The Greeley Company
November 19, 2018 5 Min Read

The Joint Commission’s “Enhanced Survey Process” Puts a Microscope on the Sterilization/Disinfection Cycle

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Sterilization / Disinfection Cycle Joint Commission’s “Enhanced Survey Process”Four steps healthcare organizations can take to meet the scoring revisions

The Joint Commission has changed its survey process to focus on four areas:

  • high-level disinfection and sterilization;
  • sterile compounding of medications;
  • identification and protection of potentially suicidal patients; and
  • hemodialysis.

As part of this refocusing the Joint Commission has sharpened the way it will score. Citations under that section often lead to condition-level findings.

The following is Greeley’s recommendation for steps all healthcare organizations should do to prepare for this closer look at the disinfection cycle.

Step 1: Put disinfection on leadership’s agenda

The infection control representatives at your institution have probably been monitoring sterilization / disinfection issues years. At most hospitals, it’s not working well because: 1. Infection control representatives are very busy with many competing priorities; 2. there are a number of other locations outside of central sterile processing to worry about (like ambulatory care); and 3. disinfection may seem easy and natural, but it’s not.

It is time to expand compliance efforts beyond infection control and put it on the priority lists for managers across the organization.

Disinfection is not infection control’s issue, it is an issue for each clinical manager!

Step 2: Establish local responsibility with central oversight

We recommend presenting the following process for leadership’s approval:

  1. The manager of each patient care location should become clearly and unequivocally responsible for the elements of the disinfection cycle performed in their unit or setting. Although not all locations perform high-level disinfection or sterilization, virtually all patient care areas participated in one or more aspects of the disinfection cycle: collection, transportation, cleaning, etc.
    Unit Manager Date of Response Store sterile items Collect/hold sterile items after use Transport sterile items after use Decontaminate and clean sterile items
    Operating Room Sally Smith 1/1/20 Yes Yes Yes No
    Central Sterile Supply Sol Smothers 1/2/20 Yes No No Yes
    Dental Clinic Billy Bam 1/3/20 Yes Yes No Yes
    Gastroenterology Suite Brend Breem 1/4/20 Yes Yes Yes Yes
    Occupational Health Pat Patton 1/5/20 No No No No
  2. Training and tools should be provided to these managers about your requirements for each phase of the disinfection cycle (see below).
  3. An individual (infection control or quality and compliance) should be responsible for creating an inventory of all units and settings where non-disposable items are used (items that have been or will need to be sterilized or disinfected). The Greeley sample inventory tool should give you an idea about what to look for.
  4. Each unit or location of the inventory should be reviewed against the following criteria, based on the Joint Commission scoring guidelines, for the corresponding part of the sterilization / disinfection cycle.

[NOTE: The following guidelines apply to sterile / disinfected items that will be re-used. It is important to make sure that hospital policies are followed, which should address all of the elements listed below. However, we do not recommend trying to repeat or summarize the IFUs for items to be disinfected, disinfecting solutions or equipment, and wrapping materials. It is also necessary to have access to and comply with the manufacturer’s instructions or IFUs for the sterile item, the packaging for the sterile item, the sterilizer / processor and any disinfecting solution.]

  1. Storage of Sterile / Disinfected Items
    1. Items that are ready for use should not be visibly soiled.
    2. Items are stored to prevent contamination (e.g. solid bottom shelf)
    3. For drawers used to store items that were processed through high-level disinfection
      1. Storage is consistent with the IFUs (or facility guideline if IFUs don’t address storage) of the disinfected items.
      2. Container or location of storage is not visibly soiled
      3. Materials are handled to avoid contamination
  2. Collection / Holding and Sterile Items After Use
    1. Wiping or flushing of soiled instruments at the location of use (e.g. procedure room, operating room, utility room for bedside procedures)
    2. There must be a process for keeping soiled instruments moist immediately following use (check instrument IFUs and hospital policy). [Example: Some IFUs recommend using enzymatic solutions to keep the instrument moist.
  3. Transportation
    1. Sharps in compliance with OSHA regulations
      1. Puncture resistant
      2. Biohazard label
    2. Non-sharps transmitted to prevent contamination
      1. Biohazard label
      2. Covered
      3. Drip prevention
  4. Decontamination
    1. Use of PPE
    2. Negative air balance
  5. Packaging
    1. Hinged instruments in the open (not ratcheted) position.
    2. Disassembly of instruments per IFUs
    3. Use of packaging per IFUs
      1. No folds for any internal (double) package
      2. Beyond use dates or criteria
  6. Disinfecting / Sterilizing
    1. Hinged instruments in the open (not ratcheted) position.
    2. Sterilizers (Check IFUs)
      1. Monitoring
        1. Daily biological monitoring for each sterilizer
        2. Routine sterilizer function monitoring
      2. Release of loads after
        1. Internal chemical indicator
        2. External chemical indicator
        3. Physical monitoring of sterilizer functioning
        4. For Implants: Reading of biological indicator
          1. Exception for emergency situations
    3. Disinfectants (Check IFUs)
      1. Chemical Monitoring
      2. Exposure monitoring when indicated
    4. IFUs for drying and frequency of disinfection are followed for scopes.

If you would like to schedule a review of your disinfection or sterilization practices, or a more comprehensive mock survey, contact us at or call 888.749.3054.

Let’s start the conversation.

About the Author

Bud PateBud Pate has more than 40 years of high-profile problem solving to his work with hospitals and healthcare organizations across the country. Bud is a nationally recognized expert in CMS and Joint Commission compliance, clinical process simplification, clinical quality and patient safety. His work brings him to institutions and podiums across the country, sharing his unique approach to compliance: guiding his clients to shed overly-complicated, unrealistic expectations that don’t work for simple, common sense solutions that promote efficiency, protect patients, comply with external standards, and last.

Prior to joining The Greeley Company, Bud spent 15 years as an executive consultant and director of licensing and accreditation for Kaiser Permanente’s Southern California region. Before joining Kaiser, Bud was responsible for state licensing and Medicare certification for all hospitals, home care agencies, and clinics in Los Angeles County. Bud also represented the California and American Hospital Associations on various Joint Commission committees.

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