inconsistencies in the handling, transport and delivery of flexible
scopes."
The team delved into where in the process there could be potential
breakdowns, assigning a code to each one that reflected the potential
for it to result in patient harm. For example, a scope that wasn't
cleaned correctly would be assigned a different weight than mistakes
in documentation.
Armed with that analysis, the team devised a comprehensive
response plan that touched many departments, including sterile pro-
cessing, clinical engineering, infection control, surgery, endoscopy,
anesthesia and process improvement. Here are the key aspects of the
new process.
• Limited access. The first change the Baystate team implemented
addressed the relatively easy access to scopes, which led to them being
all over the hospital and difficult to track down. "Before, pretty much
anyone could go into sterile processing and obtain a scope simply by
opening the door of the cabinet, and off it went," says Ms. Betti. "If a
scope was sitting on a counter in SPD, they could grab it."
Now, only an SPD supervisor is permitted to access and assign out a
high-level disinfected scope. "This was a big culture change," says Ms.
Betti.
• Consolidated reprocessing. Baystate was reprocessing scopes
across 4 buildings. Now all scope reprocessing is performed in one
specialized, renovated area. There was also a "purposeful" decrease in
the number of staff members deemed competent in reprocessing of
scopes; Ms. Betti says now 4 validated experts dubbed endoscope
reprocessing technicians carry out all aspects of cleaning, testing,
inspection and disinfecting of flexible scopes. "Tightening up the
reprocessing to have it in one area made it easier to maintain consis-
tent practice," says Ms. Betti. "We can really keep an eye on it and
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