Joint Commission: High-Level Disinfection (HLD) and Sterilization BoosterPakTM

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The Joint Commission (TJC) has created several Standards BoosterPaks.  These are searchable documents that provide specific information about TJC standards associated with a high volume of non-compliance scores in the health care field. The BoosterPaks were created for accredited organizations and staff within TJC to improve the understanding and consistency of standards interpretation. BoosterPaks are available to TJC accredited and certified organizations on the secure Joint Commission Connect Extranet.1

Last December, the Joint Commission (TJC) released its newest BoosterPak titled “High-Level Disinfection (HLD) and Sterilization.  This resource is directed toward hospitals, ambulatory services and office-based surgery practices as they prepare for an accreditation survey.  The goal of the BoosterPak is “To ensure work practices are carried out following regulatory standards and evidence-based guidelines for HLD and sterilization in order to minimize potential risk of infection transmission to patients”.1

During accreditation surveys, TJC continues to cite facilities for serious noncompliance with the Infection Prevention and Control standards. This document was created to help facilities improve patient safety and compliance for a successful accreditation process.  The BoosterPak highlights the related TJC standards and their requirements.  It provides links to references and training sites.  It also lists “Important Takeaways” and “Important Things to Know” regarding Leadership, Risk Assessment, Sterilization, Environment of Care, Human Resources, Competency and Training.

The HLD and Sterilization BoosterPak emphasizes the importance of having and following published resources such as,

  • The Association for the Advancement of Medical Instrumentation (AAMI):
    • ST79 Comprehensive guide to steam sterilization and sterility assurance in health care facilities,
    • ST58 Chemical sterilization and high-level disinfection in health care facilities; and
    • ST91, Flexible and semi-rigid endoscope processing in health care facilities, and
  • The Association of periOperative Registered Nurses (AORN):
    • Guidelines and Tools for Sterile Processing. 

The document also lists several other resources/links for published standards, guidelines, and educational resources.
The BoosterPak also describes the concept of doing a risk assessment to refine your HLD and sterilization processes, and the importance of using multidisciplinary teams to perform these assessments.   When conducting a risk assessment TJC states it is important to create teams that involve key stakeholders, which should include:

  • Infection Prevention,
  • Environmental Services,
  • Facilities/Engineering,
  • Managers/Supervisors,
  • Front-line Staff,
  • Directors

It is suggested that a senior leadership champion be identified to help implement best practices and to supervise the development and activities around these procedures.  The senior leadership may be necessary to help make the case for the necessary improvement projects as they compete with other priorities within the healthcare facility. 2

The BoosterPak includes an appendix that lists standards relating to HLD and/or Sterilization Processes that may be addressed during a survey for healthcare facilities that reprocess reusable medical devices.  Those standards include:

  • Infection Control,
  • Human Resources,
  • Leadership,
  • Environmental Controls, and
  • National Patient Safety Goals.

 The number one thing to keep in mind as you prepare for your next survey is that risk reduction and process improvement are the heart and soul of any accreditation surveys. Above all else, patient safety is number one.

 

References:

  1. High-Level Disinfection (HLD) and Sterilization BoosterPakTM , The Joint Commission Available at: http://www.jointcommission.org/standards_booster_paks/
  2. News from TJC and CMS. Patton Healthcare Consulting Newsletter December 2015

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