Below, I’ve shared insights gleaned from Ed Ross, a former Joint Commission surveyor, as well as practical advice from Summit participants who have been through the trenches.

The Joint Commission (TJC)’s philosophy can be summed up in one word - compliance. Surveyors want to see that facilities are in compliance with what they say they do. Most surveyors are "process people" who do not know all the details of what goes on day to day in the Sterile Processing Department (SPD), therefore they look for conformity with policy and procedures.

Healthcare professionals should let go of the mindset that that TJC is concerned with a specific practice, such as sterilization, or with a specific department, such as the Operating Room. They look at the big picture. Surveyors will take the opportunity to evaluate compliance with other things while they are reviewing processes. In decontamination and sterilization there are two things to remember:

1. TJC will want to see all areas that perform any reprocessing such as, decontamination, sterilization/disinfection, or sterile storage, (e.g. Dental clinics, Labor and Delivery), and

2. They will always look at other processes while in an area (e.g. fire extinguishers or the proper use of PPE).

There are three risk reduction tools facilities can use to look at patient safety issues. They are the Root Cause Analysis, a reactive process; the Failure Mode Effect Analysis, a proactive process; and Tracer Methodology, which looks at the process real time. A tracer follows a selected patient through the continuum of care in the effort to evaluate facility compliance to standards, and is the only risk reduction tool that looks at the entire process.

The tracer is a living flow chart. It picks up on every aspect as it follows the process throughout the organization across departments or units. It looks for evidence of compliance, picks out process problems, and nails down accountability. Ross encourages SPDs to conduct routine internal sterilization tracers in order to evaluate compliance throughout their facility. The tracer should start with 20-25 processes involving areas that you suspect may have non-compliance with policies.

The two most common themes identified by SPD leaders were issues around flash sterilization and loaner instrumentation.

TJC surveyors have been impressed by efforts to significantly reduce flash sterilization. Best practices implemented by participants included instituting procedures such as:

1. Purchasing more commonly used instrument sets;

2. Asking the OR staff to verify three things before an item can be flashed:

3. Following manufacturers’ written recommendations (for many flashing is not a validated option);

4. Posting cycle parameters for items requiring extended exposure times by all sterilizers;

5. Cleaning and flashing only done by the experts in SPD;

6. Record keeping mandatory for each flash load to include date, time, sterilizer identification, staff initials, parameters, items flashed and patient name;

7. Document why implants were released before results of BI available; and

8. Standardize policies and procedures and perform routine audits.

Every facility needs to develop a clearly written policy for managing loaner instrumentation. The policy should address who is responsible for managing the loaners; how loaners are transported, checked in, processed and traced to the patient.

Facilities need to partner with vendors to ensure loaner trays are delivered in enough time to adequately process the items — preferably the day before the scheduled procedure. For the successful management of loaner instrumentation, it is imperative to get support for enforcement from administration.

When surveying Ambulatory Surgery Centers (ASCs), TJC looks for compliance with the same procedures as larger institutions. According to Summit participants, TJC surveyors have looked for some of the specific instrument reprocessing compliance issues below:

1. Clearly written policies and procedures that follow evidence based recommendations;

2. Written infection control, and risk assessment prevention plans;

3. How the ASC maintains a clean environment;

4. Sterile storage:

5. Transportation of contaminated items;

6. Flash sterilization practices;

7. Biological Monitoring

8. If the staff responsible for reprocessing can explain what to do if there is a load failure.