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3 Strategies to Standardize High-Level Disinfection

Publish Date: March 25, 2020

High-level disinfection (HLD) remains a serious safety challenge in perioperative care. The Joint Commission surveyors have reported finding a number of high-risk deficiencies in HLD practices across hospital settings.

Determined to standardize variable HLD practices at Beth Israel Deaconess Medical Center in Boston, a multidisciplinary team began a journey in 2018 to assess the current state of HLD. They conducted audits, gap analyses, and failure mode effects analyses along with real-time education to understand their current state and to identify improvement plans, according to team leaders Ross Simon, BA, senior quality engineer, and Nancy Doraiswami, RN, BSN, CGRN, CRCST, CFER, director of Central Processing.

High reliability principles such as a focus on persistent mindfulness, proactively correcting failures, and working with the staff doing the work as well as the managers leading the work drove the team’s approach. “Change is only possible when you collaborate with your people doing the work, such as those disinfecting scopes to give them the support to speak up,” Doraiswami stresses.

Their dedicated approach with front line team members resulted in a successful Joint Commission survey in 2019, including compliments from the survey team on their HLD practitioners. Here are three key strategies they applied and are still using to maintain standardized HLD practices.

  1. Start with a Detailed Plan
    In 2018 a team of 24 people representing most HLD practice areas, as well as clinical engineering, health & safety and infection control were organized for the improvement project and a charter was established to outline these specific goals for HLD process improvement. 

    1. Create and standardize workflows based on IFUs for HLD at each site.
    2. Ensure and establish compliance with PPE standards and confirm by auditing.
    3. Ensure and establish compliance with logs for use of equipment on patients, and for inventory/repair and confirm by auditing.
    4. To the extent feasible, harmonize logs across the institution and consider electronic workflow.
    5. Develop a plan and timetable for the certification of all staff performing HLD.
    6. Ensure that instrument storage containers and cabinets are compliant.

    “We took a very structured approach with a large team representing many different perspectives,” Simon says. “This allowed us to evaluate every step of the HLD process in all practice settings to be sure we were in compliance with The Joint Commission and the AAMI ST58 “Chemical sterilization and high-level disinfection in healthcare facilities standards.”

  2. Complete Comprehensive Audits 
    A team of auditors including Simon, and representatives from clinical engineering, health & safety and infection control conducted an audit and completed a gap analysis for 17 different areas in the health system where HLD is used. 

    “We asked the people who reprocess equipment to describe their roles and processes for HLD to understand variance from standard practice and took many pictures to document the current situation,” Simon explains. “We also spoke in the moment and didn’t hold back when we witnessed opportunities for improvement.” 

    Learning the results of these audits and observations often surprised the leaders as they did not expect to see these lapses in HLD practices, Doraiswami acknowledges. “In many areas we learned that HLD training varied between practitioners and incorrect practices were introduced and then passed down to other trainees.”

  3. Standardize and Share Correct Practices
    Understanding where practices needed to be improved, the team developed a shared database to help standardize products, best practices, and data collection logs. They also identified chemical and equipment inventory, and developed standards for PPE. 

    Additional training and staff competencies were developed and implemented to make sure all staff members understood the rationale behind safe practices. “During our Joint Commission survey, it was so rewarding to observe a technician explaining to the surveyor details such as the specific level and temperature of the water for cleaning a scope,” Doraiswami shares. “This is what surveyors are looking for and it’s this level of understanding and actions taken by the front line that strengthen a standardized approach.” 

    The team is now in their third phase of work with a new set of goals. Simon notes, “Workplace safety is linked to patient safety. Ensuring that our HLD processes are safe for patients and those who reprocess equipment addresses Beth Israel/Lahey Health’s goal to strengthen our quality and safety foundation.”

Free Resources for Members

Guideline Essentials: Standardize high-level disinfection in your OR with access to implementation tools and much more.

  • Gap Analysis Tools: Tools to assess areas in which your facility may not be compliant with the guidelines.
  • Policy & Procedure Templates: Ready-to-use customizable templates for developing your facility’s policies and procedures.
  • Competency Verification Tools: Ready-to-use customizable templates for verifying competency to meet facility requirements.


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