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most compelling story of why this team should be assembled. Your Quality or Infection Control team may be able to pull information to paint a picture showing broken processes or gaps that could be easily prevented. At a minimum, this team should collaborate on a monthly basis and discuss issues openly in a safe environ- ment. Each of the four teams should con- sist of at least one leader or staff member who is able to make knowledgeable deci- sions and communicate effectively. Issues, reoccurring problems and procedures with gaps or opportunities should be identi- fied and written down to create a priority list. As a rule, the team should focus on one issue or project at a time and errors identified from a single person should be addressed by that staff member’s direct supervisor. One way to identify gaps within periop, whether in the Operating Room or Sterile Processing department, is to perform audits that identify compliance issues related to a facility’s policies, pro- cedures and agency standards and regu- lations. Once you have a narrowed down priority list, identify which issue impacts patient safety directly and begin there. One thing to keep in mind; your priority list may seem long at first, but if you focus the team’s attention to resolving one issue at a time you may find that other issues start to resolve themselves as a result.
Staff compliance
Focus on the processes and returning staff to a compliant state. It is reasonable to be concerned about whether staff will find a process easy to achieve or if staff will like a new process, but this group should ensure decisions are made based on best practices, compliance, and prac- ticality. As the issue is discussed, bring awareness of what can be done to correct the issue immediately but ensure that all the gaps are filled in, so the issue does not return. For example, let us say that the Operating Room staff are not per- forming point-of-use treatment before transporting to the decontamination area. Specifically, staff are not spraying enzymatic detergent; a few questions that should arise are: • Is the Operating Room supplied with the enzymatic spray?
• Who is responsible for restocking the supply when it is out?
• Who is responsible for treating the instru- ments during and after the procedure?
• Does your facility have a policy, proce- dure or guideline describing the care and handling of instruments at point of use? Is it easy to understand or has it been recently updated?
• Has Education addressed this issue? • Is treatment skipped in certain services or rooms? Is there a pattern to this issue?
• If education has already occurred, is this an accountability issue or a process issue? Having these kinds of questions answered together with the four teams present can bring awareness of the true reason staff may be uncompliant, if it is found to be an accountability issue the correct leader will be present to make corrections. I would like to add that most often I have found staff to be unaware of their facility’s policies and procedures or the regulations concerning the issue, or they may have known of the policy, but roles were not clearly stated. Your Quality team can be the team who investigates the details of how and when errors occurred and deliver results back to the team so everyone can then bring ideas to the table. Once there is a clear action plan for correction, the Education team can begin to prepare the delivery of information or in-service.
It can be easy to get carried away by the presumptions that staff should be knowl- edgeable about the roles and responsibili- ties in their own job descriptions and the fact is that we all should hold ourselves accountable for our individual learning and progress in our careers. With that, there are always gaps, educational needs and updates in the healthcare arena. A single person or team alone cannot keep up with the ever-evolving changes in our industry, so as this heroic team of profes- sionals dive deep into evaluating their departments, keep a few things in mind. Keep ideas simple to understand and
plan out how all staff and stakeholders will receive the information. A simple blanket statement or email from an Educator or Manager may work for a few staff but should never be considered absolute. Edu- cators, fill in gaps and deliver information in a well-rounded and well thought out manner with the help of the Quality and Leadership teams. Sterile Processing and Operating Room leaders, be explicit about the actions you want staff to take, the out- come, goals and the expectations of what will happen if the expressed actions are
SELF-STUDY SERIES
not followed. In other words, level set the playing field for all and be sure everyone is aware of the roles and responsibilities each one of them have.
Education and training Educators should present ideas in a man- ner that will capture the audience. Every- one learns differently, and some even require visual aids to capture concepts. The Sterile Processing Team leaders and Operating Room leaders should be pres- ent when these concepts, in-services and information are being presented. Nothing says, “this is important to me,” more than a leader being present and voicing their concern on the topic.
Going back to the example where point- of-use treatment is not being performed, let us provide an example that shows how a program can be developed. We have already supplied the questions to investigate what can be impeding staff from spraying and wiping down instru- mentation at the end of the case. I will propose that in this case, the facility has a policy that suggests the “scrub person” is responsible for point-of-use treatment. As the Quality and Education team start to investigate, it is noted that some staff understand that the scrub technician, not the scrub person, is responsible for spraying the instruments at the end of the surgical procedure. When asked what the process is when a scrub/surgical techni- cian is not present in the case, and no one is able to identify who should be responsible, someone may suggest the PCT helping in these situations. It is observed that although there is a policy in place there needs to be education to describe the roles within it because we can all interpret poli- cies in unique ways.
When putting together an in-service or training, plan around how the staff learn and how their processes actually work. Review processes to see if they are in fact achievable or easy to produce and try to eliminate obstacles that can impede staff from being compliant. For example, if the enzymatic solution is found only in certain areas of periop, why not suggest having them closer to surgical suites so staff do not have to waste time retrieving it? Some hospitals may not have sterile water listed on preference cards. How can staff stay compliant in flushing cannulated instru- ments during cases if the proper tools are not being supplied to them? It is more com- mon to see that processes are broken rather than staff wanting to stay uncompliant.
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Self-Study Test Answers: 1.B 2. A 3. A 4. A 5.B 6. B 7. A 8. B 9. A 10. B
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