1. © Copyright, The Joint Commission  The employees and/or speakers for this presentation have disclosed that they do not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity.  Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or off-label use of products. Disclosure Statement

2. © Copyright, The Joint Commission The Down and Dirty of Sterilization OR Today – Surgical Services Conference August 31, 2015 Lisa Waldowski MS,APRN,CIC Infection Control Specialist The Joint Commission

3. © Copyright, The Joint Commission  At the conclusion of this presentation, the participant will be able to: –Relate Infection Prevention and Control Standards and IC-related NPSG’s to challenging areas in the field of Infection Prevention and Control –NPSG’s –Medical Equipment, Devices, and Supplies Learning Objectives 1

4. © Copyright, The Joint Commission  Hand Hygiene  SSI’s IC related NPSG’s Goal 7 – Healthcare-associated infections (HAI’s) 2

5. © Copyright, The Joint Commission Center Infection Focus Areas 3

6. © Copyright, The Joint Commission Confidential Separate from Accreditation Guided Robust Process Improvement  Measure current state  Analyze causes  Select targeted solutions  Sustain and spread improvements MOVING TOWARDS RELIABILITY 4

7. © Copyright, The Joint Commission Robust Process Improvement ® leads to dramatic results Center Projects Results(%) Hand hygiene 71  Colorectal SSIs 32  Milbank Q 2013;91:459-90 5

8. © Copyright, The Joint Commission RELIABILITY 6

9. © Copyright, The Joint Commission Jt Comm Journal on Qual Pat Safety 2015;41(1):4-12 and 13-25 7

10. © Copyright, The Joint Commission  IC.02.02.01 The organization reduces the risk of infections associated with medical equipment, devices, and supplies  EP2 Performing intermediate and high- level disinfection and sterilization of medical equipment, devices, and supplies  EP4 Storing medical equipment,devices, and supplies Related Standards 8

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14. © Copyright, The Joint Commission Overarching Risks in Reprocessing Medical Equipment, Devices, and Supplies  Not adhering to manufacturer’s instructions for use (IFUs)  Not following recommended practices or evidence-based guidelines  Lack of documented staff competency  Lack of competent, trained managerial/supervisory oversight  IC involvement 12

15. © Copyright, The Joint Commission Standards that support Sterilization  Human Resources –Staff competency and training –Infection Control Practitioner (ICP) –Managerial/Supervisory oversight 13

16. © Copyright, The Joint Commission Standards that support Sterilization  Leadership –Centralized versus de-centralized locations conducting sterilization– to include off site locations –Knowledge, support, and accountability 14

17. © Copyright, The Joint Commission Standards that support Sterilization  Environment of Care –Ventilation/pressure relationships 15

18. © Copyright, The Joint Commission Standards that support Sterilization  Infection Prevention and Control –Risk assessment, IC Plan –Quality monitoring process and documentation – sterilization –Use of evidence-based guidelines 16

19. © Copyright, The Joint Commission  Monitoring Program: –Compliance to protocols –Assess if current P&P’s are effective –Document competency and training –Provide feedback to improve performance  How do you report reprocessing breaches/lapses? What actions do you take? To Do List: 17

20. © Copyright, The Joint Commission Case Study - Sterilization  No pre-cleaning at point- of-use  Leaving hinged items in the closed position  No documentation of sterilizer preventative maintenance/cleaning  One BI documented for the year 2015  Double peel packs; inner peel pack folded over/wet  Premature releasing of IUSS  No competency, training of frontline staff on file  Manager of OR has oversight with no competency/training 18

21. © Copyright, The Joint Commission What do you do or say?  A. Do or say nothing.  B. Opportunity to re-educate and train staff on sterilization processes.  C. Reprocess all instruments involved in these breaches.  D. Both B and C. 19

22. © Copyright, The Joint Commission Efficient Workflow – Lean Process  Encompass reprocessing with related systems –Concentrate improvement effort on workflow  Eliminate variability (waste)  Reduce error 20

23. © Copyright, The Joint Commission Standardize Work Practices  Determine process/best practice – Standardize to it  Involve frontline staff  Develop P&P  Train/Re-educate  Follow-up to assure sustainability and provide feedback 21

24. © Copyright, The Joint Commission From OR to SPD and back again  Process efficiency  Questions to consider: –How often is a case delayed due to contaminated equipment, devices, or supplies? –What is the cost of a delayed case due to contaminated equipment, devices, or supplies? 22

25. © Copyright, The Joint Commission Articles  Wubben, I., Van Manen, J.G., Van Den Akker, B. J., Vaartjes, S.R., VanHarten, W. H. (2010). Equipment- related incidents in the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process. Quality & Safety in Health Care, 19, 1-7. doi:10.1136/qshc.2009.037515 23

26. © Copyright, The Joint Commission Key Points  OR RN’s reported equipment related incidents over a 4 week duration  57.7 % response rate (911/1580)  Equipment related incidents = 15.9%  Non-sterile equipment = 5.4%  Findings/Conclusions –Under-reporting –Extra work, delays, added time per event 24

27. © Copyright, The Joint Commission Articles  Wong, J., Khu, K.J., Kaderali, Z., &Bernstein, M. (2010). Delays in the operating room: signs of an imperfect system. Canadian Journal of Surgery, 53 (3), 189-195. 25

28. © Copyright, The Joint Commission Key Points  1531 elective surgical cases (2000-2009)  Delays (33.6%) = most common error type occurring  51.4% of all cases had at least 1 delay  Contamination (ranked #3) = 24.4%  Conclusions –Human error and system deficiencies related to delays – most commonly equipment related 26

29. © Copyright, The Joint Commission Measure Process Performance  Identify a process issue  What is real versus perception?  Measure facts  Obtain a baseline  Measure what you value 26

30. © Copyright, The Joint Commission Trust Report Improve High Reliability and Infection Prevention and Control Adapted from AHRQ; Castle, Wagner, Ferguson & Handler (2011); Reason (2000) 27

31. © Copyright, The Joint Commission Safety Culture –Empowered to report errors –Visible effective leadership –Respectful treatment of staff –Collaboration across departments –Sense of teamwork –Training and education –Effective communication Castle, Wagner, Ferguson & Handler (2011) 28

32. © Copyright, The Joint Commission For Consideration …..  Internal/System resources  What can/is immediately corrected  Leadership response  Infection Control involvement  Patient risk, look-back, notification 29

33. © Copyright, The Joint Commission use these colors

34. © Copyright, The Joint Commission Resources  Sterilization: - AAMI ST79:2010 & A1 & A2 & A3 Comprehensive guide to steam sterilization and sterility assurance in health care facilities - AAMI Sterilization Part 1: Sterilization in Health Care Facilities, 2014.2 Edition 30

35. © Copyright, The Joint Commission  AORN 2015 Guidelines for Perioperative Practice –Guideline for Sterilization –Guideline for Cleaning and Care of Surgical Instruments Resources 31

36. © Copyright, The Joint Commission  2008 CDC Guideline for Disinfection and Sterilization in Healthcare Facilities. Resources 32

37. © Copyright, The Joint Commission Email: lwaldowski@jointcommission.org 33