Sterilization Station: A Sterile Processing Empowerment Podcast
Welcome to "Sterile Processing Empowerment Podcast, the podcast dedicated to elevating the field of sterile processing and surgical services! In an industry where precision and care intersect, we believe that knowledge is power. Our mission is to empower, encourage, and motivate every professional engaged in the transformative world of healthcare.
Join us each week as we delve into enlightening discussions that shine a light on best practices, emerging innovations, and the critical role sterile processing plays in patient safety. Whether you're a seasoned expert or just starting your journey, our panels and expert guests will provide invaluable insights through engaging conversations and real-world stories.
From the nuances of instrument handling to the latest in sterilization techniques, we cover it all. Expect thought-provoking interviews, educational segments, and motivating content designed to inspire you to elevate your craft. Together, let’s foster a community that champions excellence in surgical services and celebrates the unsung heroes of healthcare.
Tune in to where expertise meets passion, and every episode empowers you to make a difference in the operating room and beyond.
Sterilization Station: A Sterile Processing Empowerment Podcast
Skills with Jill: Bridging the Gap with Sterile Processing and Accredidation
The critical but often overlooked realm of sterile processing comes to light through expert insights on building effective partnerships with healthcare accreditation teams. Regulatory professional Amy Asleson shares her 17 years of experience navigating the complexities of SPD and accreditation collaboration.
• Accreditation professionals often have clinical backgrounds but limited understanding of sterile processing operations
• Building effective partnerships requires sterile processing managers to proactively reach out and educate accreditation teams
• Risk assessment tools bring together multidisciplinary teams to evaluate incidents and ensure appropriate responses
• Regular multidisciplinary rounding with infection prevention, EVS, engineering and SPD creates comprehensive improvement opportunities
• Current survey focuses include tape on instruments, outdated trays in emergency departments, and documentation for bidirectional tracing
• SPD and high-level disinfection are distinct processes requiring different evaluation approaches and documentation standards
• Excellence in sterile processing should be maintained year-round, not just during survey preparation
• Collaboration across healthcare systems allows sterile processing departments to learn from each other and implement best practices
If you enjoy the show, please give a like, follow, or share - it really helps us grow this platform and continue bringing valuable content to the sterile processing community.
Welcome to the Sterilization Station, where precision meets purpose. Here, every tray tells a story and every instrument holds the power to save a life. But behind the scenes, it's you, the sterile processing professionals, who keep the cycle of care moving. I'm Bill Rochelle, and this is the podcast that empowers, inspires and elevates the world of sterile processing. Each episode brings you educational, deep dives, real success stories, thought-provoking industry hot topics and conversations with the people reshaping the future of our field. Because here we don't just clean and prep, we lead, we grow and we transform through education. This is your place to plug in, level up and stay sharp. So this is the Sterilization Station, and I hope you enjoyed this episode today.
Speaker 2:Welcome to the Skills with Jill mini-series, a series that will explore various skills through sterile processing, accreditation, quality and endoscopes. I'm looking forward to bringing you a series all to you and hope you can take away from key insights and support you on your journey wherever that leads you. Good morning, we have Amy Aslason today. She's a regulatory professional with over 17 years of experience in the healthcare accreditation and regulatory landscape. She has worked in Minnesota, california, north Carolina and moderately sized healthcare system. She has a focus and passion for sterile processing and high-level disinfection processes in the OR and procedural areas in hospitals and ambulatory surgery centers. She has worked closely with the SPD, hld leadership and the infection preventionists to encourage multidisciplinary rounding so that all stakeholders can discuss and identify opportunities for improvement as a team. In her spare time, amy can be found curled up with a good book or planning her next trip to Disney World. Her Minnie Mouse year collection continues to grow with every trip. Good morning, amy. I'm so glad you're here with us.
Speaker 3:Thank you so much for inviting me.
Speaker 2:So I'm just going to dive in because I can't even wait to hear. I appreciate the collaboration that you have. I think your role is very unique in accreditation, and so I'm hoping that there'll be teams that'll be able to find the accreditation teams within their site and we'll learn here. How did you build your accreditation skill set in sterile processing?
