policy if they don ’ t have the product that the organization has chosen to use right there for them to use ?”
A third element of implementation that surveyors are looking for are competent employees .
“ That means employees who are competent to perform their job functions through education , training , or competency testing ,” she said . “ It ’ s up to the healthcare organization to determine what kind of education , training , or competency evaluation that staff member needs to be able to perform their job functions .”
A fourth element is Infection prevention and control involvement .
“ In many facilities , there is just one of you ,” Wiksten acknowledged . “ We can ’ t divide you , we can ’ t split you in half , you can ’ t be everywhere at once . Many IPs are the sole IP and you still wear multiple hats , so now you ’ re divided even more . Infection prevention and control involvement happens in a couple of ways ; there are things that you ’ re going to have direct input on , such as developing policies , processes , and procedures that fall in the infection control realm , plus working with other services that have infection control implications . There are a lot of departments that you interface with that have infection control implications that you should be working with . Surveyors are looking to see that your activities are implemented as intended , as per regulation IFUs or your policies , in all relevant locations for all relevant staff , and that they are receiving education and training .”
A fifth element is leadership oversight , with participation by stakeholders to help uphold IP & C efforts . Frequently cited observations by surveyors include leaders not effectively managing the implementation of IP & C activities .
Switching gears , Wiksten addressed reprocessing reusable instruments , devices and equipment , No . 1 on the most frequently cited higher-risk accreditation requirements for 2023 for hospitals , critical access hospitals , ambulatory health and office-based surgery that process instruments . It has the highest percentage of high-risk findings and findings evaluated for immediate threat to health and safety .
“ When you ’ re looking at items that are being reprocessed in your organization , think about where they could be distributed in your facility ,” Wiksten said . “ If you are an ambulatory site and you have one clinic , hopefully you know your inventory . But when you work in some of these larger organizations , your reprocessable instruments can be found in centralized locations and decentralized locations . Think about your specialty services such as dental , podiatry , gynecology and endoscopy , urology , radiation oncology , pain clinics , ophthalmology . There is a wide variety of products that are single-use versus reusable , with varying levels of disinfection and sterilization required . A common scenario is that the Spaulding classification sometimes requires high-level disinfection and the instructions for use only have instructions for sterilization . There are varying levels of complexity as well as a wide variation in sterilization cycle and parameters . Manufacturers ’ instructions for use are super important and you will find them for almost all items that are used throughout reprocessing . IFUs include instructions for the devices ’ use , maintenance , cleaning , disinfection , high-level disinfection , sterilization and when the items are no longer suitable for use if it they are degraded , chipped , cracked , oxidized or stained . The key is to talk to the manufacturer to determine if it needs to be refurbished or replaced . IFUs also will have compatible disinfection and sterilization products and processes , so they might have instructions for use that surpass the intended use . So , those semi-critical items like instruments used in dentistry might only have instructions for sterilization ,