Joint Survey's

[Nauss,Karen A (Mount Auburn)]

Hi Everyone,

 

 

5 Joint Visits in the past year.

 

If any of you have had a survey. Please forward it to me. I can send it out to the rest of the group.

 

Thanks for sharing.

Karen

 

 

1)      We had three different surveyors visit each of our three CPD’s….Life Safety engineer, a physician and a nurse,( Paula). All of the surveyors were very smart and very energetic.

The Life Safety surveyor checked for positive or negative air flow in each area, asked to see our logs on temperature and humidity, checked that overhead water sprinklers were clean and did not appear to have signs of  rust. He checked the dates on all fire extinguishers and checked the clean and dirty elevators to make sure they went to designated floors only. He checked doors to see that they latched properly and that  there was no more than a 5/8”gap on any door. He looked at ceiling tiles, storage rooms (looking for outside containers near sterile goods.) He asked staff what they would do if temperature or humidity was out of range. Did they report it to anyone? He checked to make sure that there was nothing obstructing access to fire extinguishers, gas shut-offs, etc. In the OR and CPD ,each and every room was checked. If a door was locked, we were asked to open it.

The next day the nurse focused on the reprocessing of endoscopes, she was unfamiliar with the AER that we have (Evotech),so she asked to see the documentation that indicates we don’t need to use test strips for the HLD. She suggested that the chux that were at the bottom of the scope cabinets be dated and initialed each day as they are replaced. She asked how often the cabinets were cleaned. She was fine with “weekly”.

She also asked to review our process of managing loaner kits. She liked  the tracking system and the whole process. She asked to see the log books for the biological testing  and requested a review of the process. She asked  about IUSS documentation and early release forms. She noted that we haven’t had to use the latter form this year. She also asked for copies of the PM’s on a particular sterilizer. She found the staff very engaging and well informed and was very complimentary to each of them. They pointed out a poster that was hanging by their door which had won a first prize at AORN this year. It was  describing  work they had done on improving job safety!

The following day, Dr. Grossman visited each CPD after he finished the OR’s. He also went into each and every room and area  in both departments.  Going past an autoclave in the OR, he took note of its “name” and asked that we produce the documentation of the biological testing from the previous  day.

He also looked at scope reprocessing and asked many questions. He  asked about the need to do a QA when opening the bottle of test strips. In the case of the test strips that were being used, a QA was not necessary but the IFU mentions that the QA is done by the manufacturer and is available online. He suggested that the information on each opened bottle’s lot # be downloaded  and saved in a log.  

In the OR, he asked attendants about contact time of a disinfectant they were using when they were washing an OR stretcher.

He told staff he was very glad to see all their framed certifications by the entry to CPD. He mentioned that the more evidence he sees of staff certification, the more assurance he has that the staff are “doing the right thing.” I think it went a long way that the staff was so open and welcoming. Feel free to call if you need more specifics.

 

Best wishes,

 

Dr Grossman

He looked at temps humidities 

Logs how we document for IUSS

 

2)      CSSD did well, no request for improvements. See below  for a quick list, will forward update within the next few days. Thanks again for your help with wrappers.

 

• Daily log for temperature and humidity in CSSD
• Daily log for eye wash stations
• HLD, tracking scopes back to patients
• HLD, minimum temperature for solution 68F°
• How do you accommodate for decontamination room temperature (60-65F°) and HLD minimum temperature(68F° minimum)
• BI logs

 

3)      It has been a long week with Joint Commission here for the survey and I wanted to pass along the areas of interest from the surveyors as related to CPD:

·         Air pressure

o   Checked several times by multiple surveyors (no findings) and seemed to be the only area of Life Safety focus within CPD

·         Transporting of soiled instruments

o   All (pre-treated) soiled instrumentation transported within units (exam/procedure room to soiled utility room), from units to CPD and from the OR to CPD are either in a solid rigid container with a lid or in an enclosed case cart and tagged with a biohazard tag attached to the handle.  The surveyor liked the tagging system.

·         TASS

o   Our ambulatory surveyor was very impressed that not only do we know what TASS is but also that we have multiple measures in place to prevent it at every juncture from OR to CPD (i.e. in CPD we do not use enzymatic, alcohol, or instrument polish in the cleaning process and only use DI water after the initial rinse;  do not use towels in prep and use high magnification hand held magnifiers in prep during inspection)

·         Brushes in decontam

o   We were asked what kinds of brushes we use and we noted that we have several kinds of brushes and we select the appropriate brush for the item being cleaned AND that all of the brushes we use are single use.  He was excited that we do not use reusable brushes and I noted that they are more of a headache then they are worth and he completely agreed

·         Records

o   I was asked to show records from a  specific day from the month prior and explain to our group how we “know we are doing the right thing for our patients.”  I explained all of the metrics that we record and audit, what we would do in the event of a recall, all of the information we track with biologicals and the benefits of the tracking system.  All of which he was impressed with.

·         Work flow

o   We were asked to explain the work flow in the Dental Clinic CPD (which our department staffs) and the surveyor commented on the fact that it was one of the best dental CPD’s she has seen and that it is a very rare occurrence that she had no findings or even consultative suggestions for a dental CPD.

·         Pre-treatment spray

o   At a point when a CPD rep was not present it was asked how long of a contact time was required for our enzymatic spray foam that the OR and all of the clinics and floors use at point of use on soiled instrumentation.  We submitted the IFU’s from the manufacturer and that was sufficient (the spray we use does not have a minimum required contact time)

·         Competencies and training

o   During the competency tracer interview the CPD training and competency program was reviewed as well as our quality program which provides consistent real time feedback which the surveyor was very impressed with.

·         HLD, HLD, HLD

o   Consistent with all of the other reports from other peoples surveys high-level disinfection was a HUGE reoccurring theme with all of the surveyors (every time they visited a user department the entire survey team ended up visiting CPD... looking for consistent practices across our facility).

§  Storage of HLD scopes – looking to make sure that scopes are stored in a cabinet, hanging freely and not touching each other.  I know that they touching of scopes has been a very hot issue with Joint Commission and to proactively address this we used a product called “Endo Boot” from US Endoscopy which is a foam sleeve that fits over the distal tip of the scope that  prevents the distal tip of the scope from bumping into the cabinet or other scopes.  The surveyor liked this approach a lot and was impressed that it was being used correctly (about 1” of the tip needs to be exposed to allow for drying of the channels of the scope)

§  Dry time of scopes – there was one surveyor who asked how long scopes need to hang for before they are considered dry and ready for use.  The scope that they were questioning in particular was a non-channeled ENT scope and when we provided IFUs which showed our practice was in line with the IFU’s they were satisfied.

§  Hang time for endoscopes – This topic came up three times over the course of the five day survey

§  Transport of both HLD and contaminated scopes – We use the Clean-A-Scope system which is a combination of rigid reusable trays and disposable liners and covers (two different covers, one red and one green, to distinguish dirty and ready for use).  They were very impressed with this system as well as the custom “HLD” tags that we put on each scope that has been high-level disinfected and ready for use.

 

Overall, we participated in 9 tours with surveyors (because our team works in a total of 3 CPD’s and 4 clinics) and well as 2 tracer interviews and there were zero findings with very thorough surveyors! 

 

4)      Our surveyors were tough but fair and by far the most knowledgeable JC surveyors that I have encountered.  Dr. Timothy Sorg and Kathleen Scric-Stoehr RN.

 

They spent a lot of time in SPD and the OR and focused on several practices outside of the department that deal with SPD…here is a brief list.

 

GI Lab:

1. Confirmed scope cleaning policies
2. Staff had to walk through the entire process of cleaning a GI scope from end of procedure to storage.
3. Several questions on the log books and traceability back to the patient.
4. Several questions on the HLD process and monitoring
5. He was very knowledgeable about the scopes and the OER….even when and what to do when performing maintenance.
6. Transporting of clean and dirty scopes.

 

Outside Department:

1. Pre-cleaning (how is it done and by whom)
2. How long instruments wait to be picked up by SPD (Birthing unit and ED)
3. How they are kept moist per AAMI recommendations.
4. How they are transported from around the hospital (proper marking of the cart, bin..ect)

 

SPD

1. Neg air pressure was huge in all area’s of the hospital
2. IUSS logs and rates…tracked flashed implants back to the patient cart.
3. HLD processes in decontam…wanted to see detailed training records and logs.
4. Asked staff what are area’s of concern for them in the department.
5. Looked at the biological log books
6. Eye wash stations (are they close enough and in the right spot)

 

 

5)      My area did great. The surveyor only spoke with me (strange since we always hear they want to speak with the staff. )

 

1)            Asked about our storage are, did not comment that we have some stacked items (very surprised about that. Thought I would get dinged for that, but I have no choice we are bursting at the seams).

2)            Toured assembly\sterilization. Asked about the biologicals how often we do them, Made the representative from Quality listen closely because she had no idea what we were testing.

3)            Asked if we could track a set or instrument back to the patient. Told him no we would need a fulltime employee to do that manually, said a tracking system would be ideal. He looked at our administrative rep touring with him and said this is a must and we should work on getting one. I told him I am working with Vmueller to get one in for :free” if we meet a certain spend with them.

4)            Questioned me about CJD,  asked if we had a policy,. He was surprised to hear that AAMI had a sterilization recommendation (along with isolation and incineration) . Asked me to show proof. Pulled out the standards he was fine with my answers.

5)            Liked that we date the cleaners, enzymes, and lubes each day at the level they are at to insure the pumps are actually pumping the fluids into the machine. Also like the recorded temperatures of the fluids to insure they have not been exposed to out of range temperatures, “ drain clean” check off sheets, for washers, and sterilizers. Weekly sterilizer cleaning.

6)              Asked about sonic cleaning and the run time. (explained that every manufacturer has different instructions)

 

On another note we won the test strip argument for the Medivators. I obtained additional information that speaks to the conditions and that refers to long term storage and not transportation. I will forward  the documentation.

 

 

 

---

This message is intended for the use of the person(s) to whom it may be addressed. It may contain information that is privileged, confidential, or otherwise protected from disclosure under applicable law. If you are not the intended recipient, any dissemination, distribution, copying, or use of this information is prohibited. If you have received this message in error, please permanently delete it and immediately notify the sender. Thank you.