Speaker 3:So, as you said, I've been working in accreditation for 17 years and my previous life I was a critical care nurse, so I was much more comfortable in those settings. I'd never worked in the OR and my entire auditing of an SPD was to walk in. Look at the floors yeah, they're clean. Look at the ceiling yeah, no, ceiling tiles are stained. It kind of looks clean. Don't know what else I'm looking at. Bye-bye, thank you, I'll be back.
Speaker 3:And I expected that SPD would tell me when there were problems, but I had never even communicated that with them. And then I worked as the accreditation corporate leader for 13 hospitals, and one of those hospitals had a very severe SPD event where a load wound up not being sterilized and got into the OR, to the point some of the pans were used on patients. The bidirectional tracing failed because it hadn't gone through a cycle, so we didn't even know which patients those trays had been used on, and that got out into the news, which then prompted a state survey. And so spent a year and a half working through survey after survey. Every time they came back there was a different problem and, as we discovered, we didn't have any corporate leadership. And so when we developed the role of a manager of SPD. We found that we were able to start to get on track and because that individual happened to work for me, I felt that I had to start to learn what that meant that's awesome.
Speaker 2:So it kind of was by virtue of an event that then brought you in there, and then that kind of brings us into our another question. So, thinking about surveys and rounding, what do you think makes the most impact for success in sterile processing in HLD areas?
Speaker 3:I think number one is understanding what you're even looking at, and it's not just an environmental is it dusty? Is the floor clean? Are things not blocking panels the things that we would normally look at in a hallway is what we need to start to avoid, and we, as accreditation, have to take some ownership in learning what that is and connecting with our SPD and HLD leaders and understanding that. It's a whole new language.
Speaker 3:As my manager of SPD trained me, I had a kindergarten understanding and I was told I would come and stand in an SPD department for a couple hours. And when I stood in decontam and confidently pointed at the washer and said I know that's a sterilizer, I was told you know nothing about SPD, let's start learning. And so it was okay, I'm going to show you the logs and you're going to take notes and you're going to learn this, not just have them tell you oh yeah, here are the logs, the logs are right, but be able to look at them and say but you're missing A, b and C. And so I think that collaboration with the SPD manager and getting the information and starting to learn is critical for an accreditation leader to help in that area.
Speaker 2:Yeah, I appreciate that. That. It's the willing to learn and almost like I talked about in my last one, just being brave. We really actually enjoy speaking and having individuals come in and almost lowering the playing field. I'm not here to check on you this time, it's really. Can you just help me understand the why of the process, right?
Speaker 3:Absolutely.
Speaker 2:That's fantastic. What's one of your biggest successes and what steps or tools did you use to reach it?
Speaker 3:So in my job in Minnesota, in my role, as we looked at events that were happening in SPD areas across the system and we had determined that there was no standard process for identifying a risk when there was a leak in a sterile storage area or in the sterile core, when there was a leak in assembly, when there were a number of instruments in an area that hadn't been sterilized or were missed, and at what point was that caught, or if we had water quality issues and it was identified on a test. And it was really kind of a whoever we called, whoever was in the building, we would go in, we would look, we would determine hey, yeah, we want to do this. And, working with the corporate SPD manager and accreditation and infection prevention, we developed a risk assessment tool and that risk assessment tool was used. The corporate manager went to every event and facilitated that risk assessment with the onsite accreditation, professional and infection prevention and SPD and they all went in and said, okay, here's the level of severity that this event caused.
Speaker 3:We either need to either we're fine, okay, it's a little event and we're fine, nothing has to be done or we need to look at these instruments in this localized area and do something with them, or we have water running down the side of the sterile core. We are reprocessing everything and we're going to have to get instruments from other hospitals. These are the things that are going to have to happen to make sure we have the instruments for the case while we reprocess and while we move those instruments somewhere appropriate until they can get the damage fixed. But not just a hey, we need them and they're not that, they're not that wet, they're not that stained, and I think that making sure that we had the same eyes, along with the facility eyes, to have that discussion and come to a mutual decision was really helpful in making sure that our instruments were safe for patient use, which is always key and always the most important aspect.
Speaker 2:Yeah, I think really having a tool for the SPD managers to sit at the table and sometimes I think that's one of the things that we maybe don't have is that type of a tool. So I appreciate that you were able to create that. Is there a place that someone could start to make that? Or is now maybe that out there where someone could find that, if they didn't have that right now as more of like a gap analysis type thing, that could get you to be able to have that conversation? Like, I know, we have the SBAR, the Situation Background Assessment, recommendation tools.
