Feeling prepared for a Joint Commission accreditation survey after receiving only one deficiency in an inspection three years prior, an IP was “devastated” when her hospital was written up for four lapses in infection control practices.

“The main theme from my last survey was that if you think you have a process nailed down and standardized — check again,” said Michelle Heine, BS, MT(ASCP), CIC, manager of infection prevention at UnityPoint Health–Allen Hospital in Waterloo, IA.

Heine shared her survey findings recently in Minneapolis at the 2018 Association for Professionals in Infection Control and Epidemiology conference.

The lone IP at a 204-bed hospital with multiple affiliated clinics, Heine described her June 2017 survey experience in the hope that it would help other infection preventionists prepare.

“Many of you may be wondering why am I standing up here speaking about surveys when I had four deficiencies,” she said.

“We are not up here pretending to be experts. We are here to share our experiences so you can all learn from them. I was devastated to see the final report and see four deficiencies.”

The survey was conducted using The Joint Commission’s (TJC’s) new Survey Analysis for Evaluating Risk (SAFER) Matrix, which became effective in January 2017. (See the related story in this issue.) Noting that prior inspections may not cite something unless it was a recurrent problem, Heine said under the SAFER approach “they report every deficiency they see, even if they just see it once.”

Under CMS Condition of Participation 482.51 for surgical services, accreditation surveyors cited Heine’s hospital for hinged instruments, such as scissors and forceps, being sterilized in the closed positon.

“In three of five peel packs checked, it was observed that the hinged instruments were wrapped and sterilized in a closed and locked manner, thus preventing full sterilization of the closed portions,” TJC reported. “The organization uses AAMI [Association for the Advancement of Medical Instrumentation] standards. AAMI standard 8.4.1 states that the individual instrument should be sterilized in an open and unlocked manner.”

The instruments were not intentionally closed, but became so because there was no tab or barrier keeping them open, Heine explained, showing the products purchased to ensure hinged instruments remain open during processing.

“Our corrective action was that we had to pull every peel pack in every tray to open it up to make sure that the hinged instruments were sterilized appropriately,” she said.

Some were fairly easy to block open with stops or tabs, but “if you go through and look at your hinged instruments — there are a lot of them that aren’t just scissors. That was a big process,” she added.

Surveyors also cited the hospital after observing that soiled instruments used during circumcision were rinsed in the only sink located in the procedure room. The sink was also used for hand hygiene.

“We have a process,” Heine said. “All they have to do is take the dirty, sometimes bloody, scissors they use for the circumcision and put them in the recycle tray. It’s right there. The surveyor talked to one staff member who liked to rinse them off to make sure they were clean before putting them in the recycle bin.”

The corrective action involved reiterating the proper practice to staff and putting signs on sinks indicating they are for hand hygiene only.

“We reminded staff that you do not need to rinse off instruments being sent for recycling,” she said.

In another cited deficiency, surveyors reported that two nurses in the obstetrics triage area were putting used speculums back into their peel packs and placing them in the sink until patients left the room.

“AAMI standards require precleaning begin at the point of use and sinks used for soiled instrument processing not be used for handwashing,” TJC reported.

This again called for follow-up training, Heine said, noting that “no one ever mentioned to me that they walk a dirty speculum from one end of the unit to the other in the peel pack.”

The findings underscored the importance of additional education and conducting rounds to observe staff practices, she said. “If I would have opened the cabinets and seen peel packs with speculums, I would have asked questions — that’s why rounding is so important.”

Unannounced Rounds

A colleague from another facility in the same healthcare group joined Heine in the session, describing the rounding process she uses to prepare for accreditation surveys.

A critical initial step in this is “putting your oxygen mask on first,” meaning that the infection prevention team fully understands the accreditation standards and is prepared to discuss them with staff, said Angel Mueller, MPH, CIC, FAPIC, manager of infection prevention at UnityPoint Health at Trinity in Rock Island, IL.

“We have to understand the supporting evidence — the best practices and guidelines that support the standards,” she said. “That way we can work with everyone else and explain it to them as well.”

This approach lends credibility to the process while enhancing collaboration and reinforcing the message that infection control responsibility extends to all staff. Another message driven home is that these measures are not taken just to comply with TJC, but also because they protect patients and healthcare workers, Mueller said.

“I see it as my personal role to educate our leaders and everyone throughout our organization to understand why we do this,” she said. “It’s not just because The Joint Commission says so.”

The key to being prepared when accreditation surveyors walk into your facility is a process of “continuous readiness,” she added. This process includes unscheduled multidisciplinary rounds by members of the hospital’s accreditation team.

“It is really an ongoing best practice to make sure that all of these safety initiatives are being carried out throughout our organization,” she said. “We like to see what is really going on in the unit. People don’t have a week to prepare and know we are coming at 1 o’clock.”

The team has delegated environment of care rounds to individual unit managers, focusing instead on asking questions to staff on the floor.

“We actually ask staff to walk us through when and how they do hand hygiene,” Mueller said. “That is a big focus area for The Joint Commission, so we wanted staff to get comfortable speaking about how they carry out this process. It allows your team to find gaps in the process, and it also helps frontline staff to become comfortable in speaking to surveyors.”

Other questions during rounds ask about educating MRSA patients, for example, about isolation practices. Staff may be asked about the contact times for cleaning products, or what process they follow to send instruments used at the bedside to central services, she said.