Understanding Joint Commission 360 Standards: What They Mean for SPD Teams (Part 1)

Welcome to Consensus, a podcast from Census Technologies. What's going on, y'all? It's Daniel Littwin, the voice of b two b, and welcome to another episode of the Consensus Podcast, a census podcast. Thanks for joining us. Always good to be in the hot seat here with the census team as we continue to explore major trends, technologies, timely news, and the most important actionable insights and strategies from the world of sterile processing. So today, we've got a jam packed conversation here for SPD teams. We're gonna be breaking down the Joint Commission three sixty standards. Major change to, SPD team standards, and we've got the best experts here, from the census team and beyond to pull from both folks who, you know, look over these standards and understand their complexities in and out, but also folks who are living this day in and day out already and can speak to their experience boots on the ground. So before we dig into today's episode, make sure that you are heading to our website, census dot com. Again, census dot com for more information on our previous episodes, our solutions and services, and again, to subscribe to Consensus. You can also subscribe to the Consensus Podcast on Apple Podcasts and Spotify. So just make sure you're hitting that subscribe button. You'll get all our previous convos. Alright, folks. Let's just jump right into it. A lot of meat to cover with today's episode. So again, today's episode is focused on a topic that's top of mind for a lot of sterile processing and perioperative leaders right now, and that would be Joint Commission three sixty. What's new in this approach? Right? And what this new approach to accreditation really means in practice. But rather than just talking through these standards on paper and kinda going over them bullet by bullet, we're really going to dive into how this shifts impacts in day to day operations and survey readiness and how SPD teams can prepare without adding unnecessary stress. There's all know, already a lot of stress in, the sterile processing department. We don't need more. Right? So let's break these down with our two guests for today. I'm pleased to welcome first up Sabrina Ford. She is the Nevada market manager of Central Sterilization at CommonSpirit. And Sabrina is bringing deep hands on experience leading SPD teams through audits, through compliance expectations, real world operational challenges, all of the above. Sabrina, I'm very much looking forward to having you on the podcast today going over these new joint commission standards. How are you doing today? Oh, wonderful. Thank you. Thank you so much for having me. I am so excited about being a part of this. So, I'm looking forward to our conversation. Yes, as am I. So, thank you for being here and I'm also pleased to welcome Doctor. Ivan Salgo. He's CMO, chief medical officer, and vice president at Census and ASP. Doctor. Salgo has spent significant time digging into the intent, right? The why behind Joint Commission three sixty and how these standards tie directly into patient safety, into clinical outcomes, into system wide accountability and improvements to SPD operations. So Doctor. Salgo, welcome to the podcast as well. Looking forward to pulling from your expertise here on Joint Commission three sixty updates. How are you doing today? Doctor. I'm super excited to be here. I worked for almost a decade as a cardiac anesthesiologist at the University of Pennsylvania Health System. So I've worked in the OR side and I've worked at many medical device companies with the FDA on quality systems and on lean principles. So when Sabrina and I got together and as we were going through this material, it just kept getting more and more exciting because you could see how lean principles and Accreditation three sixty really come together. It's all about the right mindset. So I'm really, really thrilled to be here today and to be doing this podcast with you and with Sabrina. Well, without further ado then, let's get into Joint Commission three sixty here. I'd love to hear from both of you to start. Can you just give our audience the high level refresher? What is Joint Commission three sixty, and why are we talking about standards updates? You know, set us off here with the news. Well, I would like to honestly say, Joint Commission three sixty, it's it's basically updates on how SPD is reinforcing what Amy's ST-seventy nine already requires us to do on a daily basis, right? So, for example, Joint Commission is focusing on environmental controls, aligning directly with Amy ST79, HVAC requirements, air pressure, temperature and humidity standards. On the floor that means we're not just checking gauges, we're documenting parameters, trending data, and escalating when we're out of range. So the emphasis on documentation and traceability connects to the ST79. So it addresses quality management systems that show up in complete sterilization records, accurate load documentation, biological monitoring, and the ability to trace trays from decon to your patient without any gaps. So when we talk about IFU adherence, you know, inspecting practices, that ties back to ST79, which is part of the Joint Commission three sixty, your cleaning verification inspection under ten, the ten times magnification and following manufacturer's instructions. So those aren't best practices. They're patient safety control. So leadership engagement is key in the Joint Commission three sixty. It highlights the reinforcement of ST-seventy nine outlining our management responsibility for training, competency, and process oversight. So for me, Joint Commission isn't something, you know, separate. If your department is truly aligned with Amy ST79, Joint Commission readiness becomes a reflection, operational discipline, not a last minute survey response. So on the SPD floor, looks like consistency, documentation, integrity, valid competencies, and a culture that understands the direct link between sterile processing and patient safety. So that's a highlight of Joint Commission three sixty. Yeah, let me use that thread of Amy to keep going and then even bring us to the picture of Amy and Lean. So also ST58 in terms of emissions