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This series of self-study lessons on Central Service topics was developed by the International Association of Healthcare Central Service Materiel Management (IAHCSMM). The lessons are administered by Purdue University’s Continuing Education Division.

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Lesson Plan CRCST 404
Joint Commission Standards Impact Central Service

Central Service personnel must be familiar with the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) and the role it plays in healthcare. Joint Commission is a private agency that carries no regulatory weight and, while accreditation is voluntary, failure to attain the organization's standards will have a significant impact on the
healthcare facility.

For example, the Medicare Act of 1965 required compliance with Joint Commission requirements for hospitals to participate in Medicare and Medicaid programs. (Note: Medicare is a federal medical insurance program that primarily serves those over age 65 regardless of income and younger disabled persons and dialysis patients. Medical bills are paid from trust funds into which covered persons have paid. By contrast, Medicaid is a federaland state assistance program that pays covered medical expenses for low-income persons; it is run by state and local governments within federal guidelines.) Hospitals that lose their ability to participate in those programs can lose millions of dollars in applicable payments.

While accreditation is in the hospital's financial interests, there are several other important benefits to be derived from meeting Joint Commission requirements. For example, it improves a facility's image within its community and among its healthcare counterparts because it demonstrates that the hospital has met rigid standards for patient safety. Joint Commission accreditation may also reduce the hospital's insurance premiums and, in some cases, maybe used to demonstrate that other state and federal inspection requirements have been met.

Joint Commission representatives conduct on-site visits (inspections) to collect information helpful in assuring that its standards are consistently attained as it fulfills its mission. The Central Service department is in integral part of this visitation process because of its critical role in the hospital. Each CS staff member should be familiar with all Joint Commission requirements specific to their department.¹ A general overview of these standards is provided in this Self-Study Lesson.

Objective 1: Identify Joint Commission's role inhealthcare organizations.

Joint Commission's mission statement accurately reflects its role in the hospital setting: “Improve quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in organizations.”²

Joint Commission representatives work to attain their organization's mission by examining the quality of a hospital's
care. They do so by analyzing a large number of indicators of planning and performance. They focus on the facility's
ability to provide quality care through its planning and preparing activities, and they also examine how that care is
delivered. Additional concerns address how hospital personnel measure performance and what is done to continually improve quality.

The work practices of Central Service staff have a significant impact on patient care. They must develop systems that consistently attain (or exceed) accreditation requirements and that provide the means to confirm that these standards are met. Emphasis is placed on developing good work practices and then on implementing protocols to assure that the overall quality of patient care is improved.

Objective 2: Note basic Joint Commission infection control standards applicable to Central Service.

Infection control is, perhaps, the area of Central Service responsibility that is most impacted by Joint Commission requirements. The majority of a Central Service technician's duties relate to infection control practices and standards and require that the facility take actions to control nosocomial (hospital-acquired) infections.

Central Service employees must incorporate practices required by these standards as they plan decontamination processes, consider cross-contamination issues and implement environmental management and sterilization protocols. They must also plan and implement sterilization quality assurance systems and work to assure sterility maintenance. Each step in the sterilization process, from initial cleaning to the distribution of sterile items, has the potential to cause significant patient and/or employee harm if it is not done correctly. For example, infection control protocols such as those relating to traffic control and dress codes are required to maintain the integrity of the work environment. Rigid adherence to required cleaning practices helps to maintain safe storage areas for sterile items.

Central Service staff also must take great care as they undertake assembly and sterilization processes, and they use several alternative quality assurance measures to assess sterilization outcomes. Each step insurgical instrument processing is performed in accordance with industry guidelines such as those developed by the American Association of Medical Instrumentation (AAMI) and federal and state Occupational Safety and Health Administration (OSHA) regulations and Federal Food and Drug Administration (FDA) requirements.

Central Service managers must develop policies, requirements and procedures to comply with the numerous regulatory recommendations, current scientific knowledge and accepted industry practices. Their employees, then, must consistently follow these facility-developed mandates as they perform all infection control responsibilities.

Objective 3: List basic environmental standards that apply to Central Service.

Several Joint Commission environmental care standards impact Central Service. Examples include safety and storage requirements including personal protective equipment (PPE), the availability of eye wash stations and standards for fire exits and evacuation routes, hallway clearances and sprinkler head clearances. The need to store items off the floor and to secure gas cylinders are additional requirements.

Cleaning requirements that include basics such as housekeeping duties are critical to all Central Service personnel as they control the work environment by managing microorganisms and their transmission within the department. These and related Joint Commission standards affect the safety of patients and employees.

Objective 4: Explain the purpose ofCentral Service performance improvement measurements.

Central Service personnel measure the department's effectiveness by using specific indicators that reflect performance. Measurements are important for sterilization activities and outcomes to help assure the quality of the trays and sets that are assembled/dispensed. Numerous mechanical, biological and chemical indicators are used to provide an indication of the quality of processes used and work outputs generated.

Data is gathered and analyzed, and action plans are developed to increase compliance and to improve quality. The goal of data collection is to provide a means for continuous quality improvement that will enable the quality of the products and services provided by the department to steadily improve.

