246 - High Reliability in High Level Disinfection…from Dream to Reality
Description: Clinical IssueVariable high level disinfection (HLD) processes and practices expanded innocuously over time as demand for ambulatory procedures had grown over the previous years without strong centralized management oversight. Many of these practices at Beth Israel Deaconess Medical Center were not standardized and did not conform to requirements of The Joint Commission (TJC) and The Association for the Advancement of Medical Instrumentation (AAMI 2017).Description of TeamThe team of 27 members representing all locations performing HLD including Gastroenterology (GI), Perioperative Services, Central Sterile, the Department of Surgery and related ambulatory clinics and key supporting services such as Clinical Engineering and Environmental Health and Safety met once a week to review status of actions and plan additional work, which was done outside of the meetings. Preparation and PlanningUtilizing lean tools and techniques, senior leadership developed the strategy for this project as documented in our charter, which guided the work. All of the following goals were achieved on-time.1. Create standard work flows based on Instructions for Use (IFUs) for HLD2. Ensure/establish compliance with personal protective equipment (PPE) standards3. Ensure compliance with logs for use of equipment on patients, and for inventory/repair4. Standardize logs across institution5. Review/correct instrument storage containers/cabinets such that they are compliant AssessmentThe team performed 17 gap analyses in all of the areas performing all modalities of HLD. We looked at the existing work flow, found ways to redesign it and took action to bring processes into regulatory compliance. A mock survey performed by a TJC auditor during the project revealed that we would have certainly failed a TJC survey.ImplementationCorrective actions were created and implemented immediately after each deficiency was identified. We tracked the completion of all work, focused on getting it done as soon as possible. We educated 26 employees in the Trophon modality. Implications for Perioperative NursingWe created standard processes. Education was provided to Perioperative Services and our partners in GI. We assured safe patient care by protecting the patient and preventing infections. Providing an understanding of how to properly handle scopes to prevent damage by nurses reduces costs.Outcome We standardizing logs and PPE, determined chemical and equipment inventory, reviewed/corrected instrument storage containers/cabinets and updated the infection control policy, supporting workflows provided by IFUs. Significant safety hazards identified during gap analyses were eliminated. Work is underway to make HLD more robust and to prepare long term plans. A TJC compliance survey was completed in May 2019; there were no findings related to HLD.
Co-Authors: Nancy Dwyer Doraiswami, Susan Crafts, Patricia Folcarelli, Jane Sellica, Jeff Lamson, Preeti Mehrotra, Cynthia Wagner, Deb McKinnon, Sarah Fostello, Veronica Kelly, Ashley Boulanger, Kervin Faustin, Rob Seeley, Peter Schooling, Matt Wheeler, Aleah King, Jamie McGloin