4/10/2013. Quality Systems for Central Service Departments. Welcome! 3M Sterile U Network 3M Sterile U Web Meeting April 18, 2013

Transcription

1 3M Sterile U Network 3M Sterile U Web Meeting April 18, 2013 s for Central Service Departments Today s meeting times are 9:00 a.m., 11:00 a.m., and 1:00 p.m. CST To hear audio, call and enter access code Phone 1 lines are muted. Audio will commence when the webinar begins. 1 Introducing the 3M Learning Connection: New Name, Same Great Courses It s an educational resource bringing you 3M Sterile U and other Infection Prevention courses. You ll soon see some exciting new benefits as our program evolves! Improved features: Add to my Calendar feature added this month! Other 3M courses will be more accessible as we expand our offerings. What do you need to do? Nothing. Your current registrations remain and our Sterile U offerings have not changed. 2 Welcome! Topic: s for Central Service Departments Facilitators: Diane Koch, 3M Dorothy Larson, 3M Speakers: Tom Ersland, Mayo Clinic, MN Housekeeping Questions Mute feature (*7 = unmute; *6 = mute) Chat feature Technical difficulties Post session follow-up For more information: 3 1

2 How do I get a CE Certificate? Next week, all of today s meeting participants will be sent an containing instructions for obtaining a CE Certificate for today s meeting. The will be sent to the address you provided when you logged-in to today s meeting. If there are others listening with you today who did not log-on, you may forward the CE certificate to them. 4 Disclosure Statement Tom Ersland, Mayo Clinic CRCST, Coordinator Rochester, MN Ersland.thomas@mayo.edu 5 Learning Objectives 1) Discuss roles and responsibilities of a Coordinator in the CS Department. 2) Describe steps for implementing projects through the CS Coordinator. 3) List examples of initiatives driven by the CS Coordinator. 6 2

3 Why s? Prior to the Industrial revolution One person/small team of people. Start to finish Mass production Huge teams of people Work on stages of production Henry Ford Recognized varying quality of output Established Departments Emphasized standardization Roles & Responsibilities Effectively implement the department quality system and ensure compliance with institutional, departmental, and external regulatory agencies. Subject matter expert for policies, processes and procedures of the quality system. Chair the Committee, set up the audit schedule, and train auditors. 9 3

4 Elements Outputs Outputs Internal Internal Operations Operations 10 Elements Outputs Internal Operations 11 Components Mission Statement & Policy Description of quality objectives Evidence of employee understanding Audit & Review Internal & external audits that add value Review and follow through of audit findings and results Upper management support 12 4

5 Mission Statement LINEN AND CENTRAL SERVICES Mission Statement As a partner of Mayo s patient care team, the Linen and Central Services expert consistently delivers superior customer service, high-quality reusable linen and patient care equipment 13 QSM Components, Continued Statistics & Measurement What do you measure in your department? Continuous Improvement to analyze, prevent or correct problems to continually improve customer satisfaction. - Issue Tracking Lean 5S Document & Records 14 5S 1. Sort The first step is cleaning work areas and organizing them. 2. Set in Order Organize, identify, and arrange everything in a work area. 3. Shine Regular cleaning and maintenance. 4. Standardize Make it easy to maintain. 5. Sustain maintaining what has been accomplished. 15 5

6 Let s get Lean! "Lean," is a practice that considers the expenditure of resources for any goal other than the creation of value for the end customer to be wasteful, and thus a target for elimination. Lean thinking is the identification and steady elimination of waste (muda). Lean is a problem solving approach for continuous daily improvement. 16 Lean in Sterile Processing: Goals: Identify & Eliminate Waste Transportation, Inventory, Motion, Waiting, Over production, Over production, Defects (rework), Unused talent Reduce / Eliminate Process Variability (Standard Work) Continuous Improvement Drive systematic change sustain the gains 17 5S Where may it apply to Sterile Processing? Sort instruments by type Sort instruments largest to smallest Let those who use it decide 18 6

