In healthcare, the objective is to continually raise the bar for patient safety to ensure positive patient outcomes. The sterile processing department plays a critical role in meeting this goal. While there are many essential tools in the sterilization quality assurance toolbox, the biological indicator (BI) is the only monitoring tool that directly measures the lethality (killing power) of the sterilization process. This presentation will explore the fundamentals of steam and vaporized hydrogen peroxide sterilization, the sterilization quality assurance tools available to monitor the effectiveness of the processes, and the rationale for performing every load monitoring (ELM) with a BI regardless of the sterilization modality.