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By now everyone should be well aware that two categories of standards rise to the top in the volume of regulatory findings. These are Environment of Care and Infection Prevention and Control. One standard in particular receives a lot of citations varying widely in range: Joint Commission Infection Prevention and Control standard IC.02.02.01. However, while a variety of findings roll up under this standard, a common theme is evident: high-level disinfection and/or sterilization. This is also a high vulnerability focus area from a CMS compliance issue.

Let’s consider for a moment the challenges associated with high-level disinfection. The process is:

  • Problem prone – numerous steps with varying requirements for each
  • High risk – if not performed correctly, patient harm can occur
  • Potentially widespread throughout an organization
  • Often is not well-standardized across the organization (even in locations using the same products on similar equipment)

One of the first steps to ensuring high-level disinfection is performed in a safe and compliant manner is to determine the current state of the processes within the organization. On the surface this sounds simple, but there are numerous types of equipment undergoing high-level disinfection in any facility as well as a variety of high-level disinfectants. Take a thorough and accurate inventory of all locations and staff performing high-level disinfection, the types of equipment undergoing the process and all of the disinfectant products in use. Be sure to include a compilation of all manufacturer guidelines for both the equipment being disinfected, equipment utilized in the disinfecting process as well as the disinfectant itself.

As with all processes the simpler the process is to perform, the better compliance will be; so consider adopting a policy that covers high-level disinfection globally with posting of manufacturer guidelines for the equipment and disinfectant specific to each location that address the individual nuances of the process accordingly.

It is also important to have a sound process for assurance of staff competence and ongoing job-specific education and training, particularly when equipment or disinfectant is changed. Lastly, will be the oversight provided for the process(es) and incorporation of this into the overall Quality program.

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