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“Are you following me?”A Surgical Instrument Tray Tracer
April 16, 2015
Today’s meeting times: 9:00 a.m., 11:00 a.m., and 1:00 p.m. Central Standard Time
To hear audio, call 800-937-0042 and enter access code 7333633Phone lines are muted. Audio will commence when the webinar begins.
WELCOME!
Topic: “Are you following me?” A Surgical Instrument Tray Tracer
Facilitators: Christophe de Campeau, 3M
Dorothy Larson, 3M
Speaker: Mark Duro, Director of Sterile Processing Operations
Housekeeping• Questions
• Mute feature (*7 = unmute; *6 = mute)
• “Chat” feature
• Technical difficulties
• Post session follow-up
For more information: www.3m.Com/3MSterileU© 3M 2015 All Rights Reserved2
How do I get a CE Certificate?Next week, all of today’s meeting participants will be sent an email containing instructions for obtaining a CE Certificate for today’s meeting.
The email will be sent to the email address you provided when you logged-in to today’s meeting. If there are others listening with you today who did not log-on, you may forward the CE certificate email to them.
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Disclosure Statement
Mark Duro, CRCST, FCS, IAHCSMM Approved Instructor
Director of Sterile Processing Operations
• New England Baptist Hospital Boston, MA
• New England Baptist SurgiCare Brookline, MA
• New England Baptist Outpatient Surgery Center Dedham, MA
Educational Consultant to 3M Health Care
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LEARNING OBJECTIVES
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Understand how tracer methodology applies to sterile processing.
Discuss how IFU’s, competencies and processes may be observed by surveyors.
Understand the importance of following manufacturers’ IFUs.
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Health care facilities must be accredited by an accrediting organization with deeming authority by CMS
• Accreditation Association for Ambulatory Healthcare (AAAHC)
• Accreditation Commission for Healthcare (ACHC)
• American Association for Accreditation of Ambulatory Surgery Facilities (AAASF)
• American Osteopathic Association/Healthcare Facilities Accreditation Program (AOA/HFPA)
• Community Health Accreditation Program (CHAP)
• DNV Healthcare (DNV)
• The Joint Commission (TJC)
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Policy and Requirements for an Application for Deeming Authority. Accessed 7/12/2012 at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/applicationrequirements.pdf
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The Joint CommissionFormerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
• JUST
• CAME
• AROUND TO
• HELP
• OUT
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The Joint Commission
• Independent, nonprofit
• Accredits and certifies over 18,000 health care organizations and programs including:
• Hospitals,
• Doctor’s offices,
• Nursing Homes,
• Office-based surgeries,
• Behavioral health treatment facilities, and
• Providers of home care services.
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The Joint Commission
• Surveyors are being trained.
• Not the same old inspections.
• Very inconsistent inspections.
• May be visited a couple times during visit Engineering /RN /MD.
• You don't know the severity of your inspection.
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The Joint Commission
• Clean like crazy!
• Loose sleep at night!
• Double and triple check records.
• Get all the junk out of the halls/move into tractor trailer and drive it to the mall parking lot?
• Check expirations everywhere.
• Stress level through the roof!!!
• If we are doing our jobs correctly there is no need to panic!
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The Joint Commission – What are they looking at?
• Clean like crazy!
• Loose sleep at night!
• Double and triple check records.
• Get all the junk out of the halls/move into tractor trailer and drive it to the mall parking lot?
• Check expirations everywhere.
• Stress level through the roof!!!
• If we are doing our jobs correctly there is no need to panic!
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The Joint Commission – High Level Disinfection
• What type of high level disinfection do you do?
• What products are you processing?
• Show me your HLD records?
• Show me the solution you are using.
• Will look at product expirations.
• Testing of test strips and lot numbers of products (are these documented in your records)?
• Manufacturers’ IFUs.
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The Joint Commission – High Level Disinfection
• Dates products open.
• Ensure new product expirations on test strips not to exceed Manufacturers expiration.
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The Joint Commission – What are they looking at?
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• Use of detergents and enzymatics.
• Eyewash stations.
• Airflow and temperature.
• Expirations.
• Chemical indicators.
The Joint Commission – What are they looking at?
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• Endoscope reprocessing and storage.
• Peel Pack usage.
• Staff competencies.
• Vapor plate exchanges.
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• Instrument IFU. • PreTreatment.• Transport in labeled cart.• IFU for Enzymes.• Proper dilution.• Training on use of chemistries.
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• Maintenance record for washer.• Washer testing.• IFU for washer.• Competency and training on washer
usage.
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• IFU for Ultrasonic.• Maintenance records for ultrasonic.• Degas.• Training on use of Ultrasonic.• Dilution of Enzymes.
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• Instrument IFU.• Proper cleaning chemistries. • Proper cleaning tools - Brushes,
equipment etc.• In-service information.• Environmental controls and airflow will be observed.
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• Appropriate tools for inspection/identification.
• Magnification.• Appropriate workstation.• Lighting.• Insulation inspector.• Insulation testing documentation.• Testing tools for sharps.• Other specific needs as listed in IFU.
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• Lubrication.• IFU for Lubricant.• Is recommended by manufacturer?• Other special Prep as indicated by IFU.
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• Proper assembly of instruments.• Instrument protection.• Ports on or off per IFU.• Other special Prep as indicated by IFU.• Competencies.
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• Wrap compatibility.• IFU for wrap.• Container compatibility.• IFU for container.• Weight of container to packaging
material.• Packaging compatibility to instrument
and sterilizer.• Instrument device manufacturer IFU to
packaging.• In-servicing/competencies.
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• Steam • Gravity or Prevac?• ETO• H2O2• Other?
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• What does the IFU state for exposure and dry?
• Do you have the correct monitoring tools?
• Which CI do you use?• Are you using them correctly?
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• Pre-cycle load configuration.• Pre-cycle sterilization selection from
IFU.• Usage of quality monitors CI/BI.• Pre-cycle verification.• Post-cycle verification.• IFU for sterilizer available.• Maintenance and PM records for
sterilizer.
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• Either manual or electronic record. • Cycle printout with verification.• Cycle start and end time.• Load contents.• BI/CI results.• Lots for BI and Control match.• Temp/Time/Pressure.• Temp for incubator if applicable.• IFU for incubator.• Biomed inspection for incubator?• Consistency and accuracy of records.
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• Items cooled to room temperature before storage?
• Adequate cooling location?
• Storage location temp/humidity.
• Quarantine for BI.
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• Storage location clean.• 8-10 inches from floor.• Solid bottom shelves.• 18 inches below the ceiling or
the level of the sprinkler heads.• 2 inches from outside walls.• Stacking of goods?
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• Route of transport.• Labeling of items Clean vs. Soiled.
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• Visual verification of item process completion.
• Product integrity.• Visual moisture?• The final verification before use.
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Conclusion
• Inspections will continue and will become more intense.
• We always need to be in a state of readiness.
• Following your processes and identifying accuracy can assure best practice.
• Everything we do is not for the sake of the inspection but for our patients!
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Questions?
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THANK YOU!
NEXT LIVE WEBINAR
Date: May 21, 2015
Title: Implementing a CS Staff Competency Assessment Program
References• Centers for Medicare and Medicaid Services
Center for Clinical Standards and Quality/Survey & Certification GroupPolicy and Requirements for an Application for Deeming Authority. Accessed 04/02/2015 at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/applicationrequirements.Pdf
• The Joint Commission. Facts About the Joint Commission.Accessed 04/02/2015 at: http://www.Jointcommission.Org/facts_about_the_joint_commission/
• oneSOURCE document sitewww.onesourcedocs.com
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