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Brandie Weidman 11-13-2012

The Joint Commission (TJC) was founded in 1951 and is the largest standards-setting and accrediting organization in health care. To earn the TJC Gold Seal of Approval, which is necessary for Medicare and Medicaid reimbursement, health care organizations must be evaluated by TJC at least every three years. According to TJC, BMCS did not have a standardized hospital-wide policy for using High Level Disinfectant (HLD), specifically Cidex OPA (ortho-phthalaldehyde). A policy change regarding infection prevention and the use of HLD was mandated by TJC for the hospital to maintain accreditation.

Members:
Manager Manager Manager Manager Manager Manager of of of of of of

Respiratory Therapy the Operating Room Endoscopy Central Sterile the Education Department Quality Control

Goals:

1.Revise the existing policy so it reflected the Cidex OPA manufacturer recommendations as well as TJC mandates. 2. Implement, educate, and ensure compliance in three weeks or less in order to meet TJC deadline to maintain accreditation.

CIDEX OPA Solution is a HLD used in reprocessing heat-sensitive medical devices. CIDEX OPA solution provides rapid high-level disinfection in 12 minutes at room temperature (68 F) for manual processing. CIDEX OPA solution is ready-to-use, requiring no activation and has minimal odor. Studies testing the Bactericidal, Fungicidal, and Tuberculocidal efficacy of Cidex OPA under controls of a diluted product for 5 minutes at 68 degrees Fahrenheit proved to be 100% successful.

All employees who use Cidex OPA Solution were presented with a Cidex OPA in-service from the representative. All employees were checked for competency by the representative in the process of using Cidex OPA Solution. All employees were checked for competency by the representative in accurately completing the Cidex OPA Solution Quality Monitoring Log.

Quality checks completed by the Central Sterile manager Consists of checking the Cidex OPA Solution Quality Monitoring Log for completeness and that test strip bottles are labeled with expiration dates (expires 90 days after opening bottle) To date all departments have achieved a 95% to 100% compliance score!

Affective Commitment to Change Positive Expectations

LeaderMember Exchange

Communication

Normative Commitment to Change

Negative Expectations Continuance Commitment to Change

Employee turn-over is the number one challenge for continued successful compliance of correct use and logging of Cidex OPA solution. The second challenge is time. Technicians are pressed for time, but they must be dedicated to always testing the solution temperature and concentration, always replacing the test strip bottle lid, and always documenting in the quality monitoring log before every use.

On October 19, 2012 TJC returned to BMCS to resurvey the departments involved with infection prevention using HLD with Cidex OPA. They found all departments to be in compliance with the standardization they required. They found competencies for all required employees had been updated, all test strip bottles were closed, expiration dates and lot numbers were written on all required bottles, and the Cidex OPA solution quality monitoring log was being completed accurately. Following TJC re-survey BMCS was able to maintain their hospital accreditation and earn the TJC Gold Seal of Approval!

Portogheses, I., Galletta, M., Battistelli, A., Saiani, L., Penna, M., & Allegrini, E. (2012). Change-related expectations and commitment of change of nurses: The role of leadership and communication. Journal of Nursing Management, 20(5), 582591. The Joint Commission (2012). About the joint commission. Retrieved from http://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx