Last updated January 12, 2025
In this episode, Kathleen Wessel, VP of Business Management and Operations at the AHA, is joined by Henry Tomasuolo, Senior Vice President for Support Services at Boston Children’s Hospital; Angus Bruce, Enterprise Director, Sterile Processing Department, at Boston Children’s; Leslie Basham, President and CEO of Surgical Directions; and Amanda Kieser Montgomery, Managing Director, Client Services, at Surgical Directions, to discuss how Surgical Directions partnered with Boston Children’s Hospital to revolutionize its Central Sterile Processing Department.
Transcript
Kathleen Wessel
Focusing on quality safety in the patient care experience are all part of a clinician’s DNA. And when we’re able to successfully apply technology and process to advance these efforts, we celebrate. Today we’ll discuss how Boston Children’s Hospital was able to revolutionize its central sterile processing department and achieve great recognition in the process. Welcome to AHA’s Associates Bringing Value, a podcast from the American Hospital Association. In this series of podcasts, we speak with associate program business partners, check on their efforts, and learn how they support AHA hospitals and health system members. I am Kathleen Wessel, Vice President of Business Management and Operations with the AHA. And today I am joined by guests from Boston Children’s Hospital and Surgical Directions. Please, let’s welcome from Boston Children’s, Henry Tomasuolo, Senior Vice President of Support Services, and Angus Bruce, Enterprise Director of Sterile Processing Department. And from Surgical Directions we have Leslie Basham, President and CEO, and Amanda Kieser Montgomery, Managing Director of Client Services. Together, this team facilitated Boston Children’s Hospital’s amazing story that we’ll explore today. So thanks for joining me today.
Guests Together
Glad to be here.
Thank you for inviting us.
Thanks for having us.
Kathleen Wessel
Yes, thank you so much. This is going to be a great conversation, and we’re going to start with you, Henry and Angus. Could you please give our listeners a better understanding of the situation that Boston Children’s Hospital found itself in and the problems that you were trying to address?
Henry Tomasuolo
Sure. So I’ll take the first crack at it. So just to set the table a little bit, I was asked to take over responsibility for SPD in May of 2022. And like a lot of other areas under my responsibility—support areas—SPD is traditionally viewed as sort of one of the offensive linemen of hospital operations. And by that I mean that people aren’t coming here because we have an unbelievable SPD department. They’re coming here because of the great doctors, nurses, and researchers that we have here at Boston Children’s Hospital. But if the offensive line doesn’t do their job, and people do come to football games to see the quarterbacks, wide-receivers, and running backs do their work. But if the offensive line doesn’t do their job, then that $700 million quarterback you have is going to spend a lot more time on his back picking himself off the ground than celebrating touchdowns, and nobody wants to see that.
So, I was asked to step in as we started to see a few leaks in our operations at Boston Children’s Hospital. Some issues concerning the quality of the work that we were doing, some accuracy; we had some issues regarding the accuracy of the trays, the quality of the instruments that were being processed. It was pretty clear that we didn’t have a very good educational program. In fact, we didn’t really have any. And so there was a large variation in the amount of training that each person did it, and there was a lot of variation in the work that was being done. Additionally, we had a change in leadership at the time. The current manager was moving on when we took over, and we had a lot of outdated information in our data systems. So our SPM hadn’t been updated in about 15 years. We had some challenges with the scheduling, and since this was sort of a post-Covid environment, we were having a number of staff challenges that the schools closed down. So we weren’t getting an influx of new employees, and we also, we had a lot of travelers on board. To put the cherry on top of the ice cream, we were also relocating to a new building. So we were building a brand new hospital with new surgical suites. We were going to still have suites in the old building. And historically, the OR had been co-located right next to SPD. In the new model, we were located in the new building and quite a distance from a number of the ORs. So we had our work cut out for us.
