Reprocessing Recommendations

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Additional Recommendations,

Education, Training, & Competencies

This page includes summaries that should not be used to create policies and procedures. Please refer to the original source documents for exact language. Links can be found here.

Multisociety, 2016

Endoscope users should be able to clearly identify whether an endoscope has been reprocessed. Competencies of personnel who reprocess endoscopes should be performed at least annually and also when a new technique, new endoscope, or new reprocessing equipment is introduced. Training should include recognition of excessive wear or damage. Temporary personnel should not be allowed to reprocess endoscopes until competency has been established.

HICPAC, 2016

Processors, trainers and managers should all be competent in each step for each endoscope. Perform competencies upon hire, periodically thereafter and whenever there is a new scope, chemical or equipment. Also train in manual processing in the event of equipment failure. Train in sterilization of accessories that breach the mucosal barrier. Reprocessing certification is encouraged, but does not negate the need for ongoing assessments of competency.

AORN, 2016

Establish and document periodic education, training updates and competency verifications.

ANSI/AAMI ST91, 2015

Establish and document periodic education, training updates and competency verifications.

APIC/JCR, 2017

Provide orientation, training and competency programs for staff involved in cleaning, disinfecting and sterilizing equipment and supplies. Develop and implement a system for assessing personnel adherence to protocols and providing the findings to these personnel. Facilities should have current references on their intranet about cleaning, disinfecting and sterilization, including guidelines from AORN, AAMI, CDC and SGNA (included in the Multisociety Guideline of this grid).

CMS, 2016

Hospital should be able to provide evidence that all personnel given responsibility for HLD have documented training and competency in accordance with facility procedure. The facility must provide evidence that adherence to procedures is regularly audited, and that feedback from those audits is provided to personnel.

TJC Booster Pak, 2015

Review, maintain, and conduct ongoing competency and training of front-line staff, and those that have oversight for HLD and Sterilization processes upon hire; on an ongoing frequency, as determined by the department hospital policy, or in accordance with law and regulation; when new devices, supplies, or equipment are purchased; and when there is a change in a staff member’s role.

Guideline Details