Infection Control Today

FEB 2019

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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Page 12 of 44

12 ICT January/February 2019 By Sylvia Garcia, MBA, RN, CIC Survey Survival Staying in Compliance by Following Policies T he Joint Commission provides an approach for writing policies that promote compliance with infection control standards There are many sources of infection prevention and control standards which often make infection preventionists (IPs) struggle to choose the best references for their infection control plans policies, and practices. Review of infection control-related sur vey findings indicate that organizations are frequently scored out of compliance because they are not following their own policy. Joint Commission commends organizations for striving to follow best practices and incorporating them into their policies. An example of this would include facilities that perform biological indicator testing of steam sterilizers daily or with every load. This means that if there is a positive biologic it is possible to prevent use of instruments until the validity of the positive can be resolved and next steps are taken. A defnite win for patient safety. However, facilities often add requirements to their policies that have no foundation. These may seem like good ideas but are often unachievable or unsustainable – for example: a facility writing a policy that says operating room (OR) staff must remove all bioburden prior to transporting soiled instruments from the OR. Following is an approach that infection control professionals can follow to ensure policies are based on requirements and chosen evidence-based guidelines. This detailed approach will help facilities meet requirements. The Joint Commission surveyors have been trained to follow the same approach when surveying compliance with standards. 1. Regulation If a regulation exists, follow its direction in creating facility policies. Infection control policies cannot conflict with law and regulation. For example, some states specify in their department of health licensing requirements that manufacturer instructions must be available to staff members in all areas performing reprocessing or the minimum frequency of biologic monitoring of sterilizers. 2. CMS If a facility is deemed accredited to qualify for CMS, then it must meet conditions for participation (CfPs), conditions for coverage (CfCs) and Quality, Safety, Oversight or QSO letters. Information can be found by visiting the following links: Cops and CfCs and policy and oversight memos to states. Facilities who are deemed need to ensure that policies do not confict with CMS requirements. For example: S&C: 14-44-Hospital/CAH/ASC directs surveyors to look for evidence that all personnel who perform immediate use steam sterilization (IUSS) are trained and competent to correctly follow the manufacturer's IFUs regarding IUSS with respect to each instrument, sterilizer(s), container(s) and cleaning supplies they are using for IUSS. 3. Manufacturer Instructions for Use Healthcare organizations must follow the manufacturer instructions for use (IFU) for equipment, supplies and products used and are required to resolve any conficts that may exist. When there are conficts, the organization must resolve these. For example: If a manufacturer indicates varying cycle parameters must be met to sterilize a variety of instruments, but the organization's sterilizer is set to only one of those parameters, then the he organization must contact the instrument manufacturer to determine if it is acceptable to use that parameter. If it is not acceptable, the organization must contact the sterilizer to determine if the parameters of the sterilizer can meet the various requirements. If it does not the policy direct individuals responsible for sterilization to an alternative location where the parameters can be met. 4. Evidence-based Guidelines or National Standards In an absence of clear requirements and recom- mendations provided by state regulation, conditions of participation (CoP) or IFUs, the next step for healthcare organizations is to review evidence-based guidelines or national standards. A facility can choose which evidence-based guidelines or national standards (EBGs) it follows and should be prepared to discuss (not required in writing) the process that it uses to determine which it has chosen to follow. It is important for infection control professionals who are writing policies based on EBGs to have a system for updating so that the policies are current. Ò T here are many sources of infection prevention and control standards which often make infection preventionists (IPs) struggle to choose the best references for their infection control plans policies, and practices.

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