Mgr, Education & Quality, Sterile Processing Department

Rochester, NY


Under the direction of the Sterile Processing Director, incumbent is responsible for the development, implementation and monitoring of Staff Education (new staff Orientation, annual competencies, department Apprenticeship program and employee development). The position is responsible for creating and coordinating the delivery of Department related Education, competencies and training programs to ensure uniform operations across all Shifts.

Helps Establish standards for work performance and methods of operations for the department. Leads and supports Performance Improvement activities and ensures that Managers and Supervisors are effectively leading and mentoring the staff. Supports and help troubleshoot customer issues between the Peri-operative services and sterile processing department.

Ensures all Safety and Infection prevention policies and procedures are adhered to. Utilizes best practices, Infection Prevention and AAMI guidelines in conducting department audits and evaluates service levels of all SPD areas and reports finding to the Director, Infection Prevention and other relevant committees. Carries out the responsibilities for the overall management of the sterilization records, high-level disinfection records, implements quality assurance program, coordinates and monitors all sterile processing quality assurance processes and functions. Conducts inspections and tests samples of all work performed by the staff, such as; assembled Instrument trays, packaging, sterilization & HLD processes, Case Carts, Completion of documentation of all department related documentation. Follows up on Client/Customer feedback and utilizes appropriate instruments and methods for quality control testing and tracking. Compiles periodic reports as necessary.

Position reports to the SPD Director. Collaborates with the department Managers and Supervisors, Peri-Op Management, surgeons, Infection Prevention and all other team members as required.


  1. Creates, delivers and coordinates the SPD training curriculum for new staff and continued education for current members. Stays abreast of developing industry trends, regulations and requirements (State and federal).

  2. Supports organizational strategies and initiatives i.e. development and implementation of quality improvement processes which are aligned with sterilization disinfection, infection control and patient care standards and which enhance the patient experience, operational effectiveness and program efficiency. Collaborates with SPD and Peri-Operative and Infection control and Quality team members as required to ensure that an appropriate quality program along with quality improvement indicators and measurement tools tailored to SPD needs are designed and implemented.

  3. Collects and interprets statistical data on the progress and success of the educational programs based on the quality performance reports, and utilizes data to schedule in-services and coordinate further education for areas identified as problematic for Technicians.

  4. Orients and monitor new staff during the orientation process, documenting progress and monitors corrective action with follow up outcome of improvement.

  5. Works with perioperative nursing clinic QA liaisons and infection prevention to educate SPD staff in approved practices for sterilization and high level disinfection of equipment and instrumentation (according to Instructions For Use) in conjunction with Infection Control.

  6. Collaborates with OR staff to determine appropriate service path to follow when in a crisis and assist in triage service demands (in conjunction with Infection Control).

  7. Operationally checks completeness of worked performed by personnel (utilizing Work Leaders and Supervisors to assure compliance).

  8. Monitors quality improvement outcomes on a regular basis and collaborates with Management to develop action plans as required to address identified issues (in conjunction with the Operations Manager and Director).

  9. Coaches staff as required to ensure continuous quality improvement initiatives are incorporated in the day-to-day activities demonstrates the links and relationships between quality initiatives and strategic goals on an ongoing basis.

  10. Assists management to ensure ongoing Accreditation standards are met and reports are completed in a timely and accurate manner.

  11. Assures patient and employee safety in the use of various sterilization and disinfection process and chemicals (Best Practice & Standards).

  12. Responsible for the monitoring of the Medical Center's SPD Quality Assurance program consisting of Reprocessing and Case Cart Preparation for all reprocessing, case cart preparation, activities, equipment maintenance and customer service.

  13. Coordinates and conducts monitoring audits assuring SPD will meet or exceed the standards established by JCAHO, Title XXII, American Operating Room Association (AORN), American Association for Medical Instrumentation (AAMI), Association for Professionals in Infection Control (APIC), International Association of Healthcare Central Service Materiel Management (IAHCSMM) and Infection Control Department for the reprocessing and sterilization disinfection of medical instrumentation.

  14. Serves as technical resource to analyze audits and report on compliance to current reprocessing and sterilization practices, protocols and or corrective action and improvement in the following departmental functions (in conjunction with Infection Control).

  15. 1.1Sterilization of critical instrumentation by Steam (wrapped and "flash: methods) Sterrad, and Endoscope repossessing technologies

  16. 1.2 High Level Disinfection of semi-critical instrumentation using Cidex OPA

  17. 1.3 Pasteurization of non-critical medical devices

  18. 2.1 Daily maintenance of sterilization and high-level-disinfection equipment

  19. 3.1 Maintenance of customer satisfaction throughout the Medical Center (OR, Labor and Delivery, Patient care areas, Clinics and off-site facilities)

  20. 4.1 Case cart preparation and accuracy ;

  21. 5.1 Instrument set assembly - instrument and accuracy.

  22. Provides for the proper labeling, storage and retrieval of department records in accordance with regulations and Medical Center record retention policies.

  23. Participates with the SPD and Peri-Operative Management staff in the quality control and performance improvement activities of the department.

  24. Arranges and participates in the organization of in-services to address instrument and equipment educational needs based on the results of monitoring and analysis of the audits.

  25. Participates in the development and maintenance pertinent quality control and performance improvement programs for the provision of instrument processing services: Such QA programs shall include Sterility Assurance and Performance Improvement but are not limited to;

  26. Customer service standards

  27. Sterilization process monitoring standards

  28. Instrument inventory management standards.

  29. Assures that OSHA, JCAHO, Title XXII, AAMI, AORN, APIC, IAHCSMM, and other relevant regulations and standards are always met.

  30. Assures that the standards of operation of the department comply with those set by the regulatory agencies and professional associations such as AORN, AAMI, IAHCSMM, and the Medical Center Infection Control.

  31. Participates in Department's infection prevention rounds.

  32. Monitors the quality indicators and implements corrective actions in a timely manner when sterilization, equipment repairs and customer services parameters are not met.

  33. Prepares written and verbal reports to the Peri- Operative Services and Infection Committees and any Organizational Quality Circles as requested.

  34. Maintains current and accurate departmental quality program policy and procedure manuals.

  35. Represents the Sterile Processing Department in the absence of the Director.


BS degree required. Minimum three years of responsible Central Service hospital experience and progressive work experiences in central service and project management experience required or equivalent combination of education and experience. Required knowledge, skills and abilities: Completion of formal supervision principles, leadership education and/or the Certification in Healthcare Leadership concepts (CHL Certification); IAHCSMM Instructor designation is also preferred; Experience in leadership role; Knowledge/expertise in Instrument Tracking Systems; Proficient in Microsoft Office, Excel, Power Point, Word; Time management Skills; Proven leadership abilities; Up to date with all the industry related scientific literature regarding all the current methodologies for instrument maintenance, sterilization, and disinfection. Certified Registered Central Service Technician (CRCST Certification) required.

The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion to advance the University’s mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion/creed, sex, sexual orientation, citizenship status, or any other status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations.

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Location: Strong Memorial Hospital
Full/Part Time: Full-Time