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Questions can be sent
to:jakridge@hpnonline.com
called in to Jeannie Akridge at HPN:(941) 927-9345 ext.202
or mailed to:
HPN CS Questions, 2477 Stickney Point Road, Suite 315B,
Sarasota, FL 34231
Names and hospital identification will be withheld upon
request. |
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Complying with regulations;
essential AAMI documents
by Ray Taurasi
Q I am the environmental services manager for a
nursing home in Pennsylvania. I was reading your article on "Making Sense of the
alphabet soup of SPD regulations" pertaining to the DPH and the Joint Commission
in HPN Vol. 31 No. 7. We have DPH and the Joint Commission visit our
facility and I was wondering where and if there was a web site that you can go
to find out how to comply with their standards and guidelines.
A Department of Public Health (DPH) regulations
vary from state to state and city to city. Some state DPH departments are more
stringent relative to managed care accreditations and inspections than are
others. Some states actually do mandatory onsite visits yearly or bi yearly and
closely monitor hospitals, HMOs and other healthcare facilities, while others
may only visit for re-licensure or to license new bed additions or to
investigate grievances. Most municipalities, cities and towns also have a health
department which may also have requirements, ordinances and regulations that
must be followed by healthcare facilities. Municipalities must not only comply
with State DPH regulations but they may also impose more rigid or additional
regulations which must be followed by healthcare organizations. I suggest that
you contact the Pennsylvania Department of Health to obtain information on
regulations which apply to your organization as well as their policy on
licensing, facility audits and inspections.
You may write to them at the following address:
Pennsylvania Department of Health
Bureau of Managed Care
Health & Welfare Building
Room 912
7th and Forster Street
Harrisburg, Pennsylvania 17120
You may also contact the Pennsylvania Department of Health Bureau of Managed
Care Health & Welfare via phone at (717) 787-5193 or toll-free
1-888-466-2787.
As you may know the Joint Commission on the Accreditation of Healthcare
Organizations (Joint Commission) sets standards for healthcare organizations and
issues accreditation to organizations that meet those standards. the Joint
Commission conducts periodic on-site surveys to verify that "an accredited
organization substantially complies with Joint Commission standards and
continuously makes efforts to improve the care and services it provides.
Accreditation visits used to be announced and scheduled with facilities.
Healthcare organizations had ample notice and time to prepare for the
inspections in such what was portrayed during the planned visit might not be
representative of routine daily practices or reality. To that end Joint
Commission visits are no longer scheduled. An inspection audit team may show up
at your door at any time during the period you are due for re-accreditation
which is every three years. It is the belief that un-announced visits will give
a more candid view of the healthcare facilities’ operations and will encourage
institutions to be in the ready state of excellence at all times.
To get a general overview of the Joint Commission, you may visit the
following site:
http://cms.h2e-online.org/ee/regsandstandards/jcaho/.
For more information relative to accreditation regulations, guidelines and to
order relative manuals and the like you may consult the following websites:
http://www.jointcommission.org,
http://www.jointcommission.org/AboutUs/ContactUs and
http://store.jcrinc.com/JCRStore/FillCatalogAnonymousAction.do?nocache=lV-T0d7DSAyK8I1urJ8z9Rc.
For information about Long Term Care, Subacute Care, and Assisted Living
publications, contact Janet Pimentel, Senior Editor
jpimentel@jcrinc.com or call
630/792-5458.
If you would like to speak to a Customer Service Representative directly, you
may call the Joint Commission toll free at 877/223-6866 (8 am - 8 pm EST) or
send an e- mail to
(jcrcustomerservice@pbd.com.) You may also send mail inquiries to:
The Joint Commission
One Renaissance Blvd.
Oakbrook Terrace, IL 60181
Q I
am a CST certified surgical technologists and was recently promoted to the
position of Central Sterile Processing coordinator. My goal is to develop a new
policy and procedure manual. The current manual has not been updated or revised
in at least 10 years. I am somewhat familiar with AAMI and understand that the
organization is very influential in CSP protocols and therefore I would like to
consider and reference AAMI as I write and develop our manual. I have several
different AAMI books that I found on the shelves. Most are dated from as far
back as 1996 and earlier. My question is what documents are the most vital and
applicable to CSP? My funding is limited but I would like to know which ones are
in need of replacement and what documents you would recommend.
A The most
essential AAMI (Association for the Advancement of Medical Instrumentation)
document that you should obtain is Comprehensive guide to steam sterilization
and sterility assurance in health care facilities (ANSI/AAMI ST79:2006).
This document is a critical tool that you should use in the development and
revision of your department policy and procedure manual. It was published in
2006. Most likely the older documents you referred to have been incorporated
into ST79. Five previously published recommended practices have been revised and
incorporated into this new standard . . .
• ANSI/AAMI ST46, Steam sterilization and sterility assurance in health
care facilities
• ANSI/AAMI ST42, Steam sterilization and sterility assurance using
table-top sterilizers in office-based, ambulatory-care medical, surgical, and
dental facilities
• ANSI/AAMI ST37, Flash sterilization: Steam sterilization of patient care
items for immediate use
• ANSI/AAMI ST35, Safe handling and biological decontamination of medical
devices in health care facilities and in nonclinical settings
• ANSI/AAMI ST33, Guidelines for the selection and use of reusable rigid
sterilization container systems for ethylene oxide sterilization and steam
sterilization in health care facilities
The ST79 document is available in PDF format or hard copy. The price for AAMI
members is $100.00 and $200.00 for non members. You may order online at http://www.aami.org/publications/standards/st79.html
or contact:
Association for the Advancement of Medical Instrumentation
1110 N. Glebe Rd.
Suite 220
Arlington, VA 22201-4795
(703) 525 4890
The International Association of Health-care Central Service Materiel
Management is also an excellent resource for CSP managers, technicians and
practitioners. IAHCSMM has a large selection of publications, documents and
educational resources that might be of great value to you as you continue your
journey along your new career path. For more information consult their website
at http://iahcsmm.org or via mail or phone at:
IAHCSMM
213 West Institute Place
Suite 307
Chicago, IL 60610
Toll Free: 800-962-8274 
Ray Taurasi is Eastern Regional Director of Clinical Sales and Services for
Healthmark Industries. His healthcare career spans over three decades as an
Administrator, Educator, Technologist and Consultant.He is a member of AORN,
ASHCSP, AAMI and a past president of IAHCSMM and has served on and contributed
to many national committees with a myriad of professional organizations,
manufacturers, corporations and prestigious healthcare networks. Taurasi has
been a faculty member of numerous colleges teaching in the divisions of business
administration and health sciences. In addition to this column he has authored
several articles and has been a featured speaker on the international scene.
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