Improving Reprocessing Compliance: 5 Steps to Take

Published Date: November 14, 2017


Following proper reprocessing procedures is a significant challenge for ASCs. When The Joint Commission released its 2016 annual summary of the "Top 10 Challenging Standards" ambulatory health care accredited organizations experienced in 2016, coming in No. 1 was standard IC.02.02.01: "The organization reduces the risk of infections associated with medical equipment, devices, and supplies."

Non-compliance with this standard is most likely due to shortcomings in reprocessing, says Phenelle Segal, RN, CIC, FAPIC, president and founder of Infection Control Consulting Services, a national consulting firm based in Delray Beach, Fla.

"There is a combination of factors that result in non-compliance with respect to reprocessing," Segal says. She notes that these include the following:

  • Failure to follow manufacturer instructions for use (IFU)
  • Inconsistent practices
  • Increased workload for reprocessing department
  • Staff turnover
  • Lack of formal training and education

When improper reprocessing occurs, patient safety is jeopardized. ECRI Institute recently issued its "Top 10 Health Technology Hazards for 2018" list. Coming in at No. 2 was reprocessing, specifically associated with endoscopes. In a press release, ECRI noted, "... healthcare facilities continue to struggle with consistently and effectively cleaning, disinfecting, and sterilizing these instruments between uses. Reprocessing failures can lead — and have led — to the spread of deadly infections."

Here are five steps Segal advises ASCs take to improve their compliance with reprocessing requirements.

  1. Obtain IFUs. Reprocessing of medical devices requires step-by-step processes. Segal says this cannot be optimally achieved unless IFUs are followed for each step. IFUs are not limited to the device itself, but also include the products used to reprocess and the reprocessing equipment (e.g., washers, autoclaves).

    "The good news is we're in a far better place now than in the past with IFU availability because there has been pressure placed on manufacturers by the U.S. Food and Drug administration and other agencies to include disinfection and sterilization in their IFUs," she says.


  2. Oversee performance. ASCs should develop a process for performing compliance monitoring of reprocessing staff. "It is imperative that the infection prevention designee oversee reprocessing steps, including ensuring that technicians are following the IFUs," Segal says. "Accreditation agencies and the Centers for Medicare & Medicaid Services expect that compliance monitoring is conducted. There should also be a support system in place if technicians encounter difficulty with reprocessing any pieces of equipment."


  3. Provide necessary resources. An ASC's reprocessing department should have the appropriate technology to ensure effective processes. There must also be enough supplies so reprocessing staff are not pressured to rush or cut corners.

    "The migration of procedures out of the inpatient arena and into the outpatient arena has helped ASCs grow their caseloads," Segal says. "But as ASCs get busier, they may not account for the increased pressure on a reprocessing department to turn over devices and instrument trays. Without the necessary resources to perform reprocessing appropriately, staff may feel forced to take shortcuts. I still see facilities using immediate-use steam sterilization because of a lack of adequate supplies."


  4. Allocate funding and time for education and training. Reprocessing technicians need training and education in order to understand and follow the steps for appropriate care of medical devices and supplies, Segal says. "Every ASC should allocate funding and time to train more than one staff member as cross coverage is vital."


  5. Call on your sales representatives. Do not hesitate to request that your sales representatives provide inservice training on how to reprocess their companies' devices. "It is extremely important for the sales rep to provide education for your staff," Segal says. "This is an opportunity to learn directly from someone who should be an expert on the device and give staff the chance to ask their questions and get answers."