Speaker 3:But to get to that risk piece, I think that's an area where we struggle sometimes and I think that's a great question because building these tools from scratch can be difficult and in accreditation we shamelessly steal because we are generalists, we are not experts, and so find the person in your system who routinely does a risk assessment on something. Take that tool. We used a green yellow red system so as you scored with numbers, it would put you in green, yellow, red. And it said and we stole the concept of that tool from risk management we said who does these risk assessments, risk management, what do you use when you have to determine if something is a high risk or a low risk? We took that tool and we sat with the SPD committees and we sat with accreditation and infection prevention and they're just as crucial in the conversation and we form-fit it to what we would need and what questions we would need to ask when we walked into that event.
Speaker 2:Awesome. Thank you for that, because I think that's really helpful for somebody to be able to take something away today and go and make something like we used. So how can sterile processing professionals reach out to the accreditation teams to start collaborating? If that's an opportunity for some of our listeners, how do we?
Speaker 3:start that. So I think the first thing is, hopefully you know who your accreditation professional is and that they've walked through and just say, hey, I'd like to set up collaborative meetings. Let's start meeting on a regular basis. Let me tell you what I think the gaps and the opportunities are and let me explain why. And will you take some time to look at our logs and I'm going to explain what should be there and make it very clear that you're looking for a partnership and your accreditation professional, who, for the most part, are clinical care providers who have worked in nursing or Okay, so you tend to have accreditation professionals who have worked in clinical bedside care and may not be comfortable in that space.
Speaker 3:So helping make them comfortable, because they're not even going to know what question to ask. And as you partner, don't hide things, this is not joint commission. This is not someone that's going to be punitive. They're going to be able to help you with those opportunities. If you don't know who your accreditation professional is, ask the OR nurse manager More than likely they are going to know who that accreditation person is. Ask the OR nurse manager More than likely they are going to know who that accreditation person is and they're going to be able to help you reach out.
Speaker 3:And I think sometimes that fear of I'm going to go in and not know what to ask and I'm going to look foolish or I'm not going to look like the professional I need to, and so I'm going to wait from that accreditation side. So do that reaching out and say I understand, you don't know this language. Can I teach you to a first grade level and then we can set up some rounding. And if you have things you know you need to be looking at, the thing your accreditation professional can help you with is developing an audit tool. We do that all the time and we do that with stuff we don't understand 100%, which is why we partner with that specialist to say what needs to be on this audit.
Speaker 3:What do you need to know? And I will tell you sometimes just the title of accreditation will help break barriers. Partner with accreditation and then, when those risks are identified, they can say you know, I know they've been saying this, but this is a regulatory risk and this happens to be a big regulatory risk. Right now you work in a very high risk area because what you do is critical to the safety of our patients and that may not always be identified as that. But once you see it and you come to understand just how critical having those sterile instruments in an OR is, you start to really appreciate the hard work that goes into making sure our patients are safe.
Speaker 2:Yeah, I'm really glad that you said it's a safe space to be able to share. This is a gap right now, or I want to help you understand what this process should look like and then having that accreditation team be able to take that to a higher level and then get the support or maybe get the funding or whatever that may look like. So, yes, it is a safe space, even though we go and tell the accreditation some of our you know things in the closet that we don't want anybody to see.
Speaker 3:That is where we get our best information, and being able to identify that and being able to share that and show that really is only going to help your department get stronger.
Speaker 2:And I think sometimes that accreditation team may also have another level of multidisciplinary support. So if there is something that we identify as a big gap and a possible risk and something that maybe the sterile processing manager has been working on for a while, you're able or your role is kind of able to take that and get a quicker resolution, absolutely. Would, that be fair to say.
Speaker 3:Yes, absolutely Awesome.
Speaker 2:From your perspective, how can accreditation teams support the work of sterile processing year round and not just at survey time? I think we touched on that a little bit. But I think, if we can dive in and pull out some of those key pieces, sometimes I feel like maybe it's just they come down once a year or, like you said, I would come in and look at the ceiling tiles and look at the floor and it looks clean. So how can we have that more of a? I'm here to observe, or maybe we can talk about setting up a tracer or some things like that.