Angus Bruce
So just to chime on where Henry left off, there was a lot of work that was done prior to me coming on board to BCH. My role when I came on was to take all of that work, or the foundation that was set up, and then carry it on and build on top of that. When I started, thank you, Leslie and team for starting me off correctly, had to look at the education, the education program that was in place was not—even though it was something that was put in place, temporary—we needed something a little bit more robust that we can consistently produce the results that we wanted. So we looked at the training and orientation. We invested in some new technology to marry it—the orientation and training piece. We extended our orientation and training—a longer period given each individual more time in the individual areas to learn because as the adult learner, everyone learns differently.
So we wanted to make sure that everyone was getting the same consistent training, but getting enough time to pick up the good habits that we want them to pick up. Then we started looking at the management team. So I had to basically onboard new supervisors, managers, and basically build a team from scratch. But also I was very selective about the folks that we were bringing in to be part of the leadership team because we all had to be on the same page as the direction of the department is going in. And the team that I selected, they were very enthusiastic to come on board. They were excited with the direction we were going in. So everyone was marching in the same direction. And when the staff saw that…change for some people is hard. Especially BCH, been through so much in the last two, three years. One can say they were a little tired of change, but when they realized that the changes that we were making was to benefit the entire department, but also support patient care in a positive way, they were all on board with that.
Kathleen Wessel
Those sound like just a full set of sea changes across the board. Sorry, I couldn’t find the appropriate football analogy for you. Henry
Henry Tomasuolo
I got plenty of them.
Kathleen Wessel
Trying to revamp an older process is never easy. And it sounds like you needed to utilize not just one, but several solutions across your organization. For the Boston Children’s team, could you talk about the solutions you applied and how you partnered with Surgical Directions to achieve those goals?
Henry Tomasuolo
Sure. So to really help convey this, I’m going to switch analogies here and talk about how when you started this work, it was sort of the equivalent of … when you start working on an old house and you start doing the work and the more you open up, the more problems you realize and you find. And this definitely became like an adventure of this old house. The challenge was that while we were doing the renovations on this old house, we were expected to sterilize instruments and provide really quality product for the largest children’s hospital in New England, and make sure that those instruments were provided to our providers in a way that would not provide any risk, but also on a timely basis because the volume that we face every day is huge. And so we had to rebuild the house but still get the product out the door, which is not easy.
Luckily, I spoke to our senior leadership team, gave them gave an update on what we were doing, and they agreed to make the investments that are necessary to bring this up. And that’s sort of the challenge of what you have in a lot of SPDs is, as I mentioned, the offensive line… people don’t spend a lot of money. You don’t have $700 million offensive linemen, right? But when the performance isn’t there, the evidence of that is pretty, pretty clear. So we started engaging some additional resources internally. We worked with our patient safety and quality team. We worked with our internal performance improvement team to get ways to help us to get through the process. We engaged clinical leadership to let them know what challenges we were facing and how that would impact what they were doing and what they could do to help us.
But really probably one of the most important things that we did was prior to my taking over the responsibilities, leadership had engaged Surgical Directions to do an evaluation of the operations, which has led to some of the changes we talked about. And they had done a very good job of doing a comprehensive evaluation of the opportunities for improvement in there, as they can see them. So I went to the leadership there and said, “Hey guys, I appreciate the work you did here. Can you help us fix it now?” Which is not very common among the consulting world. For those of you who have worked with those groups before—they’re greatest telling you what the problems are, but fixing in is your problem here. So we started working with Surgical Directions to bring in resources. We brought in interim leadership to help us because— and we made that decision because although we knew that getting permanent leadership was really important, the difference in skills between building and operating are there. And we needed to get a quick bolus of leadership there.
And that also allowed us to take our time and do a national search and find the absolute best leader in the country to come to in and take this over. So we worked with Surgical Directions and they were a phenomenal partner for us. They provided experts, they provided national benchmarks, they provided best practices for us. Whenever we had identified an opportunity for improvement that we didn’t have resources for—whether it be educators, clinical experts, operational leaders—they were able to provide us with those on pretty quick turnaround. I was really excited because during this whole chaotic period, they never said no to us. It was always, “Yes, let’s figure out how to do it.” And they were really great partners for us on this. One of the other things that’s very important, but often undervalued is they also provided a sanity check for us.
So as we started to make these builds, and the people that were largely involved from hospital side were not experts in this area. But we took the operational principles and said, “Hey guys, what do you think about this?” And they were able to provide us with some views of, “Hey, this is how it works. Maybe you guys don’t understand that.” And to their credit, they pushed back when they thought we were going in the wrong direction, and we had some really good discussions on how we can move this thing together. So as anybody who leads these things knows, you don’t want people just saying yes to you and keep moving on. You want real pushback and feedback when it’s going. So they provided a number of opportunities to really help us. And I’ll let Angus fill you in on the balance of how we got here after I was able to recruit him after numerous begging trips and phone calls.
Angus Bruce
So yeah, so initially…so story, I used to work at Boston Children’s when I was a younger, I would say a kid. And my lens then was a lot different. I remember back then, and I worked actually in the SPD department. The SPD department back then was all about education. We had classes every Thursday. We had to understand why we do what we do and the reasons, all the reasons behind that. So everything was very organized and there was no chaotic environment. So when Andy and Henry approached me, it was, “Oh, I get to return back to BCH.” So it was an opportunity. I like to build things. At my previous institution, I instituted a lot of quality program. We were down to averaging at three defects a week, sometimes zero on weeks on end, had a good solid working team. So I kind of got to the point where, “Okay, my process has been completed here, it’s time to hand over the reins.” And I jumped at the challenge to go to BCH and start anew.
When I first started there, I had to get to know what was going on, what was done, and also get to know the OR our staff. As you’re aware, in most institutions there’s always this rivalry between the OR and the SPD because they speak two different languages, but they’re working towards the same goal. So my job was to become that ambassador and bridge those gaps and be a partner with them, and showing them that we’re not here to be adversaries. We’re just here to help you do what you do every day. Let us focus on the support piece, and you worry about taking care of the patient. So have had good results with that. We’re constantly working with the teams in the operating room to make sure they have what they need. Also being a little more strategic planning with them. Having them think about what’s coming up next year so we can properly plan downstairs in SPD. That so when they make that pivot, we can pivot with them smoothly.
Kathleen Wessel
I appreciate that. Thank you for that context. Switching to Leslie and Amanda, could you tell us a little bit about Surgical Directions and what solutions you use to help Boston Children’s Hospital begin the journey of reaching 0% tray defect?
Leslie Basham
Absolutely, Kathleen. So I’ll start and then hand it off to Amanda. I’ll use fewer football analogies, Henry though, so it’s going to be less of a crowd pleaser there. But so Surgical Directions is a healthcare solutions company. We’ve worked with about 500 different hospitals and health systems, like Boston Children’s, to improve perioperative services, procedural care, anesthesia services, and in this instance, sterile processing, which is really instrumental—using that word instrumental to—change and improve the care for the patients in the New England and global market that Boston Children’s serves.
So Surgical Directions, we offer consulting services which was used here, leadership and workforce solutions, which was also important to the needs here. And then we have a technology called Merlin that helps with perioperative improvements. But what really makes us different, and I think what worked well for Henry, Angus, and their team is we use a peer-to-peer model. So there’ll be administrator to administrator. So Amanda was always working with the team. I was always working with Henry. And then we had sterile processing directors and managers that could work with Angus and his predecessors and help to have that peer-to-peer relationship— not just to assess, like what Henry talked about the beginning—but actually to execute arm in arm on how to do this and to make the changes sustainable.
