Special Edition on Sterile Processing Imperatives Special Edition- Sterile Processing Imperatives | Page 27

State DoH regulations include a statement recommending
sterile processing to comply with these standards.
● SGNA Guidelines: Voluntary guidelines for processing
GI flexible endoscopes.
● Educational resources and sterile processing technician
accrediting agencies. Both agencies provide certification
preparation materials and testing to credential sterile
processing technicians and managers.
● International Association of Healthcare Central Service
Materiel Management (IAHCSMM)
● Certification Board for Sterile Processing and Distri-
bution (CBSPD)
● Accreditation Agencies – Hospitals must be accredited
in order to receive Medicare and Medicaid payments. The
most popular accrediting agencies are:
● The Joint Commission (TJC) – Surveys hospitals every
3 years and their standards revolve around continuously
improving the quality of care and safety provided to patients.
● The JC guidance for SPD readiness - High-Level
Disinfection (HLD) and Sterilization BoosterPak
● Det Norske Veritas (DNV-GL) – the accreditation
survey is based on the integration of the CMS condition of
participation standards International Standards Organization
(ISO) 9001 Quality Management. DNV-GL also offers a sterile
processing certification.
● American Association for Accreditation of Ambulatory
Surgery Facilities (AAAASF) - accreditation for outpatient
facilities.
There many other regulatory and voluntary agencies
not discussed in this article that develop standards to help
healthcare be a more efficient and safer environment for
our patients. The sterile processing professional should be
familiar with the guidelines that impact the functions of
SPD and should incorporate them into the department’s
policies and procedures.
EXAMINE. Honest self-examination can shed light on
deficiencies in sterilization and HLD and force a reckoning for
an institution. At a loss for where to start? Check out CMS’s sur-
veyors’ worksheets for straightforward guidance, or TJC’s HLD
BoosterPk, which outlines the areas most likely to be assessed
by inspectors and details corresponding regulations. DNV-GL’s
Assessment Checklist ISO 9001:2015 makes easy work of
following steps on the way to
compliance. When in doubt,
remember that a comprehensive
examination for vulnerabilities
should cover process workflow,
quality management processes,
competencies, recordkeeping,
and flexible endoscope repro-
cessing. Healthcare organiza-
tions can engage a professional
reprocessing expert to conduct
a comprehensive review of
Courtesy of Mary Olivera
reprocessing procedures.
EDUCATE. Many states now require SPD professionals
to achieve certification in their field and submit continuing
education credits on a yearly basis. That’s a good thing.
Advances in surgical technology have introduced sophisticated
and delicate instrumentation that require even more attention
during processing and sterilization, so it is vital that SPD
professionals stay up to date, understand, and adhere to
guidelines and IFUs for processing these ever-advancing tools.
It is critical to understand that before a technician is assigned
to perform a task, they must be fully trained in all aspects
of the process. Leaders must set the example by educating
themselves and strictly adhering to protocol. They must also
take notice of employees
who are doing the right
thing and praise accord-
ingly, and address issues
where they may arise.
REFORM. After care-
ful preparation, honest
examination, and thor-
ough education, hospital
leadership must enact
the change they wish to
see in their facilities. But Courtesy of Mary Olivera
they cannot do it alone. It is imperative that leaders propose
change in collaboration with administrative leadership,
operating room teams, infection control specialists, and
sterile processing team members. These team members have
a unique vantage point of a facility’s current operations and
missteps and can offer on-the-ground insight that upper
management cannot. Plus, these teams are the most affected
by changes in process and protocol and may have to undo
years of ingrained habits. Leaders should make these teams
feel heard, incorporate feedback into new processes, and
guide resistant team members through the change.
Sometimes, the end result of the PEER process is a complete
overhaul of the SPD, and that’s okay. An SPD that provides
the proper amount of space, equipment, and resources to
deliver quality outcomes reduces the risk of infection in
patients, decreases OR case delays due to instruments, and
increases physician satisfaction. An improved SPD can also
decrease error rates and reduce staffing-related problems. A
well-organized SPD is the pinnacle of enhanced productivity.
Remember, the PEER model is more than just preparation
for an accreditation survey. It’s the foundation for being a
center of excellence and a model of sterile processing and
high-level disinfecting compliance.
And for you? Well, knowing
that your SPD is a well-oiled
machine will help you have
restful nights. 
Mary Olivera, MHA, CRCST,
CHL, FCS, has actively par-
ticipated in the monitoring,
surveying and training interde-
partmental 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 • Sterile Processing Imperatives 2020
27