Accrediting agencies have become less tolerant of sterile processing deficiencies, which means that technicians and overseers must maintain a laser focus on quality and continuous process improvement. But how can we improve? First, we must carefully examine the process.
The PEER Review series is geared toward giving you simple steps for achieving perpetual readiness, and eventually, successful accreditation. In the first article of this four-part series, I discussed the steps required to begin to prepare for an accreditation survey: compile regulatory guidelines, develop necessary policies, and promote a learning environment within the department to engage staff further develop their competencies. This is the foundation of a PEER Review.
The next step in the PEER program is to examine the process.
The ultimate goal is to prevent risk and provide the surgical staff with safe, sterile instruments. However, we can only ascertain that we are achieving optimum quality by performing a comprehensive assessment of the process. So, where to begin? We can divide the assessment into five functional sterile processing areas: process volatility, quality systems, leadership, staff development, and customer service.
- Assess the instrument reprocessing cycle and high-level disinfection process to ensure that they adhere to best practice and regulatory guidelines.
- Review best practices and regulatory guidelines. Then assess your instrument reprocessing cycle and high-level disinfection process to make certain that you are adhering to recommendations and are in compliance.
- Review the current process against hospital policies and procedures to ensure that staff is performing all of the required steps. These full-cycle assessments help identify opportunities for process improvement.
- Evaluate the design of the department to check that it meets all regulatory requirements (e.g., eyewash stations, adequate workflow, airflow, lighting).
- In order to deliver properly sterilized materials to the OR, the department should have a comprehensive quality audit program in place.
- AAMI ST79 lists a number of quality audits that should be in place (e.g., process verification, cleaning, efficacy verification).
- Establish key performance indicators to measure process consistency and effectiveness.
- Evaluate methods that are used to reduce the risk of infections associated with instrument reprocessing.
- Overseers are responsible for developing department policies and procedures for high-level disinfection and sterilization as well as adherence to regulatory compliance.
- Accrediting agencies expect front-line and managerial staff to use evidence-based guidelines to develop protocols, for staff training, and for competency for high-level disinfection and sterilization processes.
- There internal controls must be in place to ensure that staff knowledge is on par with reprocessing protocols.
- Training and competency are the most critical components for a successful sterile processing department and can always be improved.
- Staff needs to be trained on every critical task and held to a high standard. There should be a corresponding training program in place to help them stay up to speed.
- There must be evidence of initial and continuous compliance educational programs that meet your organizational and certification credentialing agency mandates.
- Staff knowledge should be based on guidelines and device manufacturer compliance programs for reprocessing medical devices.
- Examine how you communicate with the OR.
- Communicate concerns about any quality issues and implement corrective actions.
Developing a department audit tool that measures all of the pre-determined criteria and conducting your own audits on a regular basis will ensure that the department sustains perpetual readiness. At Nexera, we have a team of experts who each have over 20 years’ experience in device reprocessing and who can perform these comprehensive operations assessments. Obtaining a baseline of department performance helps sterile processing leadership set goals and create a priority worksheet to get you on your way to attaining perpetual accreditation survey readiness.