Easi-Sterilise Audit Tool: Management and Education

STERILISING SERVICES AUDIT RISK RATING & REVIEW CRITERIA BY WHOM  ACTIONS REQUIRED DATE 3. EDUCATION 3.1 100 % of staff in the sterilising facility that have undergone an annual performance appraisal process which includes-  review of each persons job description  review of annual CHRISP workplace skills assessment   review of the staff members training needs  mandatory training (as per district policy) QH ICG 3.2 70% of staff within the sterilising facility that have undertaken formal training (certificate 3) in sterilisation practice QH ICG Section 3  3.3 100% of newly employed staff within the sterilising facility t have (including casual and agency staff) undergone a formal orientation process  preceptoring with a suitably qualified staff member  complete the orientation package (which is reviewed annually)   workplace skills assessments  information is provided on how to access the sterilising services instructions QH ICG Section 3 3.4 There is a formal in unit in-service program which is routinely evaluated QH ICG  3.5 In-service is provided to all staff when new instrumentation or equipment is procured QH ICG Section 3  ADEQUATE REQUIRES IMPROVEMENT INADEQUATE (100%) (>70% = 4/5) (<70%)    OVERALL COMMENTS FOR THIS SECTION: STERILISING SERVICES AUDIT RISK RATING & REVIEW CRITERIA BY WHOM  ACTIONS REQUIRED DATE

4. MANAGEMENT 4.1 There is a copy of AS 4187 (2003) and associated relevant standards such as:  AS 1410- Pre vacuum Sterilisers  AS 1079- Packaging of items (sterile) for patient care  AS 1079.2 Part 2 Non-reusable papers- For wrapping of goods undergoing sterilisation in HCF  AS 1079.4- Part 4- Flexible packaging systems – for single use in hospitals  AS 1079.5- Part 5: Non-reusable, non-woven wrapping materials- for goods undergoing sterilising in HCF  AS 2182- Sterilisers- Steam-Benchtop  AS 2192- Sterilisers-Steam-Downward displacement  AS 2437- Flushers/sanitisers for bed pans & urine bottles  AS 2478- Dry heat sterilisers  AS 2514- Drying cabinet for medical equipment  AS 2773.1- Ultrasonic cleaner-non portable  AS 2773.2- Ultrasonic cleaner- benchtop  AS 2774- Drying cabinet for respiratory apparatus  AS 2945- Batch-type washer/disinfector  AS 3789- Textiles for healthcare facilities and institutions  AS 3789.2- Part 2- Theatre linen and pre-packs  AS 3789.6- Part 6- fabric specifications  AS 3789.8- Part 8 – recyclable barrier fabrics   AS3836- Rack conveyor type washers  AS4021- Non-reusable containers for the collection of sharp medical items used in health care areas  AS3816- Management of clinical and related wastes  AS4146- Laundry practice  AS4261- Reusable containers for the collection of sharp items used in human and animal medical applications QH ICG Section 3 4.2 CHRISP Standard Operating Procedures are operationalised to meet the needs of the department QH ICG Section 3  4.3 Standard Precautions and Workplace Health and Safety protocols are applied during all stages of the cleaning, disinfection and sterilising process QH ICG Section 3 & SOP  STERILISING SERVICES AUDIT RISK RATING & REVIEW CRITERIA BY WHOM  ACTIONS REQUIRED DATE

4. MANAGEMENT cont. 4.4 Items designed to be reprocessed are processed to a level for their intended use eg cleaning followed by sterilisation for all critical items QH ICG Section 3  4.5 Manufactures instructions are provided and available to staff for the processing of reusable medical devices QH ICG Section 3 and Cleaning Resources  4.6 Material Safety Data Sheets (MSDS) are available for all cleaning agents and chemicals which have been read and understood by staff prior to initial use SOP1.3 & QH ICG Section 3  4.7 Labelling on cleaning agents are to comply with any statutory obligations and includes the following information:  name of product  name and addresses of manufacturer  description & purpose of the product  directions for dilution and use  batch number   expiry date  advice not to mix cleaning agent with other chemicals  safety & first aid instructions  specific storage requirements SOP1.3 & Chem Alert 4.8 Chemicals used within the department are registered with the Therapeutic Goods Association QH ICG  4.9 Manufacturers instructions are followed in relation to load content QH ICG Section 3  4.10 Process in place for the notification of the manager or shift supervisor for all faults or failed processes (e.g. cleaning cycles, sterilising loads) SOP  4.11 Staffing profile is reviewed annually and meets the needs of the unit Business Planning Framework  4.12 Clear professional and operational reporting structure within the facility is evident QH ICG Section 3  4.13 Incidents relating to the processing of reusable medical equipment are reported, risk rated and actioned within corporate  and facility policy and the unit is provided with a summary of incidents regularly QH ICG Section 3 STERILISING SERVICES AUDIT RISK RATING & REVIEW CRITERIA BY WHOM  ACTIONS REQUIRED DATE

4. MANAGEMENT cont. 4.14 The sterilising processing facility has standard operating procedures for the following:  collection of used reusable items for areas outside the sterilising processing facility eg ward, other facilities  cleaning items, equipment and the environment  inspection of cleaned items  assembly and disassembly of items  handling and processing of specialised items  packaging of items  loading of items for processing  sterilisation cycle  process for linking steriliser cycle batch information to items that have been sterilised to the patient   calibration, routine monitoring and recording of sterilising equipment and cycles  unloading of sterilisers  storage of sterile items  validation of process for sterilisers  management of deviations and faults associated with processing of items  distribution of sterile items  recall of supplies or stored loads  complaints procedure QH ICG Section 3 & SOP ADEQUATE REQUIRES IMPROVEMENT INADEQUATE (100%) (>70% = 10/14) (<70%)    OVERALL COMMENTS FOR THIS SECTION: STERILISING SERVICES AUDIT RISK RATING & REVIEW CRITERIA BY WHOM  ACTIONS REQUIRED DATE

5. CONSULTATION 5.1 There is a formal communication process established between the sterilising facility and operating theatre for the following:  purchasing of instrumentation  changes to configuration of instrument trays  operating theatre scheduling   development and review of instrument count sheet QH ICG Section 3 5.2 There is a clearly defined relationship between sterilising services and other services within the district/facility, including but not limited to:  infection control  maintenance department   patient safety officer  peri-operative and surgical services  clinical procurement officer QH ICG Section 3 5.3 There is a formal consultation process with the manager of the sterilising facility for the purchase of all reusable medical devices QH ICG Section 3  5.4 The design and workflow supports designated areas for cleaning, packaging, sterilising and storage of sterile items Building & Refurbishment  5.5 Operation manuals for the sterilisers are readily available for maintenance and sterilising staff to access QH ICG Section 3  5.6 Each steriliser and associated equipment has a preventative maintenance program (monthly, quarterly, annually) QH ICG Section 3  5.7 Medical records departments are consulted about the management of sterilising records that are to be archived QH ICG Section 3  ADEQUATE REQUIRES IMPROVEMENT INADEQUATE (100%) (>70%= 5/7) (<70%)    OVERALL COMMENTS FOR THIS SECTION: STERILISING SERVICES AUDIT RISK RATING & REVIEW CRITERIA BY WHOM  ACTIONS REQUIRED DATE