Self Assess Sterilization & High-Level Disinfection Compliance

by Expert Advice

Self Assess Sterilization & High-Level Disinfection Compliance

by Expert Advice

by Expert Advice

How do you better prepare for your next sterilization and high-level disinfection compliance survey? We suggest a self-assessment. Take these 8 steps to ensure a smooth process.

Sterilization & High-Level Disinfection Compliance

1. Identify a clinical practice guideline (CPG) that served as the policy foundation. In fact, you’ll need a copy of that CPG for each department performing HLD or sterilization.

2. If you don’t have it, obtain the latest version of the clinical practice guideline. What’s more, the most current release is a revised AAMI ST 79 published in late 2017.

3. Confirm that each department that performs high-level disinfection or sterilization has a CPG and policy. In addition, ensure they have scrutinized that CPG against their policy and practice to confirm compliance.

Internal Experts

4. Is there a hospital wide content expert? Moreover, do they have responsibility and authority to inspect each department? Plus, do they perform and validate high-level disinfection compliance. And, are they able to enforce corrective action directly as needed or through other senior leaders?

In fact, any defect in the high-level disinfection and sterilization process results in an RFI. Equally important, it is usually in the red and at a COP level. Consider using your hospital incident reporting process. This will allow you to track, trend and analyze self-identified noncompliance.

5. Is the hospitals internal compliance data reviewed by senior leadership?

6. Does each person with responsibility to perform high-level disinfection or sterilization have a detailed, documented competency that is conducted on an annual basis? Equally important, a competency is not the same as training. And, it’s not the same as an orientation by a vendor to a new piece of medical equipment or product.

Instead, a knowledgeable expert conducts competency for HLD or sterilization. They use a granular checklist, observe and interview staff member who are actually performing the process. This provides compliance validation with each step of the process.

It’s More Than A Piece Of Paper

7. Review competency assessment checklists and processes. We see many that are perfunctory and just designed to put a piece of paper in front of TJC in the hope that is passes. Furthermore, it requires sufficient details to enable the hospital to verify that the staff genuinely know the steps in these complex processes.

8. Lastly, what if your hospital wide high-level disinfection and sterilization content expert identifies deficiencies and practice at a department level? Is there a process to revalidate the training, and competency assessment? You might not want to redo a competency after one failure. But, you should consider this after two repetitive failures. Or many different failures in the same department.

Patton Healthcare Consulting provides sterilization and high-level disinfection compliance support. Contact us to learn how we can support your survey needs.


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