There was a tremendous…we set the goal of how do we make sure that Boston Children’s Hospital continues to provide world-class care, and what does world-class mean for sterile processing? And we designed what that could look like, understood where there were those gaps, and the root cause for the gap. The analogy of the home was so true. You may have thought the floors creaked, but underneath maybe there was a foundation issue or something else going on. And so as we continued to dig deeper, understanding what those real root causes were, and then what we needed to fix and to sustain that. And now for nearly a year, it’s near perfect performance on everything that’s done in sterile processing. So we have a very collaborative model, Surgical Directions, and that was absolutely true in this instance with great partners. And I think that helped to drive the success of that transformation and of rebuilding that the beautiful old home, as Henry used that analogy. So I’ll kick it over to Amanda to…oh, see, “Kick it over.” I did that one…to Amanda to talk a little bit more about the details.
Amanda Kieser Montgomery
Thanks, Leslie. And as Angus and Henry have both mentioned, it really was about going back to the foundation and the building blocks that the team needed to have to be successful. And for us to build upon to reach that world-class, as we defined it as a group. One of the main items we started was daily audits with a 360-feedback loop to the employees, with education. So these conversations weren’t punitive, it was educational to let them know in real time if they were responsible for a defect that either went to the OR or just met with our quality assurance team. So we placed a quality assurance tech on every shift so that all the trays were audited prior to even leaving the department. And again, this allowed us to have the collaboration between our team, but also as that stop gap before it ever left the department. We also had to ensure that all of the technology that is available for these team members at their stations was available. So adding screens in decontam so that they had the information readily available at their fingertips, ensuring that their workstations were standardized, and that the process flowed the same no matter what station that you were at. So again, having that repeatable, consistent process, no matter the tech that was in place.
Another item that we really honed in on was our partnership with the OR. So how do we have a liaison that the OR nurses are comfortable with, and these experts downstairs, to ensure that the trays for that service—any specialty items—that they could educate their fellow team members and be the point person when the OR needed something. So it really was back to the basics and then partnering with not only the OR, but the frontline team members to ensure that the workflows met their needs and made their job easier every day.
Kathleen Wessel
I appreciate you providing just the full context there. Because this isn’t just about process, this isn’t just about the tools of the technology—the mindset shift that people have to go through seemed pretty significant. And if you don’t have that—both with that safety within the team and then extending to the teams that connect—that could be a pretty daunting task.
Are there other things that either fuel ,or Henry and Angus haven’t mentioned that would be considered best practices, or other recommendations you could provide for us?
Angus Bruce
Sure. So SPD usually operates in a shotgun mode. Everything is all reactive and people don’t take a second to stop, pause, and ask a question. So with my team that I’ve built, I’ve changed their mindset to like, “Hey, stop operating in shotgun mode. Let’s think, stop, think, pause, take a pause for a break.” When things come up, we investigate thoroughly. We investigate whether it’s our fault, whether it’s someone else’s fault, it doesn’t matter at that point. We need to investigate because whatever solution we put in place has to be a permanent solution and not just a Band-Aid. So for them, it was a change in the way they operate. Also, we collect data on all of our audits. We looked at all of that as a team and we look for trends. And when we have our meetings, I call it out and say, “Hey, do you guys see what I see?” Give them a second to think about what they’re seeing and then let them respond and try to guide them to start looking at the data in a way that is objective. And then, “Okay, if we’re seeing trends, let’s dive into this a little bit more of what’s causing this.” We just don’t want to be collecting numbers just for the sake of collecting numbers. We got to use the numbers to help us make smart decisions in how we operate. So that was the change for the team.
Leslie Basham
I’ll add onto that, Angus, because I think it’s important that data and reporting… because when this transformation happened, and Henry talked a little bit about how he was communicating to the executive leadership team and the OR, communication became so important because people were saying, “Well, why isn’t this done yet?” And especially from our perspective where we’re working with health systems across the country, that was very instrumental in bringing the entire organization along with the change was how we were making it very fact-based. Not “he said, she said”, but very fact-based and communicating what was happening across the organization.
Kathleen Wessel
That’s wonderful. I think it’s impressive to hear about such a structured approach with several solutions in place and all of that being addressed all at the same time to really achieve a solid end. But Henry and Angus, could you share with the team or with the audience, what were some of the results of the initiative and ultimately what was recognized and awarded?
