I have
often said there is no such thing as a foolish question, what would be foolish
is to not understand something and not seek clarification. I appreciate your
question, trust me a lot of people get a little confused differentiating between
a policy and a procedure and often the words get misused.
A policy is a planned or agreed course of action(s) that will be followed
and/or enforced regarding performance, behaviors, service or governance of same;
a policy is usually based on principles and rules. Some examples of a policy
might be:
• All staff working in decontamination area must wear the appropriate PPE,
gloves, cap, gown, booties and face shield
• Vendors must deliver loaner sets to CPD control center 24 hours prior to
scheduled surgery and provide a complete inventory list of contents
• A biological indicator test will be run in all sterilization loads
containing implants, devices will not be released for use until the results of
the biological are known and recorded.
A procedure is the sequence of steps, actions or instructions to be followed
to accomplish a task. A procedure supports established policy. Some examples of
a procedure for accepting loaner trays might be:
• CPD coordinator will verify with vendor designee that set is complete and
in proper state in accordance with inventory sheet – any discrepancies will be
noted on receipt and both the vendor representative and CPD coordinator will
sign the receipt form.
• CPD coordinator will confirm that the specific loaner tray has cleaning and
sterilization instructions on file in CPD – if not the vendor representative
must provide written instructions – do not accept any trays until processing
instructions are received.
• Provide the vendor with a copy of the receipt to include pick up time of
used tray
• File receipt in loaner file box under manufacturer’s name
• Upon receipt of a loaner tray the CPD coordinator shall record the set
name, manufacturer, time received, surgical procedure and time in the loaner log
sheet
• CPD coordinator will assign job code to loaner set, label accordingly and
place tray on loaner decontamination rack.
Competency is the quality of being adequately or well qualified physically
and intellectually to carry out an act or function in full accordance to
established policy and procedure. It is imperative that all CPD staff are
trained and able to competently carry out all tasks and responsibilities of
their job description. Staff performance with verification of competency for
each task must be documented and maintained in employee file. One way to
accomplish this is to have a form for each relative procedure or policy that an
individual is required to know or perform – list each step or key point on the
form and assign columns next to each statement to denote the employees
performance. A department supervisor or management resource person will
personally observe the employee conduct each task step and record the employee’s
performance competency level on the form. When appropriate a written test may
also be used to verify knowledge competency. An example of some things that
might be included on a basic skills competency form for Sterile Processing can
be found on the chart below.
Sterile Processing
Competency: |
Competency Level |
|
Demonstrated basic knowledge of the sterile processing
technology by completion of IAHCSMM/CBSPD certification
program. |
87.50% |
|
Utilizes PPE appropriately in accordance with
department
policy |
Satisfactory |
|
Demonstrates proper procedure for manual
cleaning |
Satisfactory |
|
Utilizes correct cleaning products appropriately with
proper
dilutions |
Satisfactory |
|
Demonstrate proper protocol for loading
sterilizers |
Satisfactory |
|
Understands how to use and interpret results of
appropriate sterilization monitoring devices i.e. chemical and biological
indicators |
Satisfactory |
Q
One
of the OR team leaders insists that certain instruments get wrapped and placed
inside the sterilization container with the other instruments. We use
polypropylene disposable wrappers and seal them with autoclave tape I don’t feel
this is acceptable. Could you advise if this is a proper and safe practice? Also
if it is not acceptable what would be a more appropriate alternative?
A
Wrapped
packages should not be placed inside of containment devices or other wrapped
packages. The packaging material identified and the process you are utilizing
have not been validated for such application.
The density of the internal package could challenge the sterilization process
and it’s likely it would obstruct the permeation of the sterilant and or require
an extended exposure time. Unless you can obtain written documentation,
validation and detailed instructions for such use from the wrap and container
manufacturers you should stop this practice immediately. As for acceptable
alternatives there are products available which can be used to organize, protect
or hold small or delicate items inside of wrapped or containerized sets such as:
metal and plastic insert cases, paper sterilization bags, and paper multi pocket
pouches.
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.
