Whether you work for a large healthcare system, a community hospital, or an outpatient ambulatory center, individuals at your organization might struggle to properly disinfect or sterilize medical and surgical equipment or devices that are not single-use disposable. It may seem like a small or isolated problem, but like any Achilles heel, it can result in major failure.

The improper use of this equipment can make any organization vulnerable during survey to Joint Commission standard IC.02.02.01: Reducing the risk of infections associated with medical equipment devices and supplies. To address this Achilles heel, it’s critical to ask four questions:

  1. What are the common culprits that prevent your organization from meeting the standard?
  2. How can your organization prevent findings associated with High-Level Disinfection (HLD) or sterilization?
  3. Who are the primary stakeholders responsible for Infection Prevention and Control at your organization?
  4. What are the associated risk factors?

Let’s dive into these questions to uncover what organizations can do to provide safer, quality patient care.

What are the common culprits preventing us from meeting this standard?

When it comes to medical and surgical equipment or devices, the two most common issues are either incorrectly performing HLD or sterilization or omitting a step in the process. (Unfortunately, another common culprit is not performing HLD or sterilization at all!) Depending on the device, the proper process will be stated in manufacturer instructions for use or as part of nationally recognized evidence-based guidelines.

Not meeting this standard will place your organization in the “red zone” of The Joint Commission (TJC) Criticality Matrix due to the high likelihood to harm a patient with a noted pattern or widespread occurrence within the organization. This also commonly triggers a CMS condition-level deficiency. In the worst-case scenario, TJC may declare an Immediate Threat to Health and Safety (ITL), which is the equivalent of an Immediate Jeopardy (IJ) by CMS.

How can we prevent findings associated with HLD or sterilization?

The good news is, your organization can absolutely prevent findings. A good starting place is a comprehensive, multidisciplinary Infection Prevention and Control risk assessment. This risk assessment is ongoing; whereas a thorough inventory will determine the devices or equipment that require HLD or sterilization, additional areas that perform or need to perform HLD or sterilization are identified during the assessment.

Who is responsible for Infection Prevention and Control?

While most HLD and sterilization findings are scored under IC.02.02.01 EP2, these processes should not be interpreted as the sole responsibility of Infection Prevention and Control. In fact, nearly everyone is an important stakeholder when it comes to your organization’s HLD and sterilization processes:

  • Infection Prevention and Control
  • Central Sterile Processing
  • Perioperative Services
  • Materials Management
  • Plant Operations
  • Endoscopy
  • Radiology
  • Ambulatory and Inpatient Departments
  • Nursing
  • Medical Staff
  • Leadership

What are some of the associated risk factors?

It’s essential to identify and address Infection Prevention and Control risks early and on an ongoing basis in order to minimize findings that arise during survey. Other risk factors that your organization should be on the lookout for include:

  • Ongoing frontline staff competency and training
  • Oversight competency
  • Availability and use of manufacturer instructions
  • Use of evidence-based guidelines
  • The number and location of sites performing HLD or sterilization
  • Infection Prevention and Control involvement
  • Leadership support

Addressing the Achilles heel

If you want to address your organization’s Achilles heel, it’s important to dig into these questions. Understanding TJC standards, knowing how to prevent findings associated with HDL or sterilization, empowering stakeholders to own their responsibility for Infection Prevention and Control, and identifying potential risk factors will ensure your organization is compliant with industry standards. More importantly, early detection and preventative efforts will support a safe patient care environment and workplace.

About Lisa Waldowski, DNP, APRN, CIC

Lisa Waldowski, DNP, APRN, CIC, has worked in healthcare as a pediatric nurse practitioner, supervisor, director, and Infection Preventionist. She has spent over a decade in Infection Prevention and Control, with focus and extensive knowledge in high-level disinfection, sterilization, Infection Prevention and Control Standards, and Infection Control related National Patient Safety Goals with the Standards Interpretation Group at The Joint Commission. She has also directed infection prevention programs with exemplary accreditation survey outcomes. Read more about Lisa.


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