Standardizing High-level Disinfection in the Outpatient Setting

Session Description: Over the past 2 years, our infection prevention team has reviewed instructions for use (IFU), regulatory standards and guidelines to construct, adapt, and implement new standardized resources across 28 clinics to achieve sustainable and reliable education and skills training for staff who perform high-level disinfection. Using the Lean Six-Sigma improvement structure, our team outlines the root causes of high-level disinfection non-compliance. Throughout this work, we aimed to achieve sustainability by creating a process that would maintain the same process outcome and align with Infection Prevention best practice recommendations and standards. Through analysis of the data collected (including feedback from frontline staff), a semi-critical device inventory review, breakdown of manufacturer instructions, and examination of current tools and resources available within our hospital system; we created customizable reprocessing resource guides and a universal skills competency tool. After identifying gaps in educational resources and competency construction our team was able to decrease the risk of non-compliance, in reprocessing, and increase staff's ability to speak and demonstrate compliant workflows with the confidence of aligning to the IFUs and regulatory standards. These resources provide clear, concise guidelines that are easily adaptable whenever a new device is implemented in the outpatient setting or when a device’s instructions for use are updated. Following a successful implementation, the outcomes showed a reduced number of regulatory non-compliance findings during our recent tri-annual accreditation survey. By standardizing the skill’s competency tool and resource guides, with the capability to customize to the individual clinic environment, for high-level disinfecting semi-critical scopes and probes in the ambulatory setting we can ensure that staff are educated to the appropriate reprocessing methods in alignment with complex IFUs. Meeting our goal of decreasing the transmission of infections and creating a safe environment for staff and patients that are cared for in our health system.