A large U.S. health system underwent preparation for a major accreditation survey. A consulting firm identified deficiencies in the handling of reusable instruments. Examples included the poor condition of instrument tape, inadvertent reprocessing of single-use instruments, and packaging errors, such as closed hinges and missing sterile indicators. Subject matter experts in sterile processing, infection control and prevention, nursing, and process improvement collaborated to create the Best Practice Tools. Clinical leaders engaged all unit managers to conduct a ‘sweep’ of their clinical areas to identify and correct deficiencies and then educated those at the point of use to prevent future deficiencies.
Tool: Peel Pack Sweeps Workflow
Problem:1) Describe the exact nature of ‘right’ and ‘wrong’ elements when evaluating a peel pack. 2) Enable managers and teams to conduct peel-pack sweeps and to correct deficiencies.3) Enable bedside caregivers to inspect a peel-packed instrument just prior to use and enable stopping the line when necessary
Tool Selection: The multidisciplinary team developed a tool to educate caregivers about best practices and to empower each caregiver to take action when a deficiency is identified. The ‘sweep’ tool is a novel step-by-step guide developed by subject matter experts. The workflow allows participation by non-clinical caregivers for an ‘all-hands-on-deck’ approach
Usage: To determine feasibility, the tool was piloted in four offices or inpatient units. After the content was finalized, subject matter experts collaborated with clinical leaders to define a strategy for implementation. Managers and teams conducted peel pack sweep over a 4-week period with in-person and remote support by subject matter experts
Results: With over 500 clinical units (inpatient, procedural, and outpatient), it was not feasible for subject matter experts to round in all locations. Empowering local teams to identify deficiencies and implement corrections fostered local ownership and enhanced sustainability. There were no significant findings related to peel packs at the time of the survey.
