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SDS Accreditation Update
Infection control, safety key issues for endoscopy
Surveyors look at safety goal compliance
Low-stress, thorough, and focused on patient safety are a few of the adjectives same-day surgery managers use to describe their recent experience with the Joint Commission on the Accreditation of Healthcare Organization surveyors looking at their endoscopy labs.
"Not only did our surveyor look for policies and practices for our lab that met the requirements of the national patient safety goals, but the surveyor also wanted to see how we made sure our contracted services were meeting the goals as well," says Nichole Breeden, RN, BSN, safety and infection control coordinator for Tallahassee (FL) Endoscopy Center.
The surveyor looked at the center’s contracts for physical plant concerns such as elevator, sprinkler system, and emergency generator contractors, as well as clinical areas such as pathology and pharmacy for which the center uses outside contractors, Breeden says. "The surveyor wanted to see specific wording in the contract that described the need to meet the requirements of the patient safety goals," she explains.
Patient safety also was at the top of the list for the surveyor visiting the endoscopy lab at Kalispell (MT) Regional Medical Center. The surveyor especially was interested in the process for patients undergoing any type of sedation or analgesia, says Karen Lee, RN, director of surgical services. "Our process clearly defines a need for a history and physical by the physician, a patient evaluation by the anesthesiologist, a re-assessment immediately prior to administration of anesthetic, and vital sign monitoring every 10 to 15 minutes," she adds. "Although the Joint Commission does not set a specific time frame for monitoring, our surveyor was pleased to see that we were specific."
Rather than just read the procedure, the surveyor asked different staff members, including physicians, to articulate the process, she says.
Infection control also was an important item for the surveyor at Tallahassee’s Endoscopy Center, Breeden explains. The center’s zero infection rate impressed the surveyor, who spent time with the medical assistant who is responsible for cleaning scopes, she says.
One of the keys to Breeden’s excellent control of infection is consistency, she explains. "We have the same staff members cleaning the scopes all of the time, instead of rotating the responsibility," she says. This not only gives the staff members an opportunity to perfect their jobs, but also gives them a real sense of responsibility, Breeden adds. "The staff members who clean the scopes are especially proud of the zero infection rate."
While Kalispell’s surveyor talked with employees one-on-one, even asking nurses about their credentials that were specific to endoscopy, the Tallahassee surveyor spent more time looking at the process from a patient’s perspective. "The surveyor started at our front reception desk, then walked through the process, asking employees to explain what is done at each step and why," adds Breeden.
Overall, she says she is pleased with the different approach the surveyor took during this survey. "The surveyor’s demeanor was very open, and we definitely felt that this survey was a beneficial process with everyone learning from it."