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Among the topics slated for “enhanced” attention during Joint Commission surveys are high-level disinfection and sterilization, which continue to be problematic for hospitals across the country. Issues related to disinfection usually lead to condition-level findings, sometimes placing the hospital into “Immediate Threat to Life” or “Immediate Jeopardy” status.

Background

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In early 2012 the FDA issued an alert regarding outbreaks of CRE (Carbapenem-Resistant Enterobacteriaceae) in Illinois, Pennsylvania, Seattle, and Los Angeles. These outbreaks were associated with the incomplete disinfection of duodenoscopes used for ERCP (Endoscopic Retrograde Cholangiopancreatography) procedures. On April 3, 2012, CMS issued a survey and certification memo instructing survey teams to focus on the processing of such scopes, which in turn led to a broader look at disinfection and sterilization by survey agencies.

Addressing Vulnerabilities

One would think that findings related to disinfection would have subsided over the six years since this issue has been on the front burner, but not so. Our experience with hundreds of hospitals in recent years tells us that this issue is far from resolved. And, as Joint Commission surveyors dive deeper, we fear many facilities will find themselves in a tight spot. So, here are a few tips, remembering that the overall secret to sustainable compliance lies in simplification: making the right thing to do the easy thing to do.

  1. Simplify and Customize: Don’t over-complicate your policies and procedures. Remember that the key to effective disinfection and sterilization lies in the FDA-cleared Instructions for Use: the “IFUs” for 1) the device being disinfected, 2) the solutions and equipment used for cleaning and disinfection, and 3) any materials used for packaging. However, DON’T try to repeat these IFUs in your policy. Instead, assure that IFUs applicable for the setting are conspicuously posted and that quality control sheets capture the important steps specified in the IFUs.The secret to sustainable compliance lies in simplification: making the right thing to do the easy thing to do.
  2. Quality Control and Supervision: Establish logs for site-specific quality control and supervision, including a documented double-check by operational leadership.
  3. Monitoring: Regularly monitor the supervision process by observing actual practice. Greeley advocates a “care facilitation” approach – an approach we typically work with clients to implement through in-person or online education, but here are a high-level few tips you can try on your own:
    • Monitoring should be done with an open hand (of help) rather than a closed fist (of enforcement). For example, infection prevention and compliance representatives should be viewed as a resource for operational leadership and front-line personnel rather than something to be feared.
    • Monitoring should focus on actions rather than documentation alone.
    • The expected practice should be immediately reinforced when variations are identified. Monitoring personnel should seek to understand the “why” behind any observed variance. (One cannot correct the what, only the why.) Data collected should reflect practice before and after reinforcement.
    • If the data suggest persistent non-compliance, the process should be improved. The instructions, the logs, the layout, the materials, and so forth should be simplified. Remember:
      • Focusing on the right thing being the easy thing and using the collective “whys” as a resource for this simplification,
      • Continuing to reinforce a broken process will not result in compliance, and
      • Little monitoring and reinforcement is necessary for a well-designed process.
  4. Oversight: The final step is meaningful and productive oversight. Effective oversight means:
    • Meaningful data analysis before the oversight meeting,
    • More thoughtful recommendations with respect to adverse situations,
    • Credible and thorough accountability tracking, and
    • Less meeting time with more accomplished.

Watch This Space

Greeley will be sharing additional information on the disinfection and sterilization cycle in upcoming blog posts and educational opportunities. If you are interested in exploring simplification and care facilitation initiatives at your facility, let’s start the conversation.

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