explained.

UF Health Shands designed and built its ORC to support projected surgical services growth for the next 20-25 years. During the planning and opening of the ORC, UF Health expanded by adding 14 additional ORs with plans to open eight more in 2025.

Designed with continued growth in mind, the ORC features a unique one-piece flow layout to increase efficiency and create shelled space for expansion as needed. Innovative features, including real-time location systems (RTLS) software and automated inventory management systems, streamline workflows to enhance efficiency and productivity. Furthermore, investments in advanced analytics refined the UF Health Shands SPD team’s ability to guide strategic initiatives and key performance metrics.

In-housing instrument maintenance and repairs

Recognizing the importance and challenges of timely surgical instrument preventative maintenance and refurbishment, UF Health Shands strategically positioned an in-house instrument repair lab within the ORC. Vinson described their use of technology to streamline these processes:

“Our instrument tracking system flags how often a set is due for refurbishment, which will signal to the assemblers when they need to deliver a set to our onsite repair technicians. Once the technician completes their inspection and refurbishment, the set returns to the decontamination room. Now these repairs can occur during the reprocessing cycle versus the traditional model of running reports and locating sets each day that a repair technician comes to your facility.”

With this new proactive model and enhanced tracking of repair cycles, UF Health Shands has significantly reduced the number of sets overdue for repair by 66%. According to Vinson, this has had a direct impact on the SPD team’s customers, “as their instruments are maintained at the highest quality standards to ensure proper function and sharpness is available consistently.”

Inventory optimization supports exceptional customer service

One challenge that comes from transitioning to off-site reprocessing is the additional time it takes to turn around trays due to increased logistics and transport. To ensure each department has the instruments they need when they need them, UF Health Shands increased its inventory of most used instrument assets by 30%. The result: an 18% reduction in sets requiring rapid, 24-hour reprocessing turnaround. 

The team renovated and converted former hospital-based SPDs into sterile storage to accommodate the additional inventory.

Managing inventory investments

As part of its strategic plan, the UF Health Shands SPD team continuously monitors instrument usage and adjusts inventory as case mix and volumes change. Vinson noted how this was and continues to be a significant financial investment for the health system. For Q1 of the 2024 fiscal year (July – September 2024), they were 53% over budget in their instrument spend. Vinson described the steps they took to serve as “good financial stewards of the organization.” 

“We developed a standardized instrument request form and tracking tools that help us monitor our total requests compared to our actual spend and our current budget,” Vinson explained. “We also use these tools to monitor the response time and performance of our instrument coordinators.”

Since implementing and using these tools, the team ended Q2 2024 only 9% over budget fiscal year to date (FYTD). “We have set ourselves up for successful completion of meeting our budget by the end of the fiscal year,” Vinson added.

Integrating technologies to replace missing instruments

Another challenge that arose from moving to the ORC was an increase in missing instruments. 

“Those most familiar with the OR and SPD know it’s not an uncommon occurrence that instruments can become mixed within other sets used from the same case and then subsequently misplaced or lost,” said Vinson. “With the logistics of transporting multiple OR locations to a central reprocessing location, you need to be well organized and maintain a robust backup instrument inventory.”

In November 2024, UF Health Shands SPD team began piloting the Summit E-Procurement Platform, which works in conjunction with the health system’s Sonar instrument tracking system. This allows the team to run missing instrument reports and submit requisitions for replacements more efficiently and effectively. 

During the first two months of using the integrated solutions, they noted a decrease in tray assemblies with missing instruments. Addressing missing instruments continues to be the team’s top key performance indicator (KPI) for 2025. They have created a project charter and will be collaborating with the UF Health operational effectiveness and surgical services teams in a multidisciplinary missing instrument task force.

Teamwork ensures a smooth transition

“The phrase ‘It takes a village’ takes on a whole new meaning when you are developing and planning for a major change and transition,” said Vinson. 

Vinson and her team worked extensively with all key stakeholders to ensure their concerns were heard and addressed, including the UF Health Shands OR teams. They held several pre-planning meetings to help ease anxiety among surgical services team members. 

To ensure a strong collaborative relationship between the SPD and OR teams was maintained, they created a team structure and supporting processes. This includes having a dedicated OR liaison who is present and performs rounds in each of UF Health Shands’ main OR locations. This individual helps communicate issues and troubleshoot them in real-time.

UF Health Shands Clinical Coordinator Rebecca Qualmann, MSN, RN, CNOR, CST commented on this work:

“I am extremely proud of the UF Health sterile processing department who, on a daily basis, promotes teamwork, quality, and collaboration. This team has worked incredibly hard to navigate a great deal of change all while promoting UF Health’s mission and focusing on patient outcomes. The staff care and it shows through their dedication and hard work!”

Gaining support from industry partners

The UF Health Shands SPD team acknowledged not only the role of internal teamwork in achieving strategic goals but also the support of external partners in driving their success. 

“From consultants to equipment and instrument manufacturers, storage solutions and software platforms, we would not be as successful as we are today without these partnerships,” said Vinson. “A special thank you goes out to the teams at Aesculap, Ascendco, DSI, and STERIS.”

