JCAHO gets reacquainted with central sterilization

Materials Management in Health Care

Ernesto Gonzalez says a visit two years ago by surveyors from the Joint Commission on Accreditation of Healthcare Organizations was a sight for sore eyes.

Gonzalez , manager of the central processing department at Children's Hospitals and Clinics in Minneapolis , says JCAHO surveyors used to routinely visit the hospital's central sterilization unit. Then, about 10 years ago, they mysteriously stopped coming.

“I was assuming no one would ever come down here again,” he says. “Then, on the last visit in 2002, a surveyor spent 45 minutes with us.”

Other CS personnel have also verified Gonzalez ' impression the CS departments were routinely visited until 10 years ago and now are being visited again.

Edwin S. Ross , a consultant at Applied Healthcare Research in Los Angeles , says he is amazed with the suddenness of the joint commission's new interest in CS.

Just a few years ago, at a meeting of central sterilization personnel, Ross asked how many in the audience had been visited by the JCAHO. Out of a group of 120, two of them raised their hands.

Then in September, at the 2004 meeting of the American Society of Healthcare Central Service Professionals (ASHCSP) in Orlando , Fla. , he asked basically the same question. A sea of hands went up, making up about 80 percent of hospitals that had been inspected recently.

“You could have knocked me over with a feather,” said Ross , who served as a joint commission surveyor until recently.

Come and visit us, and stay

A lot of central sterilization directors welcome the new attention.

Feeling much like the host who prepares feverishly for a party, only to have no one show, CS directors are eager to display the high standards they have been keeping for all these years.

“JCAHO doesn't come to our central services department and frankly, it's a disappointment,” says Nancy Chobin , a corporate consultant and educator at St. Barnabas Healthcare System, West Orange NJ .

JCAHO surveyors have not come to CS at her organization and Chobin is still skeptical that that they ever will. Just three weeks ago, she said, the joint commission visited a nearby hospital and did not stop in central sterilization.

She adds that the New Jersey Department of health is known for tougher inspections than the JCAHO.

And yet, Chobin says, there are many reasons why joint commission surveyors ought to be intensely interested in central sterilization.

“We are probably the most important part of the hospital and we're proud of what we do,” she says. “The surgeon is important, but he can't do his work without clean instruments.”

She says the best JCAHO survey of CS that she ever witnessed took place 25 years ago, when she was just starting her career.

That surveyor told her: “When I go to a hospital, I want to start in central sterile because if they are doing a good job there, I don't have to worry about the rest of the place.”

Chobin says the next best joint commission visit she ever saw also took place many years ago. The surveyor stayed five hours, tore her CS department apart and gave it a commendation.

“It's so nice to see your hard work validated,” she says.

Big changes at JCAHO

Judging from all the changes swirling around the joint commission accreditation process, Chobin and others may well get plenty of validation in the next few years.

JCAHO representatives say the organization has no explicit rule that surveyors must visit central sterilization. Visits are at the discretion of the surveying team, which is made up of a physician, nurse and administrator. The JCAHO teams visit more than 4,500 hospitals in three-year cycles.

Now the joint commission is under increasing pressure to do a better job.

For example, a September 2003 study in the Journal of Clinical Outcomes Management found little relationship between JCAHO accreditation ratings and actual mortality rates at hospitals.

Then, in July 2004, the Government Accountability Office (the new name for the General Accounting Office) took the joint commission to task for failing to identify "serious deficiencies" at hospitals.

Based on a survey of 500 hospitals inspected by JCAHO from 2000 to 2002, GAO found that the organization failed to identify 167 of 241 deficiencies that state inspectors had found at the same facilities.

That finding echoes a complaint by Chobin that inspectors from her state health department are more demanding with her facilities than the JCAHO.

But the JCAHO is implementing several changes that could improve its effectiveness.

In January, the joint commission began “Shared Visions -- New Pathways” program, which consolidated and streamlined standards, instituted a mid-accreditation cycle review of performance, and revamped the accreditation survey.

A chief feature of the new standards is the t racer methodology, under which s urveyors track a current patient's path through the various health care services in the hospital. This methodology also looks at processes, such as sterilization controls.

And in a separate change that goes into effect in January, JCAHO will implement a revised set of infection control standards. This will affect central sterilization, where infection control is the key mission.

Hospital leadership is expected to pay much more attention to infection control, in the wake of the new standards and national studies showing that it lags well below expectations and is very costly.

