● Collaboration : Partner with your infection control practitioner , operating room nurses , surgeons , nurses , and reprocessing technicians to discuss quality issues at your facility and establish plans for improvement . Encourage team members to engage in open and constructive discussions of the issues and demand active listening from the group . Each team member should feel heard in the brainstorming process and understand that they have a stake in the team ’ s success . Initiate a relationship with the infection control practitioners at your facility by asking them to review your process , competencies , and policies . Ask for advice and share your concerns . It will show the infection control team members that your team respects their judgments . Create an action plan outlining the purpose and goals for the cross-functional working group at your organization and take the lead assembling the team . A cross-functional working group will raise the standards for the SPD and expose SPD professionals to diverse ideas and solutions . It will also enhance the rapport between the operating room and SPD .
● Competency : Staff education is critical for the success of any program but particularly for one that asks team members to step out of their typical roles . Evaluate your team members and determine the best learning methods for all involved . Teach in the ways that your team members learn , whether it is by book , by audio , or by doing . Determine the competencies needed based on the critical tasks performed by the technicians . Competencies must also be in accordance with the established processes , policies and procedures . If the department reprocesses endoscopes an additional list of competencies related to decontamination and high-level disinfection of scope is needed . Set benchmarks to track skills progression and create a plan for a skills competency enhancement program . Be sure to communicate it at the cross-functional team ’ s meetings . Schedule meetings with your infection control professional and share the latest updates of the industry to jointly create an implementation plan of action . Learn from your infection control practitioner what steps are taken to achieve a successful accreditation survey .
● Controls : Implement a process improvement program that can help the team identify products / trays that do
The Four C ’ s Model
not conform to established standards . This quality audit program should track a product / tray from sterilization to packaging to delivery and put in place steps that must be taken when a product / tray does not meet the quality audit . Establish benchmarks using your current state to set targets and auditing schedules for the department . Install an “ Achievement Board ” where the audit outcomes can be posted . Then , invite your IP to conduct audits of your process . Unannounced infection control audits help to maintain readiness . A simple , straightforward audit can be :
• Open the trays that have had most issues with residual soil ;
• Review a sampling of sterilization records to ensure that loads are verified and all parameters were met ;
• Observe the high-level disinfection process to assess if any steps were skipped ;
• Audit the washer decontaminator loads to assess if multi-level trays were disassembled correctly ;
• Audit the washer decontaminator loads to ensure lids are not obstructing the washer cleaning action .
• Audit the sterilization load to ensure all items were recorded .
• Review all biological culture documentation to ensure all tests were recorded and verified .
• Audit and document all equipment routine maintenance tasks .
• Residual soil in lumens and flexible endoscopes .
• Instrument functionality and sharpness .
• Inspection of rigid containers for dents and defects that can compromise sterility . Damaged filter retention plates must also be inspected as misaligned plates can create gaps and improper seal .
● Checks : And finally , as a group , analyze the quality audit outcomes and investigate process failures to determine the root cause of the problem . Take in suggestions and ideas from all team members for problem solving . Use tools like fishbone diagrams , process mapping , flow charts , and pareto charts . Evaluate the proposed process change and implement any changes needed to achieve your goals . Continue to monitor progress at established intervals to ensure the process improvement is sustained . Alert team members of the achievements by posting audit outcomes on boards .
The sterile processing department , operating room and infection control practitioners play critical roles in keeping patients safe from harmful microbes , but neither can succeed without the other ’ s commitment to the cause . Team up with your fellow germ fighters , learn from them , and achieve with them . After all , our patients ’ lives depend on it .
Mary Olivera , MHA , CRCST , CHL , FCS , has actively participated in the monitoring , surveying and training interdepartmental staff in the proper cleaning , decontamination and sterilization practices and has been highly committed to the standardization of interdepartmental processes . Currently , she is the president and CEO for OSPECS Consulting , LLC . a company dedicated to facilitating process re-engineering in healthcare organizations .
www . healthcarehygienemagazine . com • june 2021
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