Jacho

[Guest]

Has anyone recently gone through a JACHO inspection? What were some of the questions you faced by the surveyors?
Mine is next week and I want to be ready for anything!
Thanks!

[Nannette Braley]

We went through JACHO last fall. The Doctor was the first we have ever had that asked to go through our department. He gathered my staff - told them he did not want them to tell him what the procedures or policies stated, but he wanted them to walk through "what they do". He started in decontam and went through sterile item distribution. He was very interested in our Cidex OPA and was very impressed when he asked for the test strips and saw we had written the expiration date on the bottle (first time he had seen it done correctly). At the end he praised the staff and told them had they not down well it would not have been their fault, but mine and the institution. What he was looking for was application of standards and principles - he did not ask them to quote what was written down. The point was - are we training them to do it correctly with the understanding of why we do things the way we do. (Education was the KEY) He was also impressed that we require all CS techs to complete and pass the IAHCSMM CS Tech course. Hope this helps, feel free to contact me off line with more questions.

[Bob Marrs]

We just finished our JCAHO survey this past Friday Oct 7th. We had a nurse surveyor who was a previous OR Director and CRNA. Needless to say, he was very comfortable in the operating room and in sterile processing. The specifics that he inquired about were as follows;

1. He asked to see our flash sterilization logs for the entire year. Looking for implants.
2. Very interested in which specialties we flash the most. i.e. ortho, neuro.
3. He asked how we were going to decrease the total number of loads.
4. We have new sterilizers and he asked how we brought them into service. i.e. 3 Bowies & 3 Biologicals before using.
5. He asked if the OR or Sterile Processing does the flashing of instrumentation. Looking for sterile processing, he thinks we should do it.
6. He spent about 30 minutes in the sterile processing area. He asked staff to explain exactly how they run a biological test in the sterilizer.
7. He then asked how they would incubate it and the read it and at what time intervals.
8. He asked staff why they run a bowie dick tests.
9. He asked what performance improvement activities we are involved with.
10. He spoke with 3 of my staff members and then asked me to produce their annual competency checklist for 2005. He read through them very carefully. He said that they should never be completed on the same day. He feels with the complexity of job tasks that it should take a couple of days.
11. He aslo looked at how the staff loaded the sterilizer carts.
12. This gentleman was very familiar with AAMI and mentioned that he knows Nancy Chobin.
13. He asked what certifications I have and asked how many of my staff were certified. He is in favor of 100% certification.

Our surveyors name was Stephen Knoll. He is from Tyler Texas. He is also very aware of TX laws and regulations.

Overall, I was very impressed with this surveyor. He was extremely competent and complimentary. He is an advocate for sterile processing and I believe that we need more surveyors like him so we can hold us accountable as leaders and we can continue to keep "Raising the Bar".

I hope this helps,

Bob Marrs
Director, Sterile Processing
St. David's Medical Center
Austin, TX

bob.marrs@stdavids.com
512.404.8325

[anna grayson]

Thank you for the wonderful insight into your experiences with JCAHO.

We will be going through the survey process in about 4 weeks and I am hoping someone stops in CS to observe and learn what we are all about. You both had two really good surveyors.
Happy CS week to all of you.And again, thanks for sharing valuable information. I am going to pass it on to my staff.

[SPD-GAL]

I had JCAHO at the end of September and the big focus was how the nurses know that the pumps in the clean room were clean. Cross contamination seemed to be the focus and he thought we should have stickers on the pumps that stated when they were cleaned. I did not see the point in putting a sticker on a pump since it proves that the pump was cleaned on that day and does not prove that it has not been tampered with or removed and returned.

They do have a new patient safety goal standard that I guess started in January that says the syringes should be labeled with a sterile sticker with the patient information and what is in the syringe.
Does anyone sterilize labels???? I am being asked to sterilize them and this is new to me.

[roelloyd]

I'm aware that this post is old however, I'm wondering if Jcaho visited your departments and what did the surveyor look for and what questions were asked.