Healthcare Associated Infections

Sterilization of Re-usable Medical Equipment

Sterilizing Services Weighting Identification Tool

As part of a review of the quality of data being provided to NSW Health by Sterilizing Departments, the Sterilizing Services Key Performance Indicators (KPI) Reference Group identified wide variations in the application of weights to activity data across the State.

A comprehensive weighting identification tool has been developed to assist hospital Sterilizing Departments in the applying of weights consistently for NSW Health hospital Sterilizing Departments.

Audit Tools to Support Reprocessing Units

The Preventing and Controlling Healthcare-Associated Infection Standard of the National Safety and Quality Health Service Standards requires that Reprocessing of reusable equipment, instruments and devices is consistent with relevant current national standards, and meets current best practice.

Australian Commission on Safety and Quality in Health Care Advisory A16/03: Reprocessing of reusable medical devices in health service organisations states that,

Where health service organisations apply AS/NZS 4187:2014, health service organisations will need to:
a. complete a gap analysis to determine the current level of compliance with AS/NZS 4187:2014 and document the findings. Access to the standard and relevant references outlined in AS/NZ 4187:2014 are also necessary to ensure that the health service organisation's action plan is comprehensive and addresses gaps within the organisation. Without access to these references the health service organisation cannot adequately assess gaps and can therefore not adequately plan for them.
b. develop and document a detailed implementation plan using quality improvement principles specifying timeframes, milestones and deliverables to enable full implementation of AS/NZS 4187:2014 over a five year period, from December 2016.
c. implement the plan and demonstrate progress toward implementation.

To support any unit undertaking reprocessing of reusable medical devices with meeting the requirements of Advisory A16/03, a suite of tools have been developed. These tools are also available in the CEC’s Quality Auditing Reporting System (QARS) and NSW public facilities are encouraged to use this system for their self-assessments, peer audit reviews and staff interviews.

Resources

Resources to enhance existing Quality Management Systems within reprocessing units for AS/NZS4187:2014 Reprocessing of reusable medical devices in health service organisations can be found on this spreadsheet: XLSX ~1.6MB

These resources include:
1. An infographic of why the Clinical Excellence Commission have developed 3 types of audits for AS/NZS 4187:2014
2. A calculation sheet to score your compliance with the self-assessment and peer review audits
3. A sample Action Plan
4. NSW Health Risk Matrix to assist you in determining the risk level for your Action Plan
5. Sample questions you can use to develop a register of all reprocessing units within a hospital, district or state/territory
6. Sample of a one-page summary that helps you develop an overview of your quality management system (QMS). This can be used for accreditation, describing your program to your manager/quality manager or educating your staff on what is included in the unit's QMS
7. Sample organisational/governance structure
8. FAQs

AS/NZS 4187:2014 Audit for CSD & Endoscopy

AS/NZS 4187:2014 Audit for satellite sites

AS/NZS 4187:2014 Audit for Oral/Dental Health Services