Feb 7, 2022 | Article

Assessment Readiness: How a Clinical Eye Can Prepare You for Future Assessments

  1. Understand why it’s important to prepare every day for an assessment.
  2. Identify common assessment discoveries.
  3. Learn how a CensiTrac Utilization Assessment can help you prepare for future assessments.

When preparing for an assessment; have you ever asked yourself why we prepare? After all your sterile processing department (SPD) should be “prepared” every single day. Through assessments, action plans, trainings, and changes your department can always be prepared, and not have to worry when they hear surveyors or inspectors are in the building.

Ethics is a set of moral beliefs, principles, and values that guide our choices with the intent of doing what is right. In sterile processing I believe we always strive to do what’s right. We follow the manufacturer’s instructions for use (IFU), we document, and we do our part in providing quality items for successful patient outcomes. However, what about when we aren’t doing what is right because we don’t know that what we are doing is wrong? Afterall, we don’t know what we don’t know. That’s where a clinical assessment led by a clinical educator, who doesn’t work at your facility, will prove to be beneficial.


Survey Finding

Years ago, I started a new position as a manager of an SPD. On day three I’m told we’re due for our survey any day and they have to be here by the end of next month, so make sure your department is compliant. I had to prepare, and I had four SPD areas. I started with the obvious of keeping doors closed (air pressure), attire (no fingernail polish and cloth hats), removing gauze and syringes from clinic trays that were to be sterilized (no sterilization IFU), and many other things I found awry. I hustled and it felt like I turned my departments upside down, and to my knowledge, I was prepared for our survey.

When our surveyors were on site, I spent the day answering questions and providing documents. When the surveyor asked a staff member if he processed a daily biological control and his answer was no, I was speechless. I, along with our surveyor, discovered we had stopped processing a daily biological control. A daily control is sterile processing 101, and of all the hard work I put forth I never thought to question this basic process. We weren’t using the CensiTrac Load Indicators module, and we were doing double work by documenting on paper. I later learned that even though staff weren’t processing a daily biological they were writing in the daily control information because it was on the document they were using. Therefore, when I looked at the documentation it was correct. I didn’t know that the previous manager understood that the new rapid readout biological didn’t require a daily control. The manager had incorrect information and hence put forth the change in the department. This was a result of me, “Not knowing what I didn’t know.” CensiTrac’s Load Indicators module has compliance measures in place, but we weren’t using the module, and had we been we would have been processing a daily biological.

The survey finding led to a year of daily tasks verifying that all PreVac, gravity, and low temperature biologicals were correctly processed and documented. I had to attend weekly and monthly meetings, and all this resulted in 18 hours per month of management time. The overall cost (management wages and benefits) for this finding was over $11,000. This finding was on our hospital record, and I felt like a failure for a finding that should never have happened.


Prevention is the Best Medicine

In medicine, the saying “An ounce of prevention is worth a pound of cure” can hold true and not only save lives, but save money, and pride. I’ve always welcomed a survey or inspection because to my knowledge my department is correctly processing instruments, properly documenting, and doing what is best for our patients. So, if a surveyor or inspector finds something amiss it must be something I didn’t know about or that we should be doing.

We know the challenges of running an SPD, and we also know the joy. I believe the joy, satisfaction, and helping others is why we work in sterile processing. Sure we’re busy, and many departments are overworked, but the fact that we play an integral part in every surgical procedure is totally awesome. We’re behind the scenes making a difference.

With the requirements and demands of sterile processing, leadership is busy, and many are working in the department while still performing their leadership duties. Lack of time, overworking, and being just too busy may result in missing a new standard. Leadership may not be able to keep up on standards and requirements. Add to this that those standards and requirements change regularly and it’s easy to not be compliant. This as we know, may result in a survey or inspection finding, or worse yet, not producing a quality product.

What is one to do and how does leadership get help, with a CensiTrac utilization assessment conducted by a clinical educator? A clinical educator visits many facilities, and not only do they evaluate processes, documentation, and utilization of your CensiTrac, they see the patterns and trends of commonly noncompliant findings. They observe, listen, share, recommend, and assist with bringing your department to be the best it can be. Your assessor is there for you and will work with you through training, improving documentation, augmenting data, and increasing compliance.

Below are common assessment discoveries:

  • Not documenting the cleaning and decontamination process of instrument sets and case carts
  • Not performing a residue wash test in a cart washer
  • Instrument sets without a count sheet (contents information)
  • Not documenting the completion of an IFU required integrity test (insulation testing, inspecting lumens)
  • Incomplete documentation of washer and sterilizer loads
  • Not documenting which instrument sets were used on which patient
  • Not documenting the leak test results for all flexible scopes

Many leaders didn’t know that these discoveries were standards and/or key elements that surveyors assess.

An assessment is your “ounce of prevention,” and sterile processing is all about prevention and being proactive. An assessment is not a TJC survey or VA Inspection. Sure an assessment is a survey similar to what they do but you don’t get cited when something is discovered. With an assessment you’re informed of the discovery, and your clinical educator and clinical trainer provide training, so your compliance improves and you’re ready for your inspection or survey.


Always Prepared

There’s a nationwide shortage of SPD staff with no easy fix in the near future. When it comes to staffing and getting sets processed a common comment is “we can’t keep up.” An assessment can assist with improving processes and workflows, while identifying process gaps. For example, if you’re documenting on paper and in your tracking system, you’re doing double work. Electronic documentation is the preferred method of TJC, AAMI, and other organizations. Electronic documentation provides real-time documentation with the click of a button or scanning a barcode, this is obviously much faster than writing on paper.

Complete electronic documentation may require experiencing a learning curve, but the payoff is compliance and efficiency. There will be more time to process sets and complete tasks. Add to this being paperless and imagine how many trees are saved. When staff aren’t overworked their risk of burnout decreases and this results in better staffing. It’s a win, win for everyone.

There’s no better time than the present to be compliant and efficient. An assessment is for you and the goal of the assessment is to optimize your CensiTrac usage, so you are always prepared when you hear that surveyors or inspectors are in the building.

For more information on CensiTrac and/or clinical assessments please contact your client manager, call us at 888-877-3010, or visit us at


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