When a hospital prepares to welcome accreditation surveyors, it is nerve-racking for everyone involved. Departments across the hospital quickly shift into surveying mode. While the hospital administrators wait for the list of departments the surveyor wants to visit, everyone else makes last-minute fixes in their respective areas. Organizations spend months preparing the physical environment, enhancing staff knowledge, and ensuring all documentation follows standards. Despite the preparation, the surveyor always seems to find a deficiency to add to the findings scorecard.
Years ago, the sterile processing department (SPD) was not on the surveying agenda. I remember preparing our team to answer questions, ensuring all policies and procedures were up to date, and making sure there were no violations in the physical environment of the department. Even though we had prepared, it was disappointing that we never had the opportunity to participate.
Today that is no longer the case. Cleaning and decontaminating surgical instruments and endoscopes continues to be the focus for The Joint Commission surveyors emphasizing patient safety. If you are in the accreditation window, you will need to be ready for a visit from the surveyor. As the SPD manager, how can you prepare your department and team? What questions can you expect from the surveyor? What documentation will you need to provide? How long will the surveyor spend in the SPD or endoscopy reprocessing area?
How can the SPD manager get ready?
Each surveyor will have a list of questions and things they want to review in your SPD based on their area of expertise and surveying experience; therefore, we must prepare thoroughly. The High-Level Disinfection (HLD) and Sterilization BoosterPak published by The Joint Commission is a great resource available to everyone. The BoosterPak aims to ensure that “work practices are carried out following regulatory standards and evidence-based guidelines for HLD and sterilization in order to minimize the potential risk of infection transmission to patients.”1
Another resource is the Centers for Medicare & Medicaid Services (CMS) Hospital Infection Control Worksheet, which lists questions that the CMS surveyor uses to assess the facility compliance with the conditions of participation in infection control. Use these resources to conduct a mock survey in your SPD and endoscopy reprocessing areas. Prepare policies and procedures that adhere to manufacturers’ instructions for use and evidence-based guidelines published by professional societies.
What questions will the surveyor ask?
During one of my most recent surveys, I was extremely impressed by the surveyor’s knowledge of SPD and endoscope reprocessing. He was uniquely qualified as an expert in the field and a PhD. While in the operating room, he opened and inspected a sterile instrument tray. He looked for the internal integrator and checked if instruments remained open during the sterilization process. He also asked the circulating nurse and scrub technician how they determined if instrument trays were safe for placement in the sterile field. His goal was to ensure that external and internal indicators were checked before using the surgical instrument tray.
The SPD survey emphasized patient safety and the department’s ability to minimize the risk of potentially sending improperly cleaned and sterilized surgical instruments to the operating room. The surveyor questioned the SPD team members about the process and wanted a detailed explanation of how they performed each task. The clinical surveyor asked the SPD team members the following questions:
- What do you do to the instrument tray once it is out of the washer-decontaminator?
- How do you ensure that there is no residual bioburden in the instruments?
- What sterilization processes do you use? Explain the steam sterilization process.
- What measures do you take to ensure the sterilizers are functioning properly?
- What is a Bowie-Dick and what is its use?
- What is a biological test? What is the microorganism found inside the biological test vial? How often is a biological test performed on sterilizers?
- How are sterilization loads documented?
- Explain the function of the washer-disinfector. How do you ensure its efficacy?
- What is the sink sequence and why does the technician follow the specific sequence? The surveyor observed an instrument tray being hand-washed.
- What is the ratio of detergent to water? How do you know the amount of detergent added to the sink basin? How long are the instruments soaked and what are the detergent manufacturer’s instructions for soaking?
- What is the function of the ultrasonic machine and what process does the machine use to clean the instruments?
- How does SPD communicate with the OR when there are discrepancies in trays or issues related to residual bioburden in the trays sent to SPD?
- What quality process does SPD have in place to promote patient safety and reduce human errors?
The surveyor spent several hours in the SPD before he moved on to the endoscopy reprocessing area, where he asked similar questions about the automatic endoscope reprocessing equipment efficiency, manual endoscope cleaning, and manufacturer instructions for use. He observed the manual cleaning and high-level disinfection (HLD) of an endoscope and requested that the technician verbalize the process while completing the steps. He asked questions about soaking time and detergent dilution. He also asked how the detergent doser is calibrated, how often, and who performs the calibration? He inspected the HLD documentation and asked how often we measure staff competencies.
The environment of care surveyor assessed the department for potential safety concerns. He looked at fire extinguishers, sprinklers, and the eyewash station. He reviewed the sterilization records for efficacy and efficiency testing. To our surprise, he also checked behind the sterilizers for potential fire hazards. He also evaluated the negative and positive pressure areas of the SPD.
The inspection was thorough and lengthy. In the end, the department obtained a score of ‘zero’ findings and had several commendations from the surveyor. The collaboration between the operating room, endoscopy, and SPD directly contributed to the success and excellent rating received at the end of the survey. Advanced preparation, maintaining a continuous readiness status, and constantly wanting to improve the process to ensure patient safety made our team successful. As Winston Churchill said, “To improve is to change; to be perfect is to change often.”
- The Joint Commission. High-Level Disinfection (HLD) and Sterilization BoosterPak. Oakbrook Terrace, IL, 2015.