The Centers for Disease Control and Prevention estimates that two million individuals acquire an infection each year while being treated in hospitals for other illnesses or injuries, and that 90,000 people die as a result.

In a study at a Chicago hospital, published in the journal Clinical Infectious Diseases in 2003, infections added an average of 10 days to the patient's hospital stay and an extra cost to the hospital of $15,275.

Finally, in another change that could affect CS, JCAHO will begin making unannounced visits at all hospitals in 2006. The visits are an effort to take a true snapshot of activities in the hospital, rather than rehearsed shows that occur when hospitals know that surveyors are coming.

An inside look at JCAHO

Ross , the former JCAHO surveyor, says he can understand both why surveyors withdrew from CS and why they have rediscovered it.

Until recently, he says, the surveyors were focusing on outcomes, which mainly meant looking at clinical care. Surveyors could still have gone to CS, but with backgrounds in clinical services, they were not likely to, he said.

On the whole, Ross says, “they assumed that if the care of the patient was good, then the support services were good, too.”

Then times changed. “Like any other organization, the Joint commission reinvents itself,” he says. Now, through the new tracer methodology, “they are trying to replicate the process.”

In many cases, he says, surveyors are looking tracing steps in clinical care, looking for garbled communications, which are considered a key factor in clinical errors.

But they are also looking at processes that underscore the new interest in infection control. Surveyors have to think ahead, because a new infection resulting from an error in the hospital may not show up until after the surveyors leave, he says.

Ross says surveyors may point to a sterile tray in the OR and ask, “How was the prepared?” Or they could point to a piece of equipment and ask, “When was that cleaned last?”

“When you stop and think about it, every patient has some item that Central Service has prepared,” Ross says. “CS disinfects IV pumps, GI scopes and ORT instrumentation, anything that is wrapped, packed or sterilized.”

Cheryl Gessley , director of central supply at Truman Medical Center Lakewood, Kansas City, Mo. , has come to the same conclusion.

“I don't think people realize how much goes on in CS,” she says. “When I was a nurse in the OR, I would use supplies all day long and I never really stopped to think where they can from.”

How you can prepare

Cheryl Gessley was pleasantly surprised when Ross and others at the Orlando meeting indicated that the JCAHO might soon be at their door.

“I was ready to get up and run home and fix things,” says Gessley, director of central supply at Truman Medical Center Lakewood, Kansas City, Mo. , which had not yet been visited recently.

To prepare for a possible visit, Gessley says she will be focusing on processes within CS, such as the flow of dirty and clean equipment through the department, procedures for cleaning equipment and how a department assembles sterile trays and carts.

For example, Gessley says JCAHO states that there need to be boundaries, preferably walls, between contaminated and clean sites.

Ross says the rule in central sterilization should be: “There is a place for everything and everything has its place.”

“If everybody knows where everything is,” he adds, “then things go the right way. Consistency is its own reward.”

For example, Ross says surveyors would be impressed with CS departments that are working toward standardized trays.

“If you standardize, you get better quality control,” he says.

But he adds the goal is easier said than done. Each surgeon has a different idea how a tray should be configured, and it can take years for CS to get everyone in the OR to agree. Also, he says mapping out where each instrument goes on a sterilized tray has a long way to go, compared with ratchet sets sold in hardware stores, where each piece has its own indentation.

At Children's in Minneapolis , Gonzalez says he is on the way to achieving many of the standards that Ross cites, thanks to high-level interest at his institution.

Gonzalez says his department has created “recipes” on Word and Excel documents on how sterile trays should be set up, but most trays still do not have recipes and 20% of those that do just have them in paper form, without a computer file.

Recently, Gonzalez got the green light to hire a secretary – the first in the department since the late 1990s – to compile a policy and procedures manual with recipes for 850 surgical trays and 500 diagnostic and therapeutic trays.

He says the manual will also cover how to select detergents for procedures and specify what kind of protective attire staff need to wear.

Chobin says if she were a surveyor, she would ask to look at departmental records and other paperwork, such as manufacturers' instructions for laying out sterile trays.

“You would need to have really good records,” she says. “I would ask you to show me your competencies. What methodology do you have to identify each person preparing each tray? Did they flow the manufacturers' instructions?”

She says she doubts that the joint commission would ever ask those questions.

But viewing all the changes afoot, it might turn out that Chobin could be pleasantly surprised.

Return to Samples Listing