Henry Tomasuolo
Well, thank you. And this is really important because what we built here isn’t just…we didn’t just fix the problem. And that’s, as you could say, I love analogy, but sort of the analogy of… you buy a new car. And the minute you buy a new car, you drive it off to a lot, it loses value. And the longer you use it, the least valuable it is. What we built here is terrific because it also helps to…we put in structures that will help us to continually maintain what we’re doing and improve what we’re doing. So we measure the performance of the department, we measure our outcomes, we measure different processes for time and quality, and we set benchmarks and then challenge those benchmarks every year to get better and better. So as Leslie and Angus were talking about, we have an accuracy rate of better than 99% at this point, which is a pretty far cry from where we were. We have continual process improvements in place here so that when we identify a problem, each week we take a look at the errors that did occur and say, “Well, what caused those errors and what can we do to prevent them?” And we look at it both as individual issues but also in a greater outcome. So if we find that some processes being repeated, some errors being repeated because of the difficulty or the challenge of this, we look at ways to streamline that and improve it.
We put in a structured educational process so that everybody knows the same thing and has all that information. Historically, we relied too much on word of mouth and individuals rather than a process in place. And we put in Angus and Leslie and the company put in a process that everybody’s going to be learning things, and we’re going to reinforce that education on a regular basis. And the organization allowed us to make investments in educators that will allow us to do that. We put in scheduled maintenance programs for the equipment. We put in inventory tracking system so we know what we have and what we need. And what’s going to be able to be forecasted, so it helps us to manage our budgets more effectively as we plan for replacement equipment. It also gives the organization a better idea as we change procedures or we change interim manufacturers, what that impact will be.
We have improved communication and trust among our end users. That was something we really struggled with and made this a very difficult process to start with. There wasn’t a lot of trust in the department, but the work that was started by Surgical Directions and now has really been reinforced by Angus, we’ve built that trust and we are moving the dial dramatically in that respect. And it’s being demonstrated in probably the most measurable terms. So people will say nice things and be kind to each other, but what they’re doing is they’re coming to us and saying, “Hey, here’s our problem, Angus. What can we do to solve this? How can you take this over so that we can do this better as an organization?” And so they’re bringing their problems to SPD and Angus is continuing on the process of taking on those challenges, and using the tools that we put in place to help improve the process downstream.
And then finally we received external recognition through the HSPA National Quality Award. And that’s demonstrated by the work that this group put together here. And we couldn’t have done that in less than two years without the efforts and the strategy that we put together here. So really for me, the one final analogy, and I take this one from a book that was written by the former chairman of GE—who really simplified the approach to this—which is the team with the best players wins. So it was really important to get the right people into the spot. And I appreciate all the work from Surgical Directions. I know as we started early in the process, Leslie injected herself more and more as she saw the challenges that we were facing, the magnitude of what we were trying to do.
Angus Bruce
So I’m going to use an analogy that…we built a Ferrari. And if you know Ferrari, Ferraris are very high end. The Italian folks are very meticulous when they build their machines, and they build their machines to last. And that’s what we’ve done here at BCH. When we did receive the award at HSPA, I did comment on LinkedIn: “When you have a strong team, all things are possible.” And that receives a lot of comments. And it’s all about the team. It truly is all about team.
Kathleen Wessel
It’s all about the team. I’ll also say it’s about the leadership as well, and I think you’ve got a really…with a combination we have assembled here… you were able to take a daunting task and make it doable, achievable. It’s been really helpful for other AHA members to hear about your journey and hear about how you were able to achieve it. So, incredibly thankful for your time today. For our listeners, if you’d like to learn more about the AHA Associate Program or anything you’ve heard on this podcast today, please visit us at sponsor.aha.org. This has been an AHA Associates Bringing Value podcast, brought to you by the American Hospital Association. Thanks so much for joining us today.
