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The Joint Commission (TJC) accreditation processes for healthcare facilities are conducted with a focus on safety and the quality of patient care. During the survey process, surveyors assess each department, including the Central Sterile Supply Department, to verify that employees’ competencies and ethical and work practices meet current published standards. Now, more than ever, decontamination and sterilization practices have become an important focus of the accreditation survey process. This lesson provides an overview of TJC standards that relate to sterile processing and suggests what CSSD professionals should do to remain prepared for an accreditation survey.
TJC is an independent, nonprofit organization that accredits and certifies more than 18,000 healthcare organizations and programs in the United States. TJC offers accreditation and certification for many types of facilities, including hospitals, doctors’ offices, nursing homes, office-based surgical centers, behavioral health treatment facilities, and providers of home care services. TJC accreditation is nationally recognized as a symbol of quality that reflects its commitment to meeting defined performance standards. Healthcare facilities must submit an application, along with a fee, to request an accreditation survey and, upon approval, TJC accreditation is valid for a three-year period. The organization must then be resurveyed within three years to maintain its accreditation and certification status. In 2006, TJC began an unannounced survey process so facilities should remain in a constant state of readiness.6
There are two main TJC resources that are essential in understanding the survey and accreditation process for hospitals and ambulatory care facilities:
The accreditation standards for ambulatory care facilities are organized similarly to those for hospitals, with slight modifications that take into account the different settings.
Copies of the resources should be available in the administration department of any facility applying to be surveyed. Much of the information is applicable to CSSDs, and it is a “must read” for CSSD professionals.
The Association for the Advancement of Medical Instrumentation (AAMI) recently published a new document, “Sterile Processing in Healthcare Facilities: Preparing for Accreditation Surveys.”3
This guidance document helps CSSD professionals prepare for an accrediting agency survey because it provides guidance about the sterile processing of surgical instruments and other medical devices in any healthcare settings.
AAMI's publication, "Sterile Processing in Healthcare Facilities: Preparing for Accreditation Surveys,"
should be a priority resource for all CSSD personnel.
Objective 2. Provide an overview of The Joint Commission standards and review examples of how they relate to Central Sterile Supply departments.
TJC uses standards, rationale statements and elements of performance (EP) to provide guidance about what to expect as a survey is conducted. The standards are the performance objectives and each objective has rationale statements to describe the importance of the objectives. Each standard also has applicable EPs that specify how the standard or objective should be met. The EP scores determine the overall compliance with the standard. Facilities must receive a minimum of score of 90% on every EP on the survey.
For hospitals, TJC standards are grouped into the following chapters1:
The standards that most affect CSSDs are in the Environment of Care, Human Resources, Infection Prevention and Control and Leadership chapters. Each TJC standard has at least one very specific EP that the surveyor reviews. For example, consider standard HR.01.06.01: “Staff are competent to perform their responsibilities.” This standard has numerous EPs that impact sterile processing such as: 1,2
EP 1. The hospital defines the competencies it requires of its staff who provide patient care, treatment, or services.
EP 2. The hospital uses assessment methods to determine the individual’s competency in the skills being assessed.
Note: Methods may include test taking, return demonstration, or the use of simulation.
EP 3. An individual with the educational background, experience or knowledge related to the skills being reviewed assesses competency. Surveyors look for three types of staff competencies: demonstration, certification and involvement with professional associations. They want to see job descriptions that match responsibilities, documented skill check lists, and training-based annual evaluation forms.4
Another example of a standard directly applicable to CSSDs is LD.04.01.11: “The hospital makes space and equipment available as needed for the provision of care, treatment, and services.
EP 2. The arrangement and allocation of space supports safe, efficient and effective care, treatment, and services.
EP 5. The leaders provide for equipment, supplies and other resources.
Sterilization is a complex process requiring environmental controls (examples: for controlled air changes, exhaust ventilation, temperature, and humidity); appropriate equipment and supplies; adequate space; qualified, competent personnel who are provided with ongoing training and personal protective equipment (PPE); and monitoring for quality assurance.
TJC surveyors include an engineer who, more than likely, will visit the CSSD to review environmental concerns, such as temperature and humidity controls, water quality, the presence of eyewash stations, and appropriate ventilation (air exchanges and positive and negative air flows). The separation of clean and dirty areas, traffic control, absorbability of surfaces (such as unpainted shelves or pegboard), and holes in smoke/ fire walls, especially after removing/replacing equipment, are assessment concerns.
Objective 3. Define National Patient Safety Goals
In 2002, TJC established the National Patient Safety Goals (NPSG)1. These are targeted goals that the surveyors address regarding problems known to create significant challenges. The NPSG that is most important for CSSD is NPSG.07.05.01: Implement evidence-based practices for preventing surgical site infections (SSI). There are two priority EPs that this NPSG addresses:
EP 3: Implement policies and practices aimed at reducing the risk of surgical site infections. These policies and practices meet regulatory requirements and are aligned with evidence-based guidelines [for example, the Centers for Disease Control and Prevention (CDC) and/or professional organization guidelines].
Surveyors determine whether the facility is following national and local standards. The Comprehensive guide to steam sterilization and sterility assurance in health care facilities, ST79, is the reference guide used for the survey, and CSSD professionals should ensure that their departments follow the procedures described in the most current edition. 3, 5
EP 4: As part of the effort to reduce surgical site infections:
TJC surveyors consider CSSD personnel to be the subject-matter experts who set the reprocessing standards for the facility. These standards, including record-keeping, should be the same in all areas, such as labor and delivery suites and endoscopy suites within the healthcare system, or facility where reprocessing is performed.
Objective 4: Discuss tracer methodology and describe how the use of mock tracers can help prepare CSSD professionals prepare for a TJC survey.
TJC’s survey process includes tracer methodology, a process in which surveyors select a patient and use his or her record as a roadmap to evaluate the facility’s compliance with specific standards. The objectives of a tracer are to assemble proof of compliance with policies and procedures, identify process problems, and establish accountability by observing and speaking with staff.
Use of a mock tracer related to surgical instruments is a great way for CSSD personnel to evaluate compliance with current policies and procedures. Mock survey tracers should be conducted routinely with staff from the operating room (OR), infection prevention and control, and the CSSD. For example, identify a patient who recently had surgery. Select a specific instrument set used for that patient’s procedure and trace it through all the reprocessing steps while looking for compliance with every applicable policy and procedure. This self-survey should also include equipment monitoring and objectively evaluating the facility’s physical spaces, such as sterile storage and clean and decontamination areas, to ensure they comply with recommended design standards.
The tracer process can include an evaluation of numerous issues including:
The processes used for each step being traced should comply with the requirements of the facility’s applicable policies and procedures. Likewise, all processes actually used should be those explained and/or evaluated in facility training and competency assessment activities.
Objective 5. Review sample survey considerations for Central Sterile Supply departments.
Endoscope cleaning and CSSD processing areas and work protocols are high priority TJC inspection concerns. Transportation of clean/ sterile and contaminated items to/from clinics and compliance with required dress codes in all processing areas are also a special focus during the on-site visit.
Surveyors review equipment cleaning and maintenance records, and they are interested in the type of maintenance—not just when it was performed. CSSD housekeeping procedures are reviewed, and surveyors evaluate the results of daily and deep cleaning activities. For example, they look behind closed doors, under racks, in hidden corners, and at high-level flat spaces in all areas of the CSSD.
Storage areas are a certain priority, including security concerns. No corrugated cardboard boxes or shipping containers should be in clean areas. If an event-related shelf life plan is in use there should be notices about “not using packages that are open or damaged” on the sterilization sticker. Staff should recognize and understand universal symbols found/located on the packaging of purchased items, such as for “single use” or “sterilized," and there are documented training activities that address them.
Common facility citations include those for frequent use of immediate-use steam sterilization (IUSS) for the same items, failing to follow the manufacturers’ written instructions for use, and inadequate instrument cleaning. Other problems that are often identified include failing to use monitoring devices appropriately, and transporting uncovered instruments to the point of use.7
TJC accreditation procedures are designed to help CSSD professionals use a systems approach to evaluate their processes and to improve them when necessary. Understanding the accreditation standards and reviewing supporting documents that relate to their department can help CSSD professionals remain ready for an unannounced survey.
Scott Davis, CMRP, CRCST, CHMMC
Susan Klacik, ACE, CHL, CRCST, FCS
Patti Koncur, CRCST, CHMMC, ACE
Natalie Lind, CRCST, CHL
David Narance, RN, CRCST
Carol Petro, CRCST, RN, BSN
Patti Koncur, CRCST, CHMMC, ACE
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