SPM Joint Commission Audit Preparedness

Be prepared for any audit, internal or external, with SPM!In addition to guiding technicians through their reprocessing work, another primary advantage of SPM is the data recorded automatically as technicians document their work. This data becomes indispensable when you need to demonstrate to auditors the processes you follow and your department’s quality during an audit process.

Whether your audit is Joint Commission, internal or from another external source, there are a few main areas that you’re likely to be looking at in your department:

  • What are your quality policies and procedures, and how are they being applied?
  • How is your staff being trained and how can they demonstrate competency?
  • Different topics in the general area of sterility assurance:
    • Are your sterilization and high-level disinfection processes following industry and facility guidelines and product IFUs?
    • Have you documented how these processes are being followed?
    • Can you demonstrate that these procedures were followed by tracing a particular product through the reprocessing cycle? 

SPM has several powerful tools and reports that can help you respond to many situations including these 2 common challenges you might need to answer during an internal or external audit:

  1. How did you handle a failed BI test?
  2. Show that all the items used on a specific patient case were properly processed and sterilized or high-level disinfected.

For our first audit challenge, we need to show how we responded to a failed BI test in a sterilizer load. When there is a failed BI test in our department, we follow the recommended steps for issuing a recall which can be found in our Microsystems Customer Resource Center. We initiate a recall on all products in the affected loads. When these products are scanned, users receive a message that they need to be returned to the SPD to be re-sterilized. We can immediately identify recalled products that might have had patient contact and implement infection control protocol


s if necessary. We can also document comments on follow-up actions we take