Standards, Guidelines and Recommended Practice Crosswalks

Writing new or updating established policies and procedures or preparing for the next accreditation’s survey are both daunting tasks. With all the published standards, guidelines and recommended practices around reprocessing Sterile Processing (SP) managers may be baffled on which ones to follow. However, there are many ways to help interpret how these published documents relate to each other. Some of the tools that I have found helpful to compare these documents are considered crosswalks.

According to Webster’s dictionary, a crosswalk is a specially paved or marked path for pedestrians crossing a street or road. This definition can “cross-over” to compare healthcare standards, guidelines, and practices that relate to each other. There are many such crosswalks available to healthcare professionals that can be very useful. Following are some of the ones that I have used and found very helpful regarding sterilization and high-level disinfection.

The Joint Commission (TJC) offers crosswalks that compare their standards to the Centers for Medicare and Medicaid Services (CMS) standards.TCH to CMS crosswalks are available for Hospitals, Critical Access Hospital, Ambulatory and Office Based Surgery via the online Comprehensive Accreditation and Certification manuals. A glimpse of those crosswalks is shown in Table 1.

The Joint Commission E-dition Accreditation Manual
  The Joint Commission Requirements
Hospital –  Infection Prevention and Control  
CMS Medicare Requirements
Hospital Condition of Participation: Infection Control
IC.02.02.01 The hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies.

Note: Sterilization used for items such as implants and surgical instruments.  High-level disinfection may also be used if sterilization in not possible, as is the case with flexible endoscopes.

§482.42 TAG:A-0747 Condition of Participation: Infection Control The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.

§482.51 TAG: 0940 Condition of Participation: Surgical Services If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered.

§482.51(b) TAG: A-0951 Standard: Delivery of Service Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the Achievement and maintenance of high standards of medical practice and patient care.

Table 1. TJC to CMS crosswalk

The Association of periOperative Registered Nurses (AORN) offers a crosswalk from their guidelines to the Association for the Advancement of Medical Instrumentation (AAMI) for instruments, high-level disinfection, packaging, processing flexible endoscopes and sterilization. Table 2 shows an example taken from the AORN Guidelines and Tools for the Sterile Processing Team.        

AORN to AAMI Crosswalk: Cleaning and Care of Surgical Instruments
AORN AAMI
Guideline for cleaning and care of surgical instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015. ANSI/AAMI ST79:2017 (Consolidated Text): Comprehensive guide to steam sterilization and sterility assurance in health care facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation.
Recommendation III.d
In preparation for transport to a decontamination area, sharp instruments must be segregated from other instruments and confined in a puncture-resistant container.
6.2: Separation of waste and reusable items at point of use.
At the point of use,a) items should be separated into reusable items, single-use disposable items, and waste categories;
b) disposable items should be separated by waste categories and disposed of in accordance with all federal, state, and local regulations; and
c) sharps must be placed in puncture-resistant sharps containers that are OSHA compliant.:

Table 2. AORN to AAMI crosswalk

AAMI’s has a cross walk from their standards to the related TJC standards in their publication titled Sterile Processing in Healthcare Facilities: Preparing for Accreditation Surveys. Table 3 offers a sample of that crosswalk.

ANNEX F Key Provisions of ANSI/AAMI ST79 in Relation to Accreditation Surveys
TJC AAMI
LD.04.01.11: The hospital makes space and equipment available as needed for the provision of care, treatment, and services.   Special area requirements and restrictions (3.3.7) Decontamination area (3.3.7.1)

  • Preparation area (3.3.7.2)
  • Sterile storage (3.3.7.4)
  • Break-out area (3.3.7.8)
  • Emergency eyewash/shower equipment (3.3.8)

Table 3. TJC to AAMI crosswalk

These crosswalk tools can prove to be very helpful in the creation of policies and procedures. Understanding the link between TJC, CMS, AORN and AAMI published standards, guidelines and recommended practices can help healthcare facilites follow best practices and be prepared for an accreditation survey.

References:

  • Full definition of Crosswalk. Available at: http://www.merriam-webster.com/dictionary/crosswalk. Accessed 11/16/2016
  • The Joint Commission. Hospital Crosswalk. Medicare Hospital Requirements to 2017 Joint Commission Hospital Standards and EPs. Available at: https://e-dition.jcrinc.com/Common/PDFs/Crosswalk_19_2_HAP.pdf. Accessed 11/16/2018
  • Guideline for cleaning and care of surgical instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015.
  • ANSI/AAMI ST79:2017 (Consolidated Text): Comprehensive guide to steam sterilization and sterility assurance in health care facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation.
  • Seavey, R. Association for the Advancement of Medical Instrumentation. Sterile Processing in Healthcare Facilities: Preparing for Accreditation Surveys. 3rd 2017
Rose Seavey MBA, BS, RN, CNOR, CRCST, CSPDT 
President/CEO Seavey Healthcare Consulting, LLC 

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