OR Manager - January 2018 - 11

Regulations
reprocessed. Previously, they did not
think there was enough data on hang
time.
AORN at that time said 5 days of
hang time was necessary, but that was
for endoscopes used in the OR.
Around 2015, when SGNA went to 7
days, AORN said there wasn't enough
data.
The multisociety guideline also says
there's not enough data.
" Many hospitals will say they follow
SGNA guidelines for scope reprocessing,
and, thus, they lock themselves
into the 7-day hang time, " he says.
" This is an example of, once you pick
a guideline, they expect you to follow it
without exception. "
Survey strategies
Whether a manager or staff member,
when preparing for a survey, remember
to project confidence, caring,
awareness, concern, knowledge,
professionalism, and teamwork, says
Rosing.
Related Content
For more on this topic, see these OR
Manager articles:
* Joint Commission survey standards
tighten for 2017 (December
2016; 1, 6-7, 12)
* DNV accreditation: A positive spin
on survey preparation (March
2017; 16-17)
* CMS immediate jeopardy trail may
lead to the OR (March 2017; 1415,
21)
* Hospital accreditation standards
expand beyond Joint Commission
(July 2015; 1, 13-17)
* Preparation, policy compliance key
to positive survey outcome (February
2016; 1, 7-9)
* Infection control noncompliance
cited in high percentage of Joint
Commission surveys (December
2015; 20-22)
He gives the following advice:
* When interviewed by a surveyor,
make statements, such as:
" This is my hospital and if my
mother, spouse, or child came here,
this is exactly what we would do for
them. "
" I am proud of the work we do here
at Mercy Hospital. "
" I care about this community; this
community needs us, and I want
Mercy Hospital to succeed. "
* If a surveyor interview is going to
take some time, be sure to ask for
a moment to do a handoff to a colleague.
However, he says, be aware
that the surveyor may want to listen
in on the handoff and possibly find
fault with the handoff.
* Be cautious, and remember
the
surveyors are not your friend. " They
are not your enemy, either, " says
Rosing. They are at the hospital to
perform an objective evaluation, but
they are savvy. " If they can project
an impression of friendliness, you
might say more, feel more comfortable,
let your guard down, and possibly
bond with the surveyor against
the best interests of the hospital, "
he says.
* When asked a difficult question,
" don't 'melt' and don't 'throw
someone else under the bus,' "
Rosing cautions. Pause momentarily
and ask them to repeat the
question.
* " If you really don't know the answer
to a particular question, say: 'I don't
recall that detail from the policy, but
I will have that policy pulled and provided
to you in the surveyor work
room so you have that information,' "
Rosing advises.
In the end, the typical nurse or staff
person isn't going to know the intricacies
of every single standard, says
Rosing, but they know their job. They
just need to be able to talk comfortably
about the job they do every day. ✥
-Judith M. Mathias, MA, RN
www.ormanager.com
References
AORN. Guideline for processing flexible
endoscopes. Guidelines for
Perioperative Practice. Denver:
AORN;2016:675-758.
Association for the Advancement of
Medical Instrumentation/American
National Standards Institute. American
National Standard, ANSI/AAMI
ST 58: Chemical sterilization and
high-level disinfection in healthcare
facilities. 2013.
Association for the Advancement of
Medical Instrumentation/American
National Standards Institute. American
National Standard, ANSI/AAMI
ST 79: Comprehensive guide to
steam sterilization and sterility assurance
in healthcare facilities. 2017.
Association for the Advancement of
Medical Instrumentation/American
National Standards Institute.
American National Standard, ANSI/
AAMI ST 91: Flexible and semi-rigid
endoscope processing in healthcare
facilities. 2015.
Joint Commission. Top standards compliance
data announced for 2016.
Joint Commission Perspectives.
2017;37(4):1, 3.
Petersen B T, Chennat J, Cohen J, et
al. Multisociety guideline on reprocessing
flexible GI endoscopes.
Infect Control Hosp Epidemiol.
2011;32:527-537.
Rosing J R. Bulletproof solutions for
finding-free Joint Commission and
CMS surveys. Workshop. OR Manager
Conference 2017.
Rutala W A, Weber D J, CDC Healthcare
Infection Control Practices
Advisory Committee. Guideline for
disinfection and sterilization in
healthcare facilities. 2008.
Society of Gastroenterology Nurses
and Associates. SGNA Standard of
infection prevention in the gastroenterology
setting. 2015.
Society of Gastroenterology Nurses
and Associates. SGNA Standards
of infection prevention in reprocessing
flexible gastrointestinal endoscopes.
2015.
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