Abstract

ISSUE: After a serious breakdown in sterile procedure, leadership targeted ensuring uniform education and training of a culturally diverse central sterile/sterile processing (CS/SP) staff. Some staff members spoke English as a second language, some were transfers from nonclinical areas, and some had been “grandfathered” into their positions. The competency of these employees required monitoring, assessment, and improvement. PROJECT: System quality management (QM) prioritized an initiative to develop uniform sterilization policies and procedures and to create a basic education program that established a minimum standard of competency. The workgroup included QM, infection control, materials management, and CS/SP staff from all of the system's hospitals. Although registration/certification is ideal to determine standard of competency, it is not always practical. Based on national, local, and system standards, a uniform educational program was approved by hospital leadership that includes six educational modules: infection control, decontamination and disinfection, sterile packing and storage, instrumentation, sterilization and quality monitoring. An objective assessment (exam) and a skills checklist are used to evaluate the learner's knowledge of each module and require a passing score of 85%. Managers tailor the program to individual needs such as offering verbal or written testing. Over 75% of system CS/SP staff are currently registered or certified by a nationally recognized organization (IAHCSM/NICHSPDP) or credentialed through the system. RESULTS: The workgroup developed a standardized system policy and procedure manual. Successful completion of the basic education program assures competency of staff involved in the sterilization process. Staff without clinical or advanced education now express pride and confidence in their jobs and are able to transfer within system hospitals with their certificates of completion. LESSONS LEARNED: The varying educational needs of employees must be addressed to ensure competency and patient safety. Many long-standing employees may not have received proper education to perform their jobs. A creative approach to staff education that is sensitive to the educational background and language competencies of staff addresses these issues. A centralized approach to employee education is being developed through the system's center for learning and innovation. The sterilization committee is developing a tool to define and uniformly track sterilization occurrences.

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