Central Service goals are often developed after data is collected and analyzed. For example, plans to reduce errors and increase efficiencies often begin as performance improvement measurement data required by Joint Commission.

In addition to routine measurements, department personnel may also be involved in special data collecting processes to identify specific factors that resulted in a failed process or system. These are called Root Cause Analysis processes and are tools used to review factors that may have created a specific process failure. When used correctly, they provide guidance to develop action plans to significantly reduce the risk of additional failures in the future.

Objective 5: Review the purpose of human resource documentation.

The Joint Commission accreditation process emphasizes the human factor and its impact on the overall quality of patient care. This requires that all Central Service employees be properly trained to perform their job correctly. All training, along with the departmental educational processes that were used, must be documented. This provides a record of the level and type oftraining provided and is an important component of the larger (facility-wide) system.

Human resource documentation for Central Service personnel includes a job description for each employee that accurately reflects the employee's duties. As well, orientation records that identify specific information covered in the employee's orientation time and training records that detail training in specific job duties must be available. These must, in total, indicate what the facility has done to improve the employee's ability to successfully perform required duties. Finally, competency evaluations that address specific job competencies must be available and documented.

The overall goal of all human resource documentation requirements is to develop a plan for employee training and development and to provide a measurement system to assess individual employee performance. This assessment process may then identify where, if at all, additional training is needed. As this occurs, the employee improves and, in the process, so does the Central Service department.

Objective 6: Describe Joint Commission tracer methodology and its possible impact on
Central Service.

Joint Commission has recently begun to shift away from pre-scheduled visits to patient care settings and has moved towards use of a tracer methodology for accreditation visits.When tracer methodology is used, randomly chosen patients are followed as they receive treatment and care. This type of review places survey team members in designated patient care areas and provides them with the opportunity to survey functional areas such as Central Service that have a direct impact on the quality of patient care and patient outcomes.

Tracer methodology can uncover system issues that impact the quality of patient care. Its focus is on the interaction of individual components in the larger system.

Historically, the Central Service department was rarely visited by the survey team. It was more common for the department's policies, procedures and documentation systems to undergo review than it was for an actual survey visit tooccur. Today, if surveyors follow surgery patients using tracer methodology, it ismore likely that the department will be visited. This will occur if the surveyor wants to establish the quality of the instruments, utensils, supplies and equipment used during a patient's surgicalprocedure(s). Questions could address any aspect of infection control or supply readiness that impacts the patient's care. All Central Service employees should be able to explain the purpose of their job and the potential impact that it has on patients.

Objective 7: Detail Central Service preparation strategies for Joint Commission surveys.

Traditionally, Joint Commission surveys were preceded by months of planning and preparation within the facility. Recently, there has been a shift from preparation for a specific survey visit to continuous compliance with standards. Instead of preparing for a single survey visit, Central Service staff should establish a system that incorporates Joint Commission requirements into everyday work practices. Then the department can continually operate at the same high level of compliance.

To be successful, Central Service managers must develop procedures and design systems that meet Joint Commission requirements. They must also develop and implement systems to continually measure system effectiveness. They must, as well,develop specific methods that address issues and improve the quality of the products and services provided to
their "customers."

In addition to standards that directly impact daily operations of the department, Central Service managers must also assure that their efforts serve the same mission as that of the facility of which they are a part. Employee education is critical. Staff mus tknow the safety and legal standards to b efollowed as they perform infection control tasks. They must also understand their rolein the facility: every employee must be familiar with basic hospital policies and know the hospital's mission. Joint Commission's emphasis is on the total facility, and all departments, including Central Service, must provide the best environment to maximize overall patient care.

Survey team members will interact with staff members, and it is very likely that one or more Central Service employees
will be asked questions about processes, procedures and/or hospital policies. Perhaps the most difficult part ofJoint Commission preparation is to get the staff involved. Meetings, mock surveys, trivia games and other review tools can
help to generate staff excitement. Once the initial information is shared, remind staff that the need to meet Joint Commission requirements should be a daily, on-going process and that required practices should be incorporated
into daily work routines.

Central Service managers must develop procedures and work practices reflecting Joint Commission requirements. By taking the time to insure that their employees understand their role in doing so, a system of continual product and service improvement that benefits patient care will result. Central Service managers should challenge their staff members to be part of the process because, often, the best process improvement suggestions are offered by those employees directly responsible to perform the required work tasks.

In Conclusion

Central Service managers and their staff are professionals and are always concerned that their work outputs best serve their facilities and their patients. They recognize that Joint Commission representatives are not adversaries trying to “catch them doing something wrong.” Instead, they see Joint Commission, industry associations and state and federal regulatory agencies to be wit hthem in efforts to continually improve. As this occurs, everyone benefits, and the healthcare industry best fulfills its service mission.

Endnotes

1 Joint Commission Standards, Joint Commission Accreditation Manual for Hospitals. (Infection Control, Environment of Care, and Performance Improvement Sections).

2 Joint Commission Mission Statement: www.Joint Commission.org.

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