What should be in our P&P Manuals?

[HRJohn]

My policy and procedure manual is a mess.

It's got procedures piecemealed together by many managers over the years including a lot of duplicate material, and its missing stuff that should probably be in there..

I want to completely overhaul this manual from scratch.

Does anyone have a good list of contents for what should be in an SPD P&P manual?

I have a couple of suggestions and references from our California Health Code books, but they are not as specific as I would like to see.

Has anyone else gone through this process? What did you decide to include in your manual, and did you find any regulatory specifications for it?.

Thanks for any and all suggestions

[ladyj]

I have revised my P/P manual it is now very streamlined. I only have covered specifics for the department, they are very concise & straight forward.
Many of the old policies were covered elsewhere in other department manuals,( hospital, Infection control, Safety Security etc.
If staff are referencing something department specific(Autoclave, Sterrad testing for department, monitor logs[ eye wash station) etc.they need to be able to read quickly, retrieve & process the information.
I probably have no more than 10 in my book.
hope this helps.

[HRJohn]

Wow, only 10 procedures?

That would be my dream to get that streamlined! :)

Following is the recommendation from the JCAHO Accreditation Manual for Hospitals from a few years ago. They recommend that a department have p&ps relating to the following "nine elements"

-The receiving, decontaminating, cleaning, preparing and disinfection or sterilizing of reusable items

-The assembly, wrapping, storage, distribution, and quality control of sterile equipment and medical supplies

-The use of sterilization monitors, including temperature and pressure recordings, and use of, and frequency of appropriate chemical indicator or bacteriological spore tests for all sterilizers

-Processes designed to provide for the continued sterility of hospital sterilized and commercially prepared items through appropriate packaging storage and other methods to provide for package integrity

The designation of time related or event related shelf life for hospital sterilized medical items

-The designation of time related or event related shelf life for commercially prepared items that do not have a specified expiration date and are labeled by the manufacturer as being sterile

-A process that provides fr recall and disposal or reprocessing of outdated sterile supplies if a time related designation is used.

-Emergency collection and disposition of supplies when special warnings have been issued by the manufacturer or appropriate government agencies, or when warranted by the hospital's quality or assurance process

- A process that provides for the timely notification of the attending physician and members of the hospital's risk management program of any emergency collection of supplies

[HRJohn]

Lady J,

Could I ask you, (if you have the available time), to list the titles of the 10 or so procedures that you decided to include in your manual?

I have some more material for what our California Dept of Health Services wants to see in the form of procedures, and I will post that when I have a little more time.

Thanks!

[HRJohn]

Here's what someone from a neighboring facility sent me as an example of what is in their p&p book table of contents.

I don't know if this is what I will shoot for, but it did seem helpful to know what another facility selected after going through this same process:

POLICY AND PROCEDURE TABLE OF CONTENTS


STRUCTURE STANDARDS


• Scope of Service

• Statement of Responsibility

• Staffing in SPD

• Staffing Call Policy





PROCESS STANDARDS

• ARS Steam Sterilizer

• ARS Steam Autoclave Loading

• ATI Sterilizer Record Card Sterilizer Record

• Autoclaving Record Chart

• Autoclave Malfunction and Power Failure

• Biological Monitoring System

• Biological Attest Monitoring (Steam)

• Biological Positive Test Results - Recall of Sterile Supplies

• Bowie Dick

• Cart Washer

• Case Cart

• Cleaning - Ultrasonic


• Decontamination of Contaminated Instruments

• Decontamination of Reusable Items

• Endoscopes - Rigid, Cleaning and Sterilization

• Equipment Decontamination of SPD

• ETO Courier Service

• ETO Contract Service Provider

• Flexible Fiberoptic Cleaning Procedures

• Heat Sealer Operating Instructions

• Instruments Brought from Physicians Office

• Instruments - Preparation of

• Isolation Articles- Handling of

• Operation of Sterrad Sterilizer

• Packaging Systems for Sterilization - Selection and Use of

• Power Equipment - Cleaning, Maintenance and Sterilization

• Preparation of Items for ETO Off Campus

• Resterilization and/or Reuse of Presterilized Disposable Medical Devices

• Sanitation of SPD

• Sanitation of Decontamination

• Sterile Supply Rotation

• Sterilization - Peracetic Acid

• Sterilization - Steam


Storage Area SPD

[HRJohn]