Speaker 3:Absolutely. And tracers are vital, not only because they kind of help you remember what to look at, but they allow you to track over time. If you are using the same questions every time you go in, you're able to track. You know we've had three rounding cycles, whether it's monthly or quarterly. This is our gap and we don't seem to be able to close it. So there's a barrier to why there's not that compliance, and those can be identified using a multidisciplinary rounding process at a set cadence. So in my situation, I work with the infection preventionist, evs, plant engineering, the SPD manager, and we round at least quarterly and we have a standard tool that we use with all of the questions, with the last question being what keeps you up at night. And so if we didn't touch on it, please tell me what it is. We didn't touch on it, please tell me what it is.
Speaker 3:And we are able because every one of us is other than accreditation. We've got the specialists in that room looking at it and plant engineering is looking at something slightly different than IP is, and SPD is really focused on where they've identified the gap and so being able to have that discussion in real time in front of what we think the opportunity is we can come up with next steps, an action plan and I'm not talking about a formal action plan, I'm talking about hey, write down these three things. We're going to do these three things and we're going to circle back in a month because this was a big deal, and so we're going to come out of cadence and we're going to come back in a month and we're going to look at it and we're going to see did that action plan work? If not, what are we going to do next? But we're going to keep working on it till we no longer identify it as a problem. And having everyone in the room at the same time plus that puts less stress on your department Then accreditation comes in and rounds quarterly.
Speaker 3:Then IP comes in a separate time and rounds quarterly, and the plan engineering is in there quarterly, and now all you've got are people running around in your department kind of looking at some things, but not having that total package of knowledge standing right there. So I walk out. I have three people I have to ask questions of later and then, unfortunately, remember to get that answer back, because now I have the answer, now I know it, but does everyone else on the team know it.
Speaker 2:So yeah, yeah, I think that that is super great insights. And just for clarity for maybe people who don't necessarily have something like that formal setup, are the accreditation teams able to make tracers typically Like is that programs that you have or could that be something that usually they would know to make or have a program to make usually at every hospital?
Speaker 3:Yes, absolutely. That is between survey rounding. Tool development is the third biggest part of my job and that is I know how to make a tool. You have to tell me what to put on it and it's not my first time I've got a template. I'm just going to plug in what you need. So don't spend your time formatting a tool.
Speaker 3:Sit down and say I think these are the things we need to be looking at and the thing your accreditation professionals should be able to do is we call it, pull the thread. But okay, you want me to ask this question. If the answer to that question is yes, what is my next question? Where do? Or if it's no, what is my next question? Help me understand how to pull that thread and get those questions on to that tracer. But let your accreditation professional help you with that, because they are going to have a tool, because they use it in every other department. They may have access to a tool like AMP, which is a joint commission resources tool that has tracers in it.
Speaker 3:You put in SPD. It's going to pull out a tracer. You look at the questions. You say yes, all of these are appropriate or no. I don't want to ask these three questions and we take it off. And now we've got a tracer tool. So whatever software, or if it's an Excel spreadsheet, it's already built and already in use in accreditation. You just need to plug in your questions.
Speaker 2:I appreciate that, knowing that we maybe have something already and we can just bring it and give you the information, and even if we don't have something to the Joint Commission resources level, we still can do something. Starting next week, what are the highest areas of potential gaps for sterile processing survey?
Speaker 3:So, right now, they are focused on tape.
Speaker 2:Tape on instruments.
Speaker 3:Yes, that marking tape on instruments where, okay, this doctor wants this, so it's, you know, a little smiley face tape around it and that tape over time frays or it was wrapped four times around just to make sure it didn't come off and now the end is peeling up and it has to be wrapped one and a half times. It has to not be frayed and there are a lot of. You have to be very careful about what that tape looks like. Surveyors are looking and they will touch every peel pack in a section if they have to, to see if they can see tape. They are looking at older pans, especially if you're in a larger facility where SPD is processing for a women's OR and a C-section OR, and they want that instrument back. They don't want a McGill forceps, they want their McGill forceps, they want their instruments and they're going to mark them in some way. And that pan that was sterilized in 2015,. The rules for what you could do and what you could put in that pan were very different in 2015,. The rules for what you could do and what you could put in that pan were very different in 2015. And what pans you have in the ED? Because that one ED provider needed this one pan that one time in 2012,. It didn't have it, so we made one. So now it's at the bottom back of the shelf Guess where a surveyor is going to look and they're going to find that pan from 2012.
