Infection Control Today

APR 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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28 ICT April 2019 www.infectioncontroltoday.com By Ashley Brooks BA, CRCST, CFER; and Jonathan Reimer, MBA, CRCST R egulatory bodies have impacted sterile processing and surgical standards significantly over the year s. T he standards, regulations, and recommendations are changing daily as sterile processing and operating room associates try to maintain the modifi cations in conjunction to meeting the expectations of daily operations. The Joint Commission (TJC) and Centers for Medicare and Medicaid (CMS) both set standards in healthcare but vary in their focuses and methods. The major difference between the two regulatory bodies is that CMS is the law and is managed by the government and TJC is an independent, non-profi t organization and has no legal authority over hospital organizations, but further set standards for those hospitals. TJC certifi es and accredits nearly 21,000 healthcare organizations in the United States. TJC is a governing body which provides hospitals their certification, should they meet their standards. TJC prefers to focus its attention on clinical practice and emphasizes heavily on clinical work processes during hospital surveys. TJC mimics the standards established by the Association for the Advancement of Medical Instrumentation (AAMI) and the Association of periOperative Registered Nurses (AORN) for practices in sterile processing areas. For sterile processing, TJC is often looking to see if staff can demonstrate and speak to their work processes in accordance with AAMI and AORN standards. TJC will look heavily at department policies and procedures and education and concentrate on the clinical processes performed by the department. TJC will also note what type of products or equipment being used and follow up to see if staff members are using them in accordance to manufacturers' instructions for use (IFUs). Failure to meet TJC's standards during a survey will result in a follow-up action plan, possibly losing cer tification, and possibly prompting a survey from CMS. C M S w i l l p e r f o r m a hospital sur vey to ensure that patient safet y is not being compromised and that basic healthcare standards are being upheld. CMS will often utilize local department of health experts to perform their surveys in certain states. CMS surveys can be very attentive from a documentation and management perspective. CMS generally likes to focus on departmental quality data, audits, metrics, and policies and procedures. The latter, as well as individual employee fi les, and education and competencies are extremely important information often requested from a CMS surveyor during a hospital survey. Onboarding practices for new hire training are also critical during a CMS survey. When CMS observes that patient safety is being compromised and standards aren't being met, hospitals risk losing Medicare and Medicaid funding; the agency will revoke this funding from any hospital failing to meet its standards or requirements. Hospital leadership and other stakeholders often lack knowledge when it comes to sterile processing. Most of them do not understand the difference between a washer-disinfector and steam sterilizer. A major reason is because sterile processing is truly a support department and is a non-revenue generating department. Revenue-gen- erating departments often receive the most attention from hospital executives. Sterile processing is also still relatively unfamiliar to the public, resulting in lack of understanding or scrutiny of practices. Therefore, hospital leadership often does not recognize its importance and how critical a department it is — and not understanding the consequences until it is too late. Some of these conse- quences include infections t h a t j e o p a r d i z e p a t i e n t safety, surgeons threatening to leave because of a lack of instrument availabilit y, lawsuits, public scrutiny, loss of Joint Commission certification, and government funding being revoked, resulting in the hospital to close. Another infl uential component of sterile processing is the need for appropriate capital equipment, such as sterilizers, washer-dis- infectors, ultrasonic cleaners, proper sinks, case carts, storage shelving, instrumentation, and suffi cient work stations. Capital dollars are very limited in many hospitals today. Healthcare institution leadership executives Surveying Sterile Processing and How Regulatory Bodies Have Shaped the Sterile Processing Community feature Ò T e standards, regulations, and recommendations are changing daily as sterile processing and operating room associates try to maintain the modif cations in conjunction to meeting the expectations of daily operations.

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