MAKING YOUR DEPARTMENT SURVEY READY
by Rose Seavey MBA, BS, RN, CNOR, CRCST, CSPDT President/CEO Seavey Healthcare Consulting, LLC
Healthcare accreditations surveys, such as those preformed by The Joint Commission (TJC) or The Centers for Medicare and Medicaid Services, focus on safety and quality of patient care. In the last few years, accreditation surveyors have increasingly targeted the reprocessing of reusable medical devices in their survey process. Surveyors are looking for risk reduction and process improvements relating to sterilization and high-level disinfection (HLD).
Last year the Centers for Disease Control and Prevention and the U.S. Food and Drug Administration released a Health Alert that stated, “Healthcare facilities should arrange for a healthcare professional with expertise in device reprocessing to immediately assess their reprocessing procedures.” This new focus is to ensure that reprocessing is done correctly, which includes allowing enough time for reprocessing personnel to follow all steps recommended by the device manufacturers.1
TJC publishes several Standards BoosterPaks for accredited organizations. These searchable documents provide specific information about TJC standards that have received a large amount of non-compliance scores. The High-Level Disinfection (HLD) and Sterilization BoosterPak is a great resource geared toward ensuring work practices are carried out in a manner that follow regulatory standards and current evidence-based guidelines in order to minimize potential risk of infection transmission to patients.2
Some of the most current HLD and Sterilization published resources include:
- The Association for the Advancement of Medical Instrumentation (AAMI)
- ST79 Comprehensive guide to steam sterilization and sterility assurance in health care facilities
- ST58 Chemical sterilization and high-level disinfection in health care facilities
- ST91, Flexible and semi-rigid endoscope processing in health care facilities
- The Association of periOperative Registered Nurses (AORN)
- Guidelines and Tools for Sterile Processing
Surveyors will want to see that facilities are conducting risk assessments to refine HLD and sterilization processes, and utilizing multidisciplinary teams to perform these assessments. When conducting a risk assessment, TJC states it is important to create teams that involve key stakeholders, which should include people from Infection Prevention, Environmental Services and Facilities/Engineering. Also, these teams should consist of staff at multiple levels—Managers/Supervisors, Front-line Staff and Directors should all be included.
TJC suggests that a senior leadership champion be identified to help implement best practices and assist in making the case for the necessary improvement projects as these initiatives often compete with other priorities within the organizatoin.2
The number one thing to keep in mind is risk reduction and process improvement are the heart and soul of accreditation surveys. The surveys are unannounced and often surveyor dependent. Each site visit will be different and may not have the same focus, but remember patient safety is number one.3
The best way to ensure a good survey is to know and consistently follow the accreditation standards, ensure staff is competent, always follow current evidence based guidelines and work closely with the infection control and facilities departments to ensure your environment is within standards.3 If you follow these suggestions, you can help to avoid citations for noncompliance on you next survey.
- Immediate Need for Healthcare Facilities to Review Procedures for Cleaning, Disinfection, and Sterilizing Reusable Medical Devices. CDC Health Alert Network. Sept. 11, 2015 Available at: http://emergency.cdc.gov/han/han00382.asp. Accessed 5/25/2016
- High-Level Disinfection (HLD) and Sterilization BoosterPakTM , The Joint Commission Available at: http://www.jointcommission.org/standards_booster_paks/
- Seavey, R. Association for the Advancement of Medical Instrumentation. Sterile Processing in Healthcare Facilities: Preparing for Accreditation Surveys.
Rose Seavey is President/CEO of Seavey Healthcare Consulting and formerly the Director of the Sterile Processing Department at The Children’s Hospital of Denver. Rose served on the AORN Board in 2008-2010. Rose is a past President ASHCSP. She received numerous awards such as AORN’s award for Mentorship in 2012 and Outstanding Achievement in Nurse Education in 2001. In addition, she received the national 2013 IAHCSMM Award of Honor, the Industry Leadership Award from the Massachusetts chapter and the Educator of the Year Award from the Golden West chapter. She was named to Infection Control Today’s list of Who’s Who in Infection Prevention in 2006. Ms. Seavey is the author of the book tilted Sterile Processing In Healthcare Facilities: Preparing for Accreditations Surveys, published by AAMI and she serves on several AAMI committees that focus on writing standards.