In a recent article, I discussed the benefits of implementing what we at Nexera call a four-step PEER program (Prepare, Examine, Educate, Rectify) to help you stay in accreditation readiness mode and prevent the associated risks.
In this first of a four-part series I will break down the elements of the program, beginning with Prepare.
In order to go through an accreditation survey successfully, you must first familiarize yourself with the requirements and equip your department and staff with the necessary knowledge to satisfy the expectations of the surveyor. You can best prepare by gathering the necessary documents and reviewing the procedures, empowering staff with knowledge through a formalized training program, and managing the process.
Gather the Necessary Documents and Review Procedures
First, obtain the necessary accrediting agency standards, which will be the foundation of the process. There are many guides available, depending on whether the hospital has chosen The Joint Commission or DNV-GL. Some of these documents can be downloaded from the Internet for free, but others must be purchased. However, it is an investment that will pay off during the accrediting survey.
- Research the accreditation elements that are relevant to the Sterile Processing Department and study them carefully.
- Compare your current policies and procedures manual to the accreditation agency’s Sterile Processing Department policies.
- Revise your policies and procedures to reflect current regulatory standards; they should serve as a guide for all Sterile Processing staff.
You can help prevent risk by making certain that both sterile processing leaders and technicians are not just knowledgeable about the current requirements, but are continuously monitoring compliance and keeping abreast of industry changes. Maintain a library of relevant materials that staff can avail themselves of at any time.
Below is a sampling of resources:
- Regulatory Standards
- Local DoH regulations for state-specific SPD requirements
- Accrediting Standards
- The Joint Commission
- There are many elements that apply to the Sterile Processing Department. Specifically, The Joint Commission has published the High-Level Disinfection (HLD) and Sterilization BoosterPak, a free guide to help hospitals adhere to regulatory standards.
- Accrediting standards are available as a free download.
- Organizations that are accredited by DNV-GL should also purchase the following ANSI ISO standards
- The Joint Commission
- Professional Standards
- ANSI/AAMI Standards
- ST79:2017: A comprehensive guide to steam sterilization and sterility assurance in healthcare facilities, regardless of sterilizer or facility size
- ST91:2015: A comprehensive guide to flexible and semi-rigid endoscope processing in healthcare facilities
- ST90:2017: Processing of healthcare products—quality management systems for reprocessing in healthcare facilities
- ST58:2013: Chemical sterilization and high-level disinfection in healthcare facilities
- ST41:2008 (R2018): Ethylene oxide sterilization in healthcare facilities: Safety and effectiveness
- AORN Standards
- SGNA Standards
- ANSI/AAMI Standards
Empower Staff with Knowledge
Take the initiative and promote a learning environment in your department. It’s great to have a comprehensive library of resources, but it doesn’t make a difference if that knowledge stays in the library. Prepare educational sessions that complement your policies and procedures, then offer sterile processing staff the knowledge they need to feel empowered to do their jobs well. Here are a few tips:
- Not all adults learn in the same manner. Use different methods to present the information. Some people learn best with visual aids, some learn by listening when you lecture, and some learn best with hands-on practice.
- Schedule time to help your staff learn and repeat the demonstrations.
- Practice regularly. This will be your showcase when the surveyor ultimately visits your department.
Education keeps your staff informed and will help them feel confident to learn more. Being truly successful requires commitment!
Manage the Process
Developing policies and empowering staff are only two of the components of preparing for accreditation readiness. Continuous process monitoring is essential to ensure that there is no variation and that protocols adhere to the standards. By managing the process, you can implement immediate corrective action—before errors reach the OR.
Remember, maintaining perpetual readiness requires commitment and process consistency to ensure that the department stays on track. Establish a culture of peer collaboration so that your department becomes a center of excellence. Preventing risk and safeguarding patients must be the ultimate goal for every sterile processing professional.