and environmental, all these things come together, But probably the story of alignment from Amy to this comes from a conference I attended that was sponsored by Amy called the Kilmer Conference. And we had many, many medical device companies get together actually last year to talk about microbiological safety and standards from a medical device company. What we all talked about is for FDA, is what all the medical devices report to, it's very much about driving very tight quality controls and being predictable. And we kind of commented to each other, and I think I can say this, having worked both in a medical device company as well as a big hospital, that there's a difference. And the difference definitely is variability. The FDA has inspections. They have very tight quality controls. If things are out of kilter, FDA will come in and actually take a look at what's going on. But I know from experience, depending on which hospital you're at, you can have wide variability. We all commented to each other, wow, this variability is something that needs to be addressed. And so when I look at Accreditation three sixty and I think about lean principles, I think about two fundamental aspects. One is how do we reduce variability so that we take the same best practices and we do them over and over as part of our daily work. And the second thing is of course the term batching, But I don't mean batching simply of instruments, but batching in terms of audits. I believe that in lean principles, really what Accreditation three sixty is driving, my opinion, is that it wants continuous data driven continuous improvement. So rather than getting ready every so many years for your audit, it's exactly what Sabrina said, which is, Hey, they can come next week. It's okay. We're doing exactly what we're supposed to be doing every day. And we're using the data to support that we're doing it and we're empowering all our SPD staff so that they can elevate and improve processes continuously. And that's why I had so much fun talking to Sabrina about it because she already is really, has a lot of examples of how she's already doing this every day. So I would say that it's actually about doing what's great and just doing it all the time. All the time. Yes. Consistency. So here, let's start to break down then more clearly what is actually changing, right? And kind of break down Joint Commission three sixty in plain language. So this would include things like continuous performance versus episodic audits, right? Doing the right thing all the time. The shifts in risk based evaluation, in more data transparency, less tolerance for the undocumented stuff, the informal stuff. So let's let's break this down more clearly for our audience. Sabrina, I'll I'll start with you again. How does like, what what are some of the specifics that are starting to be felt in practice, right, that teams need to start aligning themselves day to day on? Just more generally, how are you feeling this shift changed the way SPD teams are being evaluated or even engaged during surveys? It's a great question. So I think as far as the question related to the shift, what's really shifting is that SPD can no longer prepare for a moment. We have to demonstrate performance over time. So that's the consistency of what we're doing in the department. So under the traditional episodic model, survey readiness often meant making sure policies were in place and pulling a few charts that show compliance, right? But the Joint Commission three sixty approach moves us towards sustaining measurable performance. So surveys now want to see trending data, corrective action follow-up, and leadership involvement, not just documentation. So for sterile processing, that means daily monitoring aligned with our standards, especially around sterilization process, monitoring, cleaning verification, and again, environmental control. It's almost, it almost means we must demonstrate an active, quality management system, Not just audit, you know, that audits exist, but that we trend them, right? So we're reviewing them and improving them. So the biggest cultural shift is accountability and transparency. So there's much less tolerance for informal processes or, you know, what we used to say, we've always done it like this, right? Everything must be standardized and documented and supported by data. So for a leadership perspective, you know, it evaluates SPD's visibility. We're no longer behind the scene department, partnering tray, preparing trays. We're critical. And this is what, you know, I was speaking with the doctor about is that, you know, we're a critical safety partner whose performance and metrics directly impact the surgical outcome. Ultimately the shift strengthens patient safety, continuous compliance, that it builds confidence. We talked about that as well, not just for surveyors, but for our surgeons. They know that their patients are being safe. Infection prevention because it starts with us and our executive leadership. I think the key word that I picked up on, which is great, I'm going to run with is informal. I think some of the changes now to get more specific to your question are the numbers of regulation are going down from fifteen fifty one to seven seventy four, but that doesn't mean that there's less to do. It's actually a mindset change. I love how Sabrina talked about, Oh, it's not about the informal processes. And that's exactly right. The key part of Accreditation three sixty is to really elevate process orientation, that you're deliberately thinking not about just bullet points and this is what we have to do, but the whole why of what you do and the process that underpins it. Because it's the process and continuous improvement process that keeps it alive. When an IFU changes, it's not because, Oh, well, we always did it that way. It's like, Oh no, I actually have a system to keep up with the IFU. I know when there's an IFU change. I know when there's actually something important that I need to document or to pay attention to. It's part of what we do as a living process. I think that's key. I think not only are we elevating our processes so that we're always working with the current IFUs and the current best practices and partnering with our other functions