Here's another SPD P&P Table of Contents from another facility:

TABLE OF CONTENTS
SECTION 100 - GENERAL
Procedure #
Department Cleaning
101
Space Allocation and Work Flow
102
Dress Code
103
Safety Procedures and Protective Equipment
104
Material Safety Data Sheets
105
Preventive Maintenance of Equipment
106
Use of Loaner Instruments and Implants (24 hour rule)
107
Checking in instruments for processing 108
SECTION 200 - INFECTION CONTROL
Infection Control Goals
201
Hand Washing
202
Role of Infection Control in Supply Processing
203
SECTION 300 - EQUIPMENT OPERATIONS
Equipment Operations
301
Cleaning the Sterilizers
302
SECTION 400 - DECONTAMINATION
Receiving Contaminated Instruments and Equipment
401
Mixing Solutions for Decontamination
402
Cleaning and Disinfection
403
Inspection of Items
404
SECTION 500 - SPECIAL PROCESSING
Cleaning Flexible Fiberoptic Endoscopes
501
Leak Testing Flexible Endoscopes
502
Sterilization or Disinfection of Flexible Fiberoptic Scopes
503
SECTION 600 - ASSEMBLY AND PACKAGING
Assembly of Trays and Instrument Sets
601
Wrapping Methods
602
Sterile Packaging and Wrapping Procedures
603
Non Sterile Packaging
604
Shelf Life for Sterilized Items
605
SECTION 700 - STERILIZATION
Sterilization Algorhythm 700
Steam Sterilization
701
O.R. Sterilization (Flash)
702
O.R. Sterilization Log 703
STERRAD Sterilization
704
STERIS Sterilization
705
Ethylene Oxide Sterilization 706
Use of Gluteraldehyde
707
Reprocessing of Single Use Patient Items 708
Loading & Unloading the Sterilizer 709
SECTION 800 - MONITORING & RECORDS KEEPING
Monitoring of Sterilization and Processing
801
Biological Monitoring of Steam Sterilizers
80 2
Biological Monitoring of the STERRAD Sterilizer
80 3
Biological Monitoring of the Ethylene Oxide Sterilizer 804
Biological Monitoring of the STERIS Sterilizer
805
The Bowie-Dick Test 806
Chemical & Load Test Monitoring of Sterilization
80 7
Testing Gluteraldehyde Solutions
80 8
Glutaraldehyde Vapor Monitoring 809
Response to Sterilizer Failure 810
Reporting Requirements for Clinics
811
Recall of Hospital Sterilized Items 812
SECTION 900- SUPPLY STORAGE & HANDLING
Storage and Handling 901
Stock Rotation 902

[HRJohn]

OK- Here is my first draft for a 'table of contents' for my P&P manual.

Does anyone see anything else I should include?



Structure Standards

Scope of Care/Services
Statement of Responsibility
Staffing-Central Sterile Processing Dept.
Disaster Call Lists
Organizational Chart


Process Standards

Cleaning of the Central Sterile Processing Dept.
Cleaning of Sterilizers

Transportation/Separation of Sterile, Clean, Soiled Items to/from SPD
Handling and Cleaning of Durable Medical Equipment
Decontamination and Cleaning of Surgical Instruments and Equipment
Operation of Automated Processing Equipment

Handling and Maintenance of Clean Instruments
Packaging Systems for Sterilization
Loading a Sterilizer

Sterilization: Steam
Sterilization: Peracetic Acid
Sterilization: Ethylene Oxide Contracted Service
Sterilization : Sterrad (Hydrogen Peroxide Plasma)
Biological Monitoring of Sterrad Sterilizer


Sterilizer Daily Air Removal Test
Biological and Chemical Monitoring of Sterilizers
Positive Spore Growth/ Recall Protocol

Reprocessing of Flexible Endoscopes
Reprocessing of Disposable Products
Sterile Supply Storage/ Shelf-life