“are you following me?” a surgical instrument tray...

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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.

© 3M 2015 All Rights Reserved3

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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

• [email protected]

Educational Consultant to 3M Health Care

© 3M 2015 All Rights Reserved4

LEARNING OBJECTIVES

© 3M 2015 All Rights Reserved

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)

6 © 3M 2015 All Rights Reserved.

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


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.



• 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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• 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!


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!


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.




• Use of detergents and enzymatics.

• Eyewash stations.

• Airflow and temperature.

• Expirations.

• Chemical indicators.



• Endoscope reprocessing and storage.

• Peel Pack usage.

• Staff competencies.

• Vapor plate exchanges.

© 3M 2015 All Rights Reserved.

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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.


• IFU for Ultrasonic.• Maintenance records for ultrasonic.• Degas.• Training on use of Ultrasonic.• Dilution of Enzymes.


• 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.


• Lubrication.• IFU for Lubricant.• Is recommended by manufacturer?• Other special Prep as indicated by IFU.


• 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.


• Steam • Gravity or Prevac?• ETO• H2O2• Other?


• 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.


• 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.


• 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?


• Route of transport.• Labeling of items Clean vs. Soiled.


• 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!


Questions?

© 3M 2015 All Rights Reserved.38

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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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