As practices increase in their productive capacity, it is common to see problems develop in the sterilization and
instrument processing area. Many practices notice an increase in staff discord as this growth occurs. Insinuations that
one staff member is not pulling his or her weight, and a belief that the practice does not have enough instruments are
common symptoms of this problem.
These stresses are indications of poor organization in the sterilization area. Symptoms include grumbling
between staff members about sterilization responsibilities and a backlog of instruments to be processed. If your practice
seems to have some of the recurrent symptoms of an inadequate instrument processing system, perhaps it is time to
evaluate your process.
• Need to purchase additional hand instruments in the absence of substantial practice growth.
• The need for full or part-time sterilization staff in any practice.
• Inter-staff discord regarding sterilization duties.
In a slow practice, time is available for staff members to process instruments inefficiently during gaps in a loose-
ly scheduled day, during cancellations and before and after the doctor is at the practice. When doctors improve their
office scheduling, one result is staff complaints regarding sterilization.
Unfortunately, in order to remedy this situation, we find that most doctors’ response is an attempt simply to
speed up their existing system rather than improving the system itself. This is analogous to trying to motorize a slide
rule, rather than adopting computerization.
step time
backlog
step time
step time
Process
Workflow
(fig.1) - The rate limiting step determines the flow rate of any process.
Increases in speed alone are a recipe for failure because of the principal of rate limiting steps (fig.1), which states
that an entire process will move no faster than its slowest step. Efforts to speed up the process will fail unless the entire
process is accelerated in a balanced manner. Examples of failure abound. Many doctors have attempted to speed up the
process by purchasing a small capacity, high-speed sterilizer. Contrary to popular belief, this will not speed up overall
instrument processing. Having emergency need for such a unit only points out overall system weakness and lack of bal-
ance in the sterilization sequence. The only way that low capacity units, such as this, increase overall efficiency is
through the use of full-time sterilization staff, a concept that had many proponents five or so years ago, but which does
not and will not make clinical or economic sense.
Another proposed remedy for sterilization bot-
tlenecks is the all-in-one stericenter, with its complicat-
ed - have to go to school to figure it out - system.
Sterilization is best when the system is easy. Speed,
simplicity and reliability are the keys to successful ster-
ilization. You do not need to spend twenty thousand
dollars in order to obtain optimized sterilization!
When instruments are processed in cassettes, you eliminate handling throughout the contaminated portion of
the processing cycle. The success of this strategy depends upon two preconditions. One, cements and resin must be
removed at chairside. This is necessary in any event. No instrument processing technology will remove today’s
cements when they are allowed to set on your equipment. Two, instruments should not be allowed to fully dry prior to
processing. A processing pre-soak as instruments wait for processing delays is imperative.
Now that you have streamlined your transport system, the sterilization
sequence itself becomes simpler and far more productive.
Once you have reorganized your system in order to permit efficient workflow, you will find that the sterilization
constraints that you have been experiencing simply fade away. This will allow for significant practice growth.
None-the-less, after significant growth has occurred, you may find that you wish to further speed up the system. The
way to do this is simply by reducing the time for each step. Fortunately, this has become possible recently due to the
advent of new high speed, high capacity autoclaves. At the beginning of this article, we briefly discussed rate limiting
steps. Historically in sterilization, the rate limiting step has been actual disinfection. This is because spore kills are time
dependent. While this remains true today, that time has been markedly reduced by the chamber preheat capabilities of
newer autoclaves. The first significant reduction in autoclave processing time came with the introduction of the SciCan
Statim, by using a small chamber volume - a single cassette. Recently, units such as the Tuttnauer 2540 EHS or the
Barnstead PV Dry have been introduced, which both increase speed and have adequate chamber volume. Each of these
autoclaves has the combined advantages of room for multiple cassettes and rapid pre-heating, similar to, but not as
quick as the popular Statim units. The large capacity of these full sized autoclaves more than compensates for the mod-
est reduction in cycle time. It should be noted that if you think that you may be a candidate for a high-speed autoclave, you
should make sure that you choose a dishwasher with a comparable short wash cycle in order to balance your workflow.
10 Cassettes
Process "B" will clear the first series of
Soak Wash Autoclave
(1.5 hrs) instruments in two hours, but subse-
quent allotments are still on a 1 hour
process time.
1 Cassette
Soak Wash Autoclave
(1.25 hrs) Only process “C” will reduce actual in-
practice workflow; however, if the auto-
clave capacity is reduced to 1/10th the
original capacity net production time will
0 hr .5 hr 1 hr 1.5 hrs 2 hrs
actually increase. (fig. 5)
“slow conventional autoclaving is often faster than the “fast” process method.”
Sterilization does not have to be difficult. It is successfully organized through a diligent work simplification
process. Reliability and labor savings should be your primary goals. With this successfully accomplished, speed and
ease of use will naturally follow.
*Our company and this author neither recommend nor endorse a particular sequence of disinfection or sterilization. This article is intended to simply illustrate choices to be
made in the sterilization sequence.
Dr. David Ahearn is a member of the American Dental Association’s Ergonomic Advisory Subcommittee and is an associate professor at the NYU College of Dentistry. His private practice
is noted for its productivity. Design/Ergonomics (www.design-ergonomics.com) is a high performance design and consulting group founded by Dr. Ahearn. He can be reached at 800-275-
2547 or by email at djahearn@desergo.com.