Probably the most essential article to analyze in the June edition of The Joint Commission Perspectives is the one on “Improving High Level Disinfection (HLD) and Sterilization Processes.” This is a subject we have focused on repeatedly in our newsletter and hospitals continue to struggle.
In this article TJC graphically displays the increase in scoring on these issues from 2013-2016 and it is getting increasingly worse each year. We do not believe this is because hospitals are becoming more and more lax in fulfilling expectations, but rather that the Joint Commission’s surveyors are becoming more and more knowledgeable about the finer aspects of the requirements from AAMI and AORN. This is where we believe hospitals may have the greatest vulnerability. Surveyors have access to all the references, they appear to have read them carefully and they have received formal training on these references.
We continue to experience many hospitals where if we ask staff performing HLD and sterilization about clinical practice guidelines, show me your AAMI ST 79, or 91 or 58, provide us the manufacturer instructions for use (MIFU); we get a blank stare.
TJC provides some very sound advice to help hospitals do better with this portion of the survey. They advise hospitals to:
- Use and follow Clinical Practice Guidelines (CPG) and Recommended Practices (RP)
- Ensure availability of MIFU
- Design and follow hospital policies based on CPG’s
- Verify competency and make sure the individual assessing competency is competent
We would add to this list of suggestions that a senior leader within the organization be identified as the content expert, reviewer, administrator, assessor of all areas performing HLD and sterilization. Today there is too much variation between departments that have their own administrative reporting relationships, yet they may all be performing HLD and sterilization using different methods and degrees of thoroughness. We would encourage hospitals to think of this function like a product line, that multiple different areas provide.
Also, whomever you tag for this responsibility will need the resources and training the surveyors have and preferably even more training. They need to be able to walk into any area of the hospital, observe and dialogue with staff and identify the weaknesses before TJC does.
The Perspectives article also includes a graphical representation of the immediate threat to life situations declared by TJC’s surveyors over the last 4 years. Fortunately, this is a low frequency occurrence with only 27 in 2016, but the percentage of these events due to defects in HLD and sterilization has grown to 70-80%. So, if you want to prevent the worst possible survey outcome, this is a critical area to focus attention on.
This same subject is discussed in the Joint Commission’s Quick Safety Newsletter, Issue 33, May 2017. In this newsletter, they display the RFI history going back to 2009 when only 20% of hospitals experienced and RFI and in 2016 it was up to 60%. If you are going to make the business case argument to appoint a HLD/sterilization czar, purchase all the required references and obtain comprehensive training in your organization, this very focused newsletter is an effective and convincing component of that argument.
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