like infection prevention, but we're using data. That's where the instrument tracking system becomes so important that we can actually document what we do. We document education. We can document actually auditing. And actually, I'm going to tee it up here, but Sabrina was talking about some of the things that she does, which I thought was very cool about how she helps keep that process orientation and that up to date mindset. And Sabrina, you were telling me about some things too, but I'll pause there so you can feel the mindset change. Smaller number of regulations, more data driven, more continuous improvement, more living processes so that you're doing the right thing at the right time. And some of the things that we talked about previously when you empowering our staff, right? Just making sure that our staff are empowered with any change that is happening. You know, every single employee that works in an SPD department should feel empowered to be able to speak to the OR, a surveyor that comes within the department because they're living the day to day operations in an SPD department and therefore they are the experts. So they should be able to answer any questions that are being asked of them. And so with the Joint Commission three sixty, you know, we do, and I was speaking about this earlier, we do mock surveys within our department, and what we do is we go to each employee and we ask them questions. And when we ask them questions, we let them know, just breathe, relax, because you're doing this. This is what you do on a daily basis. So you don't have to rush to give an answer. They're not looking for how fast you can answer the question. They're asking for what is it that you do, right? And they want to see documentation which is in line with our daily audits or our weekly audits on what is it that you do. And therefore it gives them that ownership, and it also helps them feel more comfortable, when surveyors do come, you know, through the department? Two things I can think about. So this goes all the way back to the to the Toyota Production Systems. It doesn't matter who you are in the organization. If you see a problem, you're empowered to speak up. So I think it's really critical to know that it doesn't matter who you are or what your role is, you're empowered to speak up. I think that's number one. And then number two, you notice the process part, I was very, very nervous when I had to undergo my first joint commission audit. Was actually sharing that with Sabrina and actually the hospital staff was saying, No, don't worry. We just want you to tell them what you know and what you're already doing because you're already doing it. And I think a good example of a process orientation that I've had to do for government audit is you're not going to know everything, but here's a pearl that I remembered, which is if I don't know the answer, I know that I can go here. I know I can look it up here. Come with me. If you walk with me, I'll show you this is how I can get the information immediately. So if you can demonstrate, for example, to the auditor that no, you don't have three twenty eight pages of an IFU memorized, but you know exactly how to get it. And if there's a defect or a problem, you know exactly how to look it up. That's what I mean by the process orientation, meaning you're actually living the process. You're doing the right thing. I don't know if Sabrina, if that resonates with you, but I always thought Yeah, go ahead. And you're spot on with that because that's part of don't rush to give an answer. You know where to get the answer and you can welcome them to come with you like you pointed out to get that answer. If you have to ask a teammate, if you have to ask your lead, they see that you know how to get the answer. If you need to go into your electronic tracking system to get your IFU, Again, we just had our survey about four months ago, and that was definitely one of the questions was, How do I see the IFU for this instrument? They were able to go in the electronic tracking system and pull up the IFU in the OneSource. So they want to know, How do you do that? Again, ownership. Each employee, you know, that it's your department. And so you know what to do on a daily basis. Those are the things that the surveyors are definitely looking for. So I've lived that. Yes. So let's move on from here now and drill down on what this really means for SPD teams. I want to drill down with you guys on the real impact. So areas like documentation and traceability, workflow consistency now under these new standards, verbal process versus provable process. That's a big one, right? As we shift away from less informal and offline upkeep of information or processes, right? Less tolerance for that now under these new standards. So let's dig in on this front. Doctor. Salgo, I'll start with you this time around. Which SPD practices would you say most directly influence survey outcomes, right? Even if teams don't realize it. And how does that connect now with the new standards environment that we're operating under, under a Joint Commission three sixty. Let me also tune one of the words. I think for me personally, as someone who's worked with Lean and worked with government bodies, it's reproducible. Right? Formal formal almost is an intimidating word. Right? So I'm going to say reproducible. What and were talking about is if it's second nature to you, then it becomes reproducible because that's just what you do every day. So I think that's the key thing and that takes the intimidation factor out of it. I don't have one magic answer. I think maybe Sabrina and I can go back and forth. Honestly, at least from what I've seen in my experience, different surveyors and auditors, they have different things that they might be interested on a particular audit or visit based on hospitals that they visited before. For example, actually understanding IFU. So the specific answer to one of your questions is how well do you understand the IFU? Not only is this important from a joint commission perspective, but HSPA, FDA, APIC, they're all working so that actually the folks who use the IFU can use the IFU in a more, if you will, friendly and usable way because it's acknowledged that these IFUs can be intimidating. So