Accreditation Survey Site Visits for SPD: Are you Compliant?

The Joint Commission (TJC) or The Centers for Medicare and Medicaid Services survey site visits focuses on safety and quality of patient care throughout the healthcare facility.  Surveyors will more than likely want to review areas that process devices via high-level disinfection (HLD) or sterilization. Surveyors will want to see that facilities are conduction risk assessments and improving processes related to reprocessing.

In September 2015 the Centers for Disease Control and Prevention and the U.S. Food and Drug Administration released a Health Alert that stated, “Healthcare facilities should arrange for a healthcare professional with expertise in device reprocessing to immediately assess their reprocessing procedures”.  They want to ensure reprocessing is correctly accomplished, including allowing enough time for reprocessing personnel to follow all steps recommended by the device manufacturer.1

TJC publishes many Standards BoosterPaks for accredited organizations.  These documents s provide specific information about TJC standards that have received a large amount of non-compliance scores.  I like to think of them as “cliff notes“  for their standards.  Recently they published The High-Level Disinfection (HLD) and Sterilization BoosterPak which a wonderful resource aimed at ensuring work practices are carried out following regulatory standards and current evidence-based guidelines in order to minimize potential risk of infection transmission to patients.2

Published resources for the most current HLD and Sterilization include,

  • 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,
    • ST91, Flexible and semi-rigid endoscope processing in health care facilities,
    • AAMI ST41:2008 (R2012) Ethylene Oxide Sterilization In Health Care Facilities: Safety And Effectiveness
  • The Association of periOperative Registered Nurses (AORN):
    • Guidelines and Tools for Sterile Processing.

Surveyors will want to see facilities are conducting multidisciplinary risk assessments to improve HLD and sterilization processes.  Surveyors understand 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, and
  • Directors

A champion from senior leadership should be identified to assist in the implementation of best practices and help to make the case for the necessary improvement projects as they compete with other priorities within the organization2

The best way to ensure a good survey is to know and consistently follow the accreditation standards, ensure staff is competent, always follow current evidence based guidelines and work closely with the IPC and facilities/engineers to ensure you environment is within standards.3   If you follow these suggestions, you can help to avoid citations for noncompliance on your next survey. The number one thing to keep in mind is risk reduction and process improvement are the heart and soul of accreditation surveys.



1. Immediate Need for Healthcare Facilities to Review Procedures for Cleaning, Disinfection, and Sterilizing Reusable Medical Devices. CDC Health Alert Network. Sept. 11, 2015 Available at: Accessed 5/25/2016
2. High-Level Disinfection (HLD) and Sterilization BoosterPakTM , The Joint Commission Available at:
3. Seavey, R. Association for the Advancement of Medical Instrumentation. Sterile Processing in Healthcare Facilities: Preparing for Accreditation Surveys. 2014.