Improvement projects
Raising standards in scope reprocessing
In this article, Kevin Owens provides an overview of a project recently undertaken in Beaumont Hospital, Dublin, Ireland. He provides a valuable insight to the processes and end goals taken by the project team at Beaumont in the delivery of a new high-end model for ENT endoscope decontamination, which now provides sterile nasopharyngoscopes for each patient cared for by the hospital.
In 2017, Beaumont Hospital commenced a project which saw the staffing model for those performing decontamination of flexible endoscopes in the main GI Endoscopy move to direct management structures within the Decontamination function. The previous model saw different staff grades (HCAs & nurses) carrying out this vital work, the change moved these duties to a dedicated team of decontamination technicians which improved processes in the department.
As Deputy Manager for Decontamination,
I oversaw this transition and various Quality Improvement initiatives. The improvements were well received internally and in Q2 2018 it was decided by the Beaumont Hospital Senior Management Team that an expansion of this service should be extended to the ENT service. The existing infrastructure in the ENT decontamination room that was inherited by the decontamination management team scored poorly when audited against the HSE
suite of national standards for endoscope decontamination. The Irish national regulatory inspection body
HIQA (Health Information and Quality Authority) arrived at Beaumont Hospital in April 2019 and as part of the overall audit, performed an inspection of the ENT department. While they were impressed with the processes, oversight and governance arrangements of the decontamination service they raised concerns over the physical infrastructure in the department as it was non-compliant with National Standards in some aspects. This had been previously identified internally as an Infection Prevention & Control (IPC) risk and solutions had already been in discussion at the time of audit.
Preparation for change A project group was established by the Hospital COO and I was chosen (with the support of the Decontamination Manager) to lead a group of
key stakeholders from IPC, Procurement, Health & Safety, Technical Services, Clinical Engineering and Decontamination. The group was tasked with finding a solution that could raise the quality of service within the decontamination function in ENT, addressing the notes of concern raised by HIQA, allowing for expansion of services, maintaining productivity in line with service demand, while being as economically advantageous as possible, without negatively affecting quality. Initial stakeholder meetings commenced in
May of 2019, with the Directorate Management Team, Local Nursing Management Team and the project group, to discuss potential options that would be suitable. It was decided the best model achievable to
address the shortfalls within the department would be to move to a dual room pass-through model with an automated high-level disinfection process leading to a sterilised final product. This would ensure the safest possible outcomes for the service users of Beaumont and would provide our patients with the best level of service available in Ireland at that time. The project itself required a national tender
Original ENT decontamination room, before the improvement project. 92
www.clinicalservicesjournal.com I April 2025
to be run for low temperature sterilisers (LTS), as there was currently no existing framework for LTS for endoscope decontamination purposes. Having a representative from procurement on the project team was key to conducting this piece of work. While I was able to complete technical specification sections of the document with input from Clinical Engineering, a member of Procurement was required to ensure compliance with national tendering requirements. Contact was made with the HSE national procurement team to inform them of the hospital’s intention to conduct this tender and it was then utilised for the National framework process allowing others to draw
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