How TJC’s new survey scoring affects reprocessing professionals

by Julie E. Williamson

he Joint Commission’s (TJC’s) new survey scoring for IC.02.02.01 — the infection control standard that requires hospitals to reduce the risk of infections as- sociated with medical equipment, devices and supplies — is in effect and it directly impacts Central Service/Sterile Processing (CS/SP) professionals and their healthcare customers. According to a September 5, 2018, notifi ca- tion, TJC reports that IC.02.02.01 has been one of the most commonly-cited standards to be listed as “noncompliant.” In 2017, 72 percent of hospitals and critical access hospi- tals surveyed were cited for noncompliance with the standard. Because of the high level of noncompliance, and upon more careful evaluation of high-level disinfection (HLD) and sterilization process steps, TJC revised its survey scoring to focus on the process steps that represent the greatest risk to pa- tients if the process steps were to fail. The TJC notifi cation reinforces the im-


portance of following Association for the Advancement of Medical Instrumentation sterilization standards and Association of perioperative Registered Nurses guidelines. “The scoring process steps discussed in the September 5, 2018, TJC article are included in both associations’ best practice docu- ments,” reminded Susan Klacik, ACE, BS, CIS, CRCST FCS, Clinical Educator for the International Association for Healthcare Central Service Materiel Management (IAHCSMM).

Greater compliance, fewer citations TJC’s scoring revision for IC.02.02.01 has garnered praise from some industry experts who believe the changes will increase com- pliance and lead to fewer citations. “Many facilities have been cited for things that were interpretations from surveyors,” said Rose Seavey, MBA, BS, RN, CNOR, CRCST, CSP- DT, President/CEO of Seavey Healthcare Consulting, LLC. “I believe organizations will be cited less, especially if surveyors are well trained to the new expectations.” Adherence to manufacturers’ IFU is a key focus in TJC’s scoring. In the September 5 notifi cation, the agency stated that sur- veyors will continue to score IC.02.02.01 as

“noncompliant” whenever manufacturers’ IFU are not followed. Another area of focus in IC.02.02.01 that was addressed by TJC pertains to scoring when visible bioburden is found on instruments. Previously, facili- ties could be cited if an enzymatic solution was not applied to maintain moisture on instruments. TJC will now score if wip- ing/fl ushing of soiled instruments is not observed during a case in the Operating Room or procedure room and such wiping/ fl ushing is clinically appropriate. Seavey is pleased to see scoring would happen if the facility does not have a process for keeping used instruments moist. “That is easier and does not routinely mandate the use of an enzymatic solution,” she explained.

Klacik also stressed the importance of point-of-use treatment, which serves as the beginning of the cleaning process. “Infection prevention is everybody’s job and perform- ing point-of-use treatment as soon as pos- sible after an instrument’s use prevents the formation of biofi lm and reduces the risk of corrosion.” Prevention of biofi lm formation is especially important since biofi lm can tightly adhere to a surface and is diffi cult to remove, especially for lumened instrumen- tation, she said.

The new scoring also addresses transport of instruments in the building. TJC clari- fi ed that non-sharps can be transported in a way that does not lead to contamination of staff or others. Still, they will need to be transported in a biohazard-labeled or red container, according to Occupational Safety and Health Administration regulations, Seavey said. Per the standards, surveyors will also be looking to see that employees are wearing appropriate personal protective equipment (PPE) when preparing instru- ments for transport.

Previously, instruments found in the closed position were also scored. Now, TJC will score when packaged instruments awaiting sterilization are in the closed posi- tion; when items that have just been steril- ized are on the trolley or in the sterilizer in the closed position; and when items in the preparation and packaging area that have come through the washer or pass-through


window have not been disassembled ac- cording to manufacturer instructions. In- strumentation must be cleaned in the open position and disassembled in accordance with the IFU to expose all surfaces to the cleaning process and allow for proper reas- sembly, Klacik explained. In the past, scoring occurred when instru- ments were released prior to the biological indicator (BI) being read. Now, surveyors will cite noncompliance with IC.02.02.01 when routine sterilizer monitoring with a BI required by the state or per evidence-base guideline is not followed and recorded, and when non-implant loads are released without physical monitoring of cycle and external and internal chemical indicators. For implant loads, scoring will now occur when loads are released without routine sterilizer monitoring, a BI and a type 5 integrating indicator, and when a BI is not read before implant release (unless allowed in emergency situations per facility policy and the policy was followed). According to best practices, BI process challenge devices (PCDs) should be used for routine sterilizer effi cacy monitoring at least weekly, but pref- erably every day that the sterilizer is in use. Storage was also addressed by TJC. Previ- ously, surveyors scored when items in the high level-disinfected area were stored in drawers. Scoring now occurs when storage is inconsistent with the items’ intended use; when a container or storage location is visibly soiled or when staff are observed contaminating other high level-disinfected products; and when items are not stored according to the IFU or with the facility’s risk assessment/policy (if no guidance was provided by the manufacturer in the item’s IFU).

Lastly, TJC updated its scoring approach regarding endoscope hang time. Under the revisions, TJC surveyors will not score fi nd- ings related to hang time. If, however, hang time is addressed in the facility’s policy, surveyors can still score if the facility policy is not being followed.

To access TJC’s full article, 4-1-1 on Sur- vey Enhancements: New Scoring Revisions for IC.02.01.01 Now in Effect, visit www.

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