Vinson reached out to these partners to provide commentary for her team’s HPN SPD of the Year nomination. Here is what they said:

“At DSI, we are proud to partner with UF Health Shands in their pursuit of excellence in sterile processing,” said Ian Loper, VP of Sales and Marketing, DSI. “With multiple on-campus SPD locations and the new offsite SPD, UF Health Shands has demonstrated remarkable foresight in standardizing storage practices as part of their ongoing efforts to upgrade storage solutions. These initiatives, including the optimization of storage locations during backfill construction, reflect the team’s unwavering commitment to efficiency and patient safety.”

“What truly sets UF Health Shands apart is their exceptional staff, who work seamlessly together to achieve their goals,” Loper added. “Under Sara’s dedicated leadership, the team has cultivated a culture of collaboration and innovation that drives continuous improvement. Their dedication to excellence sets a benchmark in the industry, and we are honored to help support their efforts in creating a more streamlined and effective SPD environment.”

“UF Health Shands represents where all healthcare facilities will need to be in the next 3-5 years,” said Brian Reed, CEO and co-founder of Ascendco Health. “Their leadership in digital innovation and commitment to raising the bar for patient safety are setting a new standard for the industry. The best partnerships drive mutual growth, and when one organization advances patient care and safety, it strengthens the entire healthcare ecosystem. This is more than progress; it’s the future of healthcare, shaped by their dedication to collaboration and innovation.” 

Quality measures aligned with productivity improvements

A driving force behind the establishment of the ORC was the UF Health Shands SPD team’s desire to ensure standard best practices are easily implemented and monitored. To support continuous quality improvement, Vinson and team provided OR staff access to the SPD’s quality events module. In doing so, they ensured the OR had a means of communicating challenges to the offsite SPD team.

As a result, the number of OR staff members who have access to and are utilizing the module jumped from 87 to 149, a 71% increase. 

As Vinson noted, one would expect that an increase in quality event reporters of this magnitude combined with a transformational shift in SPD workflows would significantly impact overall quality metrics, but this wasn’t the case. She stated:

“Maintaining the highest quality standards during this incredible change is another noteworthy accomplishment of the SPD team. We have maintained an average defect rate per set at 1.3% and an average defect rate per instrument at 0.05%.”

“In addition to quality, we did not see a significant impact on our overall productivity rates during this change and transition,” Vinson added. “Our case volume and total output grew substantially year-over-year, but we maintained our production rates. Meeting the increased demand was achieved through an increase in nearly 30% more FTEs. During the calendar year 2024, we added 13.7 FTEs.”

Prioritizing scope processing documentation

For those SPD team members who remained on-site in UF Health Shands’ hospitals and surgical centers, a key quality improvement priority in 2024 was electronic documentation and tracking of scopes undergoing high-level disinfection (HLD). By improving utilization of software for scope processing documentation, the team aimed to boost compliance with best practices and ensure higher levels of patient safety. 

Through this effort, they increased scope processing records by 85%, from 521 in January 2024 to 964 in December 2024.

Educational partnerships establish a sustainable and talented workforce

Given the widespread and ongoing staffing shortages in SPDs across the U.S., the UF Health Shands SPD team has partnered with local colleges and academic centers to recruit and train the next generation of SP professionals. As a result, the department’s overall educational effectiveness, recruitment, and retention have improved.

One partnership is with Santa Fe College, which offers a 30-credit-hour sterile processing technology certificate program. Students learn the fundamentals of SP in the classroom then receive hands-on experience at UF Health Shands. Upon completion of the program, a student takes the certification exam and if they pass, they are ready to apply for a career opportunity within the SPD profession.

Julia Wagner, MS, CHES, CSFA, CRCST, program director, assistant professor & clinical coordinator for Sterile Processing Technology at Santa Fe College, commented on the collaboration with UF Health Shands, stating:

“Our partnership with UF Health Shands has been essential in providing exceptional education and training for our students at Santa Fe College. Through the guidance of UF Health’s educators and staff, students gain invaluable hands-on experience that prepares them to enter the workplace confidently. By practicing industry best standards and maintaining a focus on excellence, our students graduate from the sterile processing program with the knowledge and skills needed to excel in their roles and succeed on the CRCST certification exam. The partnership with UF Health Shands is a cornerstone of our program's success.”

The second partnership is with one of UF Health Shands’ local high schools, which offers a “Pathway to Healthcare Careers with a Medical Skills Program.” When a student in the program enters their senior year, they participate in an internship at UF Health Shands where they rotate through various departments to observe and learn about healthcare careers. 

“The space at the ORC has allowed us to expand the number of students we can host,” said Vinson. “Each semester, we train eight to 12 students.”

Looking ahead

“The year 2024 was a busy and exciting year for UF Health SPD,” said Vinson. “There are almost too many accomplishments to recognize in a single nomination submission.”

With a dedicated space for SPD operations in the ORC, effective and efficient workflows in place, and the integration of advanced technologies for process automation, data capture, and analytics, the UF Health Shands SPD team is positioned for continuous optimization and quality improvements. 

Alongside their technology solution investments, they onboarded a dedicated platform specialist who oversees their tracking platform and serves as a crucial liaison between departments, which Vinson said “is essential in driving process compliance and improvement.”

“Our strategic plan to support future growth and streamline our processes has completely redefined how we operate as an organization,” she added. “With a data-driven and continuous improvement mindset, there are endless opportunities for our future success.”