Let CIVCO Help with Joint Commission Compliance Challenges


According to The Joint Commission (TJC), the second most commonly cited area for noncompliance in hospitals in 2015 has been related to 'the reduction of infection risk from equipment, devices, and supplies.' TJC annually releases the most common cited standards (areas of noncompliance) and this particular infection control standard, IC.02.02.01, has been a 'leading' category for noncompliance for the past few years.

With specific regard to high-level disinfection (HLD) practices, a surveyor might cite a facility if the high-level disinfectant is not properly used. Examples would be improper efficacy testing, failure to change the disinfectant according to its reuse period or failure to observe the dilution ratio requirements.

Office-based surgery practice or clinic?

If you work in an office-based surgery practice or clinic, the same noncompliance challenges are prevalent. In fact, in the office based surgery setting, the most frequently cited was IC.02.02.01 where the practice reduces the risk of infections with medical device, equipment, and supplies.

According to reports to TJC's Office of Quality Monitoring, we've listed the findings from non-complying organizations along with ways in which we can help:

  • "Staff lack the knowledge or training required to properly sterilize or high-level disinfect equipment."
  • "Staff doesn't have access to or lack knowledge of evidence-based guidelines."
  • "Processes for sterilization or high-level disinfection are not followed (i.e., staff take short-cuts)."
  • "There is no dedicated staff person to oversee the proper sterilization or high-level disinfection of equipment."
  • "Facility design or space issues prevent proper sterilization or high-level disinfection of equipment (e.g., processing takes place in a small room that is also used for storage)."

Use a GUS Disinfection System to control vapors in small or large settings.

Moreover, the FDA and CDC issued an Advisory in September 2015 that facilities must immediately review their procedures for cleaning, disinfecting, and sterilizing reusable devices. Some of the advisory recommendations are listed below.

  • "Healthcare facilities should provide training to all personnel who reprocess medical devices."
  • "Healthcare facilities should maintain documentation of reprocessing activities, including verifying high-level disinfectants were tested and replaced appropriately."
  • "Healthcare facilities should allow adequate time for reprocessing to ensure adherence to all steps recommended by the device manufacturer, including drying, proper storage, and transport of reprocessed devices."

CIVCO Medical Solutions offers ultrasound storage cabinets designed for endovaginal, endorectal, general purpose, and TEE probes.

  • "Considerations should be made regarding scheduling of procedures and supply of devices to ensure adequate time is allotted for reprocessing."

Is there an opportunity to disinfect multiple vaginal/rectal probes or TEE probes at one time?

  • "Healthcare facilities should have protocols to ensure that healthcare personnel can readily identify devices that have been properly reprocessed and are ready for patient use (e.g., tagging system, storage in a designated area)."

The complete CDC Advisory is located on the their website.

Due to the increased spotlight and need for information, CIVCO Medical Solutions offers regular webinars and blog posts covering various high-level disinfection topics. Visit CIVCO.com/conferences to view the webinar event calendar and for access to CIVCO's In-the-Know Blog.