Speaker 3:And it is going to have tape and it is going to have g pan from 2012 and it is going to have tape and it is going to have gauze and it is going to have all the stuff that we don't process anymore, but it's going to be in there from 2012 and it is going to be ripped because I have, you know, swiped against the blue wrap with everything and anything that I store in an ED, and there is a homing device that surveyors have on those kinds of things. So if you have those pans in your EDs, in your ICUs especially look in your ICUs, cvsus, where you're going to have your thoracotomy pans you're going to have the tray to pop a chest if you have to. They are going to have them, and have that discussion with your leaders as you find that pan from 2012. Do you really need it? And let's really talk about that, because the initial gut reaction is yes, we do. And it's like do you, though, and you will take it and they'll say reprocess it, bring it right back, we might need it on the next patient. It's like will you though? So are there options?
Speaker 3:I think the other thing is really on the documentation, and do you have the logs to show that you can bi-directionally trace if you have to? If you've got an infection, can you figure out what other patients might be affected? Do you have the documentation that says, yes, I've done my quality controls? So I know, in an HLD situation, I know that HLD happened because I've got the quality checks to show that it was working at its most efficacious. And here's the other thing you're going to need to teach. Your accreditation professional is SPD, is not HLD. Hld is not SPD because what we know is low level. We know there's low level and there's everything else. So, being able to even explain that difference and that they're going to be different tracer tools, they're going to be different leaders, they're not even going to be in the same area. You're going to have to wander around the hospital to find your HLDs and they're going to have different logs. They're going to have different chemicals and it's going to look completely different. Don't lump it all together.
Speaker 2:Yeah, I appreciate you highlighting that because I do think sometimes it all falls into the same, almost back to we walk in and it looks clean. Yep, knowing what those logs should look like for sterilization versus high level disinfection versus in the clinic maybe they have some sort of device that's doing a sterilization or something like that. Do we have all the appropriate things in line versus what we do in the hospital and anything else?
Speaker 3:Go ahead. Oh, I was going to say, even knowing that when you've got seven pans that are all stacked up on the top shelf, your biggest problem there is not that the 18-inch rule rule, that it's too close to ceiling. Your problem is you have seven heavy bands sitting on top of each other on the top shelf which are probably old, too heavy, shouldn't be stacking that many, and that you're going to have problems, plus your OSHA problem of getting those back down. So those are kind of the things, yeah.
Speaker 2:Anything else you want to share with the listeners. Today We've had a great conversation. I appreciate you kind of breaking it down on how we could collaborate if there's not that in place today.
Speaker 3:How we can help people learn, I think the biggest thing is that your accreditation professional may not know how to help, but they want to help and don't be afraid to ask for that help. To help, but they want to help and don't be afraid to ask for that help. Don't feel like you have to figure out what the regulations are, because the regulations are changing. If you're working in a joint commission accredited facility, just know the regulations have changed in the last year. High-level disinfection, low-level disinfection and sterilization now all fall into one infection control EP. Don't be afraid to reach out because your accreditation professional may not know how to reach out to you. Reach out to them. They want to help. They may not know how in the beginning, but through that collaboration you'll be able to figure out what that looks like.
Speaker 2:Yeah, anything else you want to share with the listeners today, I think like we've talked about.
Speaker 3:Collaboration is the key and reach out, because they may not know how to even ask the question what can I do to help you? What do you need? And it's something that if you can help them understand your language and help they can help you because you don't know where those trays are hidden. Anesthesia has their trays. Now they put it in your anesthesia cart and your accreditation professionals, who tend to be clinical I always say I can find the naughty on a nursing unit, because I did the naughty when I was a nurse, because I didn't understand, and part of that comes from not understanding the regulations.
Speaker 3:And recently the regulations around sterilization, high-level disinfection and low-level disinfection have changed if you're a Joint Commission-accredited hospital, because they have taken what used to be about six elements of performance and they put them into one, and that means everything from the microwave was dirty in the nutrition room to an unsterilized pan was used in an OR case.
Speaker 3:All of them go into one EP and so you have to be vigilant in your IP practices around SPD because once you have a number of findings under that element performance, one of them can push that into the high, widespread or immediate threat category where you do not want to be, and so making sure the SPD and HLD are taken care of. You are critical in also keeping some of that regulatory risk on those and during survey activity down. But I do want to end with we are not doing this because we need to meet a regulatory survey and we are not doing this three weeks before joint commission is coming because we don't want them to find it. We are doing this all year round, all the time we are ready for the next patient. Then we are confident in talking to a surveyor. What we want to get to is not how can we hide what we're not doing correctly from a surveyor we want to get to? How do we tell the surveyor what we do every day so that we can brag on ourselves?
Speaker 2:That's what surveys should be. Yeah, exactly, being proud of the work that we do every day.
Speaker 3:Absolutely Tell your story, Tell it confidently and be proud of it.
Speaker 2:Yeah, and I think one of those things that I take away from you too is you can show the accreditation manager and maybe that becomes a process improvement project, where then there is a way that we can share here's what we had identified as a gap and here's all the things that we did to fix it, and it becomes really a proud moment, right.
Speaker 3:And do it as a system. If you are working in a healthcare system, borrow from each other. Make your system SPD process stronger by collaborating with each other as well.
Speaker 2:Yeah, yeah Well, thank you so much. I appreciate all of your insights and I think this is just a great collaboration of how SPD and accreditation can work together, and I appreciate you joining me on Skills with Jill miniseries. I look forward to bringing you all of the next episodes.
Speaker 3:Thank you so much for having me.
Speaker 1:Well, that's a wrap for this episode with Skill with Jill. I hope you enjoyed that. We want to thank also Amy Aslason for coming in and she did such a great job. She's really really good and knowledgeable and I hope this isn't the last time that she'll be joining us, because she was. I don't know if y'all were hearing it, but there was like bombs being dropped of knowledge. There were jewels flying everywhere. I hope you were able to grab that. That was really wonderful, and so I hope that you are leaving feeling more confident and skilled and if you enjoy it, please give a like, follow or share. It really helps and stay tuned. There's so many more exciting skills coming soon and, believe me, jill is keeping it under the wrap, so you do not want to miss it. A special shout out to our amazing sponsors, who are helping to grow this platform, so I'll go ahead and just mention a few things about the sponsors.
Speaker 1:So RMPS Publishing, rick Schultz and his team If you are looking for an excellent educational learning tool, whether it be for your SB department or maybe your surgical tech, and you want to get some good tools, I know he has some great resources at the World of Surgical Instruments. It's a 498-page textbook. It covers all you need to know about surgical instruments, from frequently asked questions testing, inspection, repair, sharpness testing and much more. So you go to wwwinstrumentlearningcom and use the code BRBOOK to get a 20% discount and to compliment the textbook. You can check out the instrument coaching cards. It's 165 color-coded flashcards. Or if you're like no, I want to get the set, it's BR set. So BR cards for the coaching cards and then BR set for the complete set.
Speaker 1:We also would like to thank MedTech College in Hayward. Kenya is a sterile processing college. If you're looking for a rewarding career in healthcare that doesn't require years of medical school, medtech College is where you want to go. They offer a comprehensive sterile processing program that prepares you for a vital role in patient safety. As a sterile processing technician, you'll be on the front lines of infection control, ensuring that surgical instruments and medical equipment are properly sterilized. So please don't hesitate to reach out. Classes are enrolling now. If you visit MedTech, that's M-E-D-T-E-K collegehaywardcom, or you can call 510-432.
Speaker 1:We also would like to thank those who have subscribed to support this podcast. Jill Behrens is one of our supporters, as well as Cliff Russell, vanessa Frank and, of course, medtech College is also supporting us, and if you're interested to support you can go to wwwbuzzsproutcom. Forward slash 243-8879. Forward slash subscribe. We see you, we appreciate you and we're so glad to have you on this journey with us. And so, if you haven't yet hit that subscribe button and consider supporting the show. Every bit helps us to keep delivering insight and impact to the SBD community. Until next time, stay sharp, stay empowered and keep making a difference, and we'll see you soon.
