Weston “Hank” Balch

Senior Principal Consultant
Beyond Clean Consulting

Preparing to pass accreditation surveys for your Sterile Processing department is never an easy feat. Even though surpassing the standards of infection control and safety is our constant goal — regardless if there are surveyors on-site or not — there is something really stressful and anxiety-producing that happens when we know that our inspection window is close at hand. It’s that same feeling you get when a police car pulls up behind you and you notice them in your rearview mirror: a sudden, yet unnecessary spike in your blood pressure and a mind racing to make sure you are under the speed limit, using your blinker, and off your phone. You know you’re not doing anything wrong, but there’s still that tinge of concern asking, “Yeah, but are you sure?”
In this short article we’ll take a look at 5 of the recent hot topics for Joint Commission surveyors in SPD this year, and give everyone a reminder to either keep doing it right — or buckle up and make it right tomorrow.
1) Reusable Cleaning Brushes
There have been a number of facilities questioned by Joint Commission this year regarding the management of their reusable surgical instrument cleaning brushes. In particular, the focus has been on showing policies and procedures regarding how often your reusable brushes are cleaned and disinfected, as well as seeing whether staff are following these inspection and disinfection processes as they have been written. If you don’t have a policy for disinfecting your reusable cleaning brushes, now is a great time to get one in writing and begin educating your team. Keep in mind, even if a brush is reusable, it must still be disposed of whenever it shows signs of excessive wear, damage, or retained bioburden.
2) Chemical Dilution Conversations
It is very common today to have surveyors key in on chemical compliance in your SPD. This can range anywhere from proper storage protocols to consistently labeling any expiration dates on containers, but it often centers around chemical dilution rates. Decontamination staff should be able to clearly and confidently speak to proper chemical dosing measurements for any chemicals that are used and dosed at the cleaning sinks. This means they will need to explain how much chemical is needed (i.e. 1 oz.) to mix into a specified volume of water (i.e. 1 gallon) for a dilution rate that is recommended by the manufacturer’s instructions for use (IFU). All sinks utilized for diluting/mixing chemicals should be clearly marked with a water line that states the volume of water present when filled. Even if you utilize chemical auto-dosers at the sink, staff still must know the proper dilution rates and speak to this process.
3) Hinged Instruments Sterilized Open
Although this topic is not necessarily new, hinged instruments being sterilized in an “open” position is still high on the radar for accreditation teams. Even if ratchet handles are not “locked,” if the distal tips of your hinged items are closed/touching, the entire instrument is considered to be in the “closed” position. Surveyors expect to see all hinged items sterilized in the “open” position. The best accessories available to ensure this standardized process is to utilize a combination of specially designed instrument processing cards and/or vented tip protectors that hold your instruments in an open position during the assembly, sterilization and storage stages. If this is a process that you need to change, ensure you locate all non-compliant peel pack items from across your facility — paying special attention to any clinic areas and ancillary departments that may not be aware of the process change.
4) Documented Competency for your Team
Besides having solid policies in place, a constant priority for surveyors is to ensure your Sterile Processing team has thorough and updated competencies on file for each employee. Do not get caught off guard by assuming that competencies are the same thing as an orientation checklist, in-service certificate or professional certification. While these are important parts of the overall education program for a Sterile Processing technician, competencies are the documented records that each employee has demonstrated the skill, knowledge and ability to do each aspect of their job safely and consistently. As a department leader or educator, you should be spending large percentages of your time ensuring your competencies cover the scope of your department’s processes, and equipment, products — and that they are up-to-date for each employee.
5) A Lot About Lot Numbers
One other hot topic for surveyors this year has been lot number documentation and compliance regarding biological indicators (BI) and their biological indicator controls. Even though it is common knowledge from manufacturer IFU’s and AAMI ST79:2017 that biological tests and controls should be run from the same lot number, department documentation must record consistent compliance. It is not uncommon to have a surveyor ask to see your sterilization log book and begin looking for lot number documentation. Keep in mind that you will want to record the BI test lot number and the control lot number separately so that an auditor can easily compare the two. A best practice is to only open one box or bag of BIs at a time in order to limit the opportunity for accidental mix up regarding the lot numbers being used.
While this list is by no means exhaustive, it is a recent sampling of some of the more common questions and citations being given by Joint Commission surveys on their visits to Sterile Processing departments around the country. Whether you read this list without batting an eye or walk away with a 5-point To-Do list for tomorrow morning, the most important thing to remember is that accreditation surveyors — just like police officers — are there to help. As stressful as their appearance may be, and as many hot topics as they may touch on, you and your team can play it cool and keep it clean. After all, true compliance happens when no one is looking.

This article was published in ReadySet Review, a newsletter intended to help educate Surgical Service Professionals on important, topical issues. The views and opinions in this article are those of the author and do not necessarily reflect those of ReadySet Surgical.