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IAHCSMM VIEWPOINT


Surveyors eyeing more CS-related processes, practices


by Julie E. Williamson L


earning that surveyors and inspectors are on premise and making their way to the Central Service (CS) department is enough to make any CS professional uneasy. All too often, the announcement of surveyors’ arrival has CS staffers wishing they’d begun preparing for the inspection many months earlier. Experts agree that’s precisely what healthcare professionals should be doing, but often aren’t. For many, inspections have always been a knee-knocking experience; however, few could argue that these visits — whether an- nounced or unannounced — are becoming even more nerve-wracking as surveyors gain more knowledge on sterile processing- related standards and practices. In August, The Joint Commission (TJC) published the top citations for non-compliance, with data aggregated from its surveys and reviews from January 1 to June 30, 2015. Notably, TJC surveyors are increasingly finding non-compliance with standard IC.02.02.01, which requires organizations to reduce the risk of infections associated with medical equipment, devices and supplies. Critical access hospitals were cited for non-com- pliance of this standard in 60 percent of the surveys; 54 percent of hospitals were cited, as were 53 percent of offi ce-based surgery centers. The fi ndings aren’t new, either: In 2013, standard IC.02.02.01 was one of the top fi ve non-compliance areas, and of 13 immediate threat to life (ITL) discoveries from surveys that year, seven were directly related to improperly sterilized or high- level disinfected equipment. “These citations underscore the impor- tance of following healthcare sterilization standards and having the documentation to demonstrate best practices are being followed,” noted Susan Klacik, CRCST, CHL, FCS, ACE, CS Manager at St. Eliza- beth Health Center in Youngstown, Ohio, and IAHCSMM representative to the As- sociation for the Advancement of Medical Instrumentation (AAMI).


The Occupational Safety and Health Ad- ministration (OSHA) is also cracking down on non-compliance in several key areas. The agency recently issued a staff memorandum stating that all inspections of hospitals and


nursing homes (including those prompted by complaints, referrals or severe injury re- ports) should include the review of potential hazards involving musculoskeletal disorders related to patient handling and unsafe lifting; bloodborne pathogens; workplace violence; and slips, trips and falls.


Focused attention on standards, processes


With broader knowledge and ongoing standards training in hand, surveyors are logging more time in the CS department and other areas of the facility where reprocess- ing functions occur. In the not-so-distant past, it wasn’t uncommon for surveyors to spend fewer than 30 minutes in the CS department, but today, that duration can easily top two hours.


Mark Duro, CRCST, FCS, CS Manager at New England Baptist Hospital in Boston, is just one CS professional who has witnessed the keener focus by surveyors. Two recent TJC surveys resulted in two-and-a-half hour visits in the department, according to Duro. In December 2013, a survey had Duro meet- ing with two different inspectors. One was an engineer who visited the CS department; the other was a physician who met with Duro in the Operating Room.


“It seems they are focusing far greater


attention on high-level disinfection, staff education and certifi cation, documentation, and record-keeping,” he reasoned. Surveyors aren’t just relying on depart- ment managers for the answers, either. Duro and other managers have seen more surveyors turning their attention to other CS staff members’ knowledge and insights — a trend that further underscores the impor- tance of departmental-wide preparedness. As Lisa Waldowski, MS, APRN, CIC, TJC infection control specialist confi rmed, sur- veyors “defi nitely want to speak with staff who are directly involved in the process.”


Standards (and IFU) prevail CS professionals can count on surveyors being well-versed on ANSI/AAMI ST79 and also guidelines and recommended prac- tices from the Association of periOperative Registered Nurses (AORN), the Centers for


44 October 2015 • HEALTHCARE PURCHASING NEWS • www.hpnonline.com


Disease Control and Prevention (CDC), Fa- cility Guidelines Institute (FGI), and more. “Having the most current versions of evidence-based guidelines is [essential] and they need to be readily accessible to all staff involved in instrument reprocessing,” Waldowski noted. She added that all staff need ongoing training to test competencies against those standards and ensure that everyone understands what’s included in them.


CS professionals should also be able to provide manufacturer Instructions for Use (IFU) for each instrument, supply, and piece of equipment. “We see staff sometimes not having these IFU right at their fi ngertips,” said Waldowski. “These need to be readily accessible to anyone involved in instrument processing.” During inspections, TJC surveyors use what is known as Tracer Methodology to follow an instrument through its entire cycle, from receipt in CS, all the way through processing and to next use (or placement into storage). For each step, surveyors will turn to standards, IFU and the facility’s own set policies and procedures to ensure that steps are in order and no process or practice breaches are taking place.


Experts agree that the path to survey success lies in facilities’ commitment to year-long survey planning to help ensure a constant state of readiness. That’s especially vital considering unannounced surveyors can fall anywhere between 18 and 39 months after the previous survey. “You never know when until they show up,” reminded Rose Seavey, MBA, BS, RN, CNOR, CRCST, CSPDT, president and CEO of Seavey Healthcare Consulting.


To help prepare, Seavey stresses the im- portance of an Accreditation Preparedness Committee that’s focused specifi cally on reprocessing. Committee representatives should include those from CS, OR, Infection Prevention, Biomed or Clinical Engineering, Endoscopy, Risk Management, Quality, Safety, Education, Materials Management, and Administration. “Surveyors also want to know that that facility has at least one subject matter expert who knows and shares all the standards.” HPN


IAHCSMM VIEWPOINT


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