7 Projects Completed at our Facility Work station move Supply carts moved Better shelving for our code cart supplies Projects Completed at our Facility Work Station Move Eliminated many steps during the course of the day (Lean) No missing documentation in over 7 months (Lean) Projects Completed at our Facility Supply Cart Moved Like the junk drawer at home Items were put away or removed from the area (5S) Cart was cleared and can be used for something else (5S)

8 Projects Completed at our Facility Better Shelving for Code Cart Supplies (Lean and 5S) One of several we purchased Better use of space More adjustable than previous shelving Easier to move the whole shelving unit Elements Outputs Internal Operations 23 Purchasing & Procurement Defined supplier selection system and evidence of purchase order review Receiving Inspection Process for inspecting items from suppliers Order Entry & Customer Requirements to review customer orders prior to acceptance and resolve differences Measuring Equipment Process to calibrate equipment (in-house or outsourced) and standard used (for example: Sterilizers) Calibration Schedules based on usage or accuracy needed 24 8

9 Elements Outputs Internal Operations Internal Operations 25 Internal Operations Customer-Owned Product to identify, segregate, and protect property to record and report damage or lost property Identification & Traceability Procedure to mark or tag items Customer paperwork 26 Internal Operations, Cont. Handling, Storage, Packaging, Preservation & Delivery Procedures to prevent damage by handling Identification of special handling/storage requirements Records to show evidence of product review Training & Qualifications Method to identify training needs, provide training for personnel, and evaluate training effectiveness Training records and Certificates 27 9

10 Elements Outputs Internal Internal Operations Operations 28 Outputs Customer-Specific Requirements Manufacturer Guidelines Process to identify, define & communicate customer-specific quality requirements Documentation Process Control Plans to control & document processes that affect product/service quality Pre-shift inspections in decontamination area. Mechanical Washer verification tools. Sterilization: Biological Indicators, Chemical Integrators, Bowie-Dick Test Records (electronic or hard copy) Preventative Maintenance records Customer Satisfaction Procedure to measure customer satisfaction Customer complaint forms/logs including improvements made 29 Our Policies: One that describes the for our department One that describes the responsibilities of our Internal Auditors

11 Policy Defines roles and responsibilities within the management team Defines roles and responsibilities of the Internal Auditors Internal Auditors are made up of staff from our entire department Auditors never audit their own shift/area 31 Audit Policy Defines the audit process An audit schedule is created for each quarter Staff are allowed time away from their normal duties to audit Staff audit against written policies and procedures All findings are documented and entered into a tracking log Follow up of findings is the responsibility of leadership Internal Auditor Expectations Committee Members Follow the flow of work Objectivity Desire to promote positive change Improvement Ideas Think outside the box Be open minded Support Long term benefits Nothing happens overnight 33 11

12 Audit Findings Rotation of stock Not always happening Temperature recording in pasteurizers New system Document control of forms and procedures Better control 34 Audit Findings Standardization of practices Two CS areas Regular Cleaning Areas Not on scheduled cleaning HLD practices Joint commission survey and our own audit 35 Summary of Key Learnings Define Documentation If it s not recorded, it really didn t happen 5S and Lean Immediate impact quality initiatives Internal auditing Helps a facility stay Joint Commission ready at all times Continuous Improvement - Do Something! Right or wrong, it s usually better than doing nothing 36 12

13 Questions? 37 3M All rights reserved. How do I get a CE Certificate? Next week, all of today s meeting participants will be sent an containing instructions for obtaining a CE Certificate for today s meeting. The will be sent to the address you provided when you logged-in to today s meeting. If there are others listening with you today who did not log-on, you may forward the CE certificate to them. 38 Thank you! Next 3M Sterile U Web Meeting: Date: Thursday, May 16, 2013 Title: Refresher Course: Steam Sterilization Process Monitoring 39 13