I know, as we said, that's one area. I think maybe I'll tee it up. The other area that I see people talk about also is maintenance, which is, have you forgotten about maintenance in the abyss or what do you do to make sure that your equipment is up to manufacturer's guidelines so that it's appropriately, maintained and checked, proactively? I don't know, Sabrina, I'll let you jump in there. Yeah, that you hit the nail on the head with the preventative maintenance because yes, Joint Commission, they're always looking for those preventative maintenance stickers, and, you can fall out of compliance if your manufacturer didn't put their sticker, on that piece of equipment. Therefore, you know, they request three to six months worth of preventative maintenance on each equipment and they look for, you know, what happened? Just like for us, with our documentation, they're looking for that trend. Are you checking? Are you documenting? And what is your action plan? You know, they're doing the same thing for the preventative maintenance equipment for your vendor. You know, and for us as leadership, we need to know, if they follow through with their part of the process. So again, when we talk about the Joint Commission three sixty and how they are definitely holding leadership more accountable for knowing the actions and the processes on the floor. We don't just get to sit in the office. We need to know what is actually happening on the floor and did we follow through. And you can even say even with the sterilization cleaning, you know, they look at that as well. How often are you, having your sterilizers cleaned? And what does the manufacturer for your sterilizers say? What does the IFU say for related to that? So these are things that are kind of what you would call low hanging fruit that most people don't really focus on. They only focus on the main things that you see daily, which is your sterilization, cleaning verification inconsistencies, you know, those types of things, doing the ATP testing. They're looking at all of those different variables and your environmental monitoring, you know, what does that look like? And that is when you have to partner with facilities, right? So we have to be partners with other departments in order for us to be effective, you know, within our department, so that we don't fall short when it comes to, serve. That makes me think of two things. One is exactly like in the spirit of SD fifty eight, environmental safety, do you have the appropriate air exchanges per hour, for example, to keep your staff safe? There's definitely literature which shows that you really wanna minimize occupational exposure to cleanings, sterilizing agents, because they can be associated with, illness, right? So it's really about keeping your staff safe. I think where I'm going to run with this is the data. So rather than have one size fits all, I think Sabrina and I mentioned two very common things, but I think what they're moving towards is, hey, in your data, if you see an anomaly, and this is a very lean principle, Toyota Production Things principle, Six Sigma. If you see an anomaly like, Oh, in the last two months, all of a sudden these cycle cancellations went through the roof. Did you know that? Was it just one machine? Who were the operators? Did you investigate it? What did you do? And I'm just picking an example, but I think I'm going to tee that up for Sabrina, which is, hey, when they're looking at the data, how do you investigate? How do you improve? And how do you make sure that continuous improvement happens when you notice something? What are your thoughts there, Sabrina? I would like to give you an example. We kind of talked about it when we were talking about, you know, when you're doing tray assembly, right? You're doing tray assembly. We know that with the standards, your tray needs to be twenty five pounds, right? So on a regular day, not just survey, right? On a regular Tuesday, you have your assembler, they're weighing the tray, the tray is now twenty eight pounds, right? So what do you do with that? Back in the day, you would just continue on and say, Oh, it's okay. But in a continuous process, you would need to then show, which is why we do tray audits, and you have the documentation to show that I weighed the tray, it was over the twenty five pounds, I communicated to my leadership and I collaborated with the OR specialty team lead so that we can come together, collaborate on this tray and look for, is there duplicates? What can we do to reduce this weight down to the twenty five pounds? Right? So with that, we have a documentation. And because what we talked about being consistent, this is not during survey. This is actually just a regular day and you have your documentation of what our action was, how we communicated and how we then resolved that issue so that now your tray is within that twenty five pounds. And all of that is documented. So that's what I would say as far as being consistent. How do you prove that it is an ongoing day to day versus just the day that survey is here? So that's a great example. So there's something to kind of your pique your curiosity after this, conferences, the five S's in lean, which are sort, set in order, shine, standardize, sustain, but specifically these things actually help. So by doing them as continuous process, you can reduce the search time. Hey. What's going on, guys? Daniel Littwin, voice of B2B. Quick wardrobe change and here to tell you we're splitting this episode in half. Yeah. That's right. The episode was just too good, too informative, and a little too long for one single episode of the podcast. So we're gonna be splitting our conversation with doctor Ivan Salgo and Sabrina Ford into part one and part two. So that's it for part one. Make sure you're heading to our website, census dot com. Again, c e n s I s dot com for more information on our solutions and services and to tap into previous episodes of the show. And to make sure you don't miss out on part two, subscribe to the consensus podcast on Apple Podcasts and Spotify. We'll see you on part two. I'll be back. Another wardrobe change incoming. I'm Daniel Littman, voice of b two b. We'll see you on this next part two episode of the consensus podcast.