Welcome! Thank you for attending today s meeting, it will begin shortly.

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1 Welcome! Thank you for attending today s meeting, it will begin shortly. How do I get a CE Certificate? Next week, all of today s meeting participants will be sent an containing instructions for obtaining a CE Certificate for today s meeting. The will be sent to the address you provided when you logged-in to today s meeting. If there are others listening with you today who did not log-on, you may forward the CE certificate to them. 3M Attest Sterile U Web Meeting July 22, 2010 The Joint Commission Tracer Methodology Applied to Sterilization and High Level Disinfection (HLD) Welcome! Facilitators: Diane Koch, 3M Sterilization Assurance Craig Wallace, 3M Sterilization Assurance Speakers: Edwin Ross Applied Healthcare Research, Inc Housekeeping: Questions; -Mute feature (*7=unmute; *6=mute) - Chat feature Technical difficulties CE Credits Post session follow-up For more information: 3 3M All Rights Reserved.

2 4 Disclosures Edwin S. Ross, MS CEO, Applied Healthcare Research, Inc. Sponsored by 3M 3M All Rights Reserved. Behavioral Course Objectives 1. Understand TJC* Tracer Methodology 2. Identify Applicable TJC Standards 3. Discuss the Sterilization/HLD Tracer Process * The Joint Commission 5 Sterilization / HLD Tracers Ed Ross Applied Healthcare Research, Inc. () Material copywrited by 6

3 7 TJC Risk Reduction Tools Root Cause Analysis (RCA) Failure Mode Effect Analysis (FMEA) Tracer Methodology Comparison of Risk Reduction Tools RCA FMEA TRACER Reactive Proactive Real Time Focus: event Focus process parts Focus: Entire Process Hindsight bias Probability bias Actual Fear; resistance Openness Objective Asks Why? Asks What if? Asks What is? Non-Statistical Non Statistical Statistical Reduce Patient Harm Reduce Patient Harm Reduce Patient Harm Team Activity Team Activity Surveyor(s) & All Levels 8 Tracer Methodology Follows Process Through Organization Surveys Across Departments/Units Multilevel Staff Participation Focus on Evidence of Compliance Surveyor s Option 1 or More 9

4 10 Goal of Tracer Process Consistent (surveyors) Accurate Standards Interpretation Comprehensive (surveyors) All Departments and Units Compliant (surveyors) Rigorous Application to all Areas Correction (Management) At Unit, Department, and Organizational Level Tracer Outcomes 1. Assess Communication between Disciplines 2. Evaluate Performance of Processes 3. Determine Compliance to Standards 11 Basis of Findings (Methods) Observation Interview Documentation 12

5 13 Tracer Flow Example (Where) Unit OR ED PACU Unit or Discharge ICU Tracer Areas Example (What) Patient Care Unit Housekeeping Equipment Maintenance Negative Pressure Rooms Patient Medical Records Medications / Precautions ICU Ventilators Catheters and IV s Equipment PACU Suctioning Body Fluids Monitoring OR Technique Universal Protocol Documentation Air Flow Sterilization/Disinfection Instrument / Supply Preparation Transportation Emergency Department Triage Utility Rooms Room to Room Technique 14 TJC Tracer Process July TJC Perspectives Official Newsletter Vol. 29, Number 7 Surveyors will focus on critical steps of sterilization/disinfection process. Surveyors will observe instruments from the time they leave one operating room to when they are returned to the next. July TJC Develops Special Sterilization/HLD Patient/System Tracer 15

6 16 Sterilization Process Tracer Uses the Same TJC Tracer Concept Follows Sterilized and Disinfected Items through the Organization Determines Compliance with TJC Standards Survey Criteria Hospital Policy & Procedures reflect: Fed and State Regulations - Mandatory TJC Standards - Mandatory Professional Organization Recommended Practices Current Scientific Knowledge Evidence-based practice Hospital P & P s 17 IC Hospital reduces risk of infections associated with medical equipment, devices, and supplies. EP 1 Cleaning and disinfecting EP 2 Sterilizing medical equipment, devices & supplies EP 3 Disposal of equipment, devices & supplies EP 4 Storing medical equipment, devices & supplies EP 5 Reprocessing single-use devices ( consistent with regulatory and professional standards). 18

7 19 IC Hospital implements its infection prevention and control plan. EP 2 the use of Personal Protective Equipment EC Hospital manages risks related to the hazardous materials and waste. EP 2 the use of Personal Protective Equipment EC Hospital inspects, tests and maintains medical equipment. EP 5 performance testing of and maintains all sterilizers. EC Hospital inspects, tests and maintains utility systems: EP 4 Infection Control utility system components 20 HR Hospital provides orientation to staff. EP 1 key safety content includes specific process and procedures related to..infection control. HR Staff is competent to perform their responsibilities. EP 5 - Staff competence is initially assessed EP 6 Staff competence is assessed on an ongoing basis 21

8 22 LD Hospital complies with law and regulation. EP 2 Hospital provides care, treatment and services in accordance with licensure requirements, laws, and rules and regulations. LD Hospital considers clinical practice guidelines when designing or improving processes Intro identifies criteria that guide the selection and implementation. So that they are consistent with mission and priorities. Sources include professional organizations. NPSG Implements best practices for preventing surgical site infections. EP 7 Hospital implements P&P s to: Reduce the risk of surgical site infections Meet regulatory requirements Are aligned with evidence-based standards (for example, CDC and or professional organization guidelines) 23 Example Functions Decontamination Packaging Sterilization Storage Transport Activities Observe Processes Check Equipment Environment Review Documentation Interview Staff Knowledge Competency Health Records 24

9 25 Functions Packaging Decon Sterilization Process Sterilization Disinfection Transport Storage Criteria Example Code Cart Criteria Emergency Medication Carts Is defibrillator PM current? Is there a numbered lock? Does lock # match log? Is log complete? Is the first expiring med/supply listed on the outside of the cart? Is the list of medications visible from the outside of the cart? Is there a backboard? Is the O 2 tank 1500 psi? Is Suction on cart? If pediatric cart, is Broselow Tape 2007? If any of the above are no, score as no. 26 Outcome of Changes Sterilization & HLD Processes will be more: Visible Vulnerable Valued Surveyed 27

10 28 Any Questions? Presenter Biography Edwin S. Ross, MS, CEO of Applied Healthcare Research, Inc. 29 Mr. Ross has extensive operational and consulting experience in the healthcare field and has achieved a successful track record as an independent consultant. Additionally, he is an internationally experienced lecturer and author in the fields of Healthcare Management, Systems Analysis, Performance Improvement and TJC topics including Sentinel Events. His specialties include preparation of organizations for The Joint Commission (TJC) accreditation surveys. A key focus includes assisting leadership teams in their tactical planning for the TJC Surveys. For 10 years he surveyed and was a team leader for TJC. He has also served as senior faculty for TJC seminars and training of new surveyors. Mr. Ross has been a member or consultant to fifteen Boards of Directors. He has held an appointment as Assistant Professor of Administration and Management at the University of Texas. 3M All Rights Reserved. Reference 2010 Hospital Accreditation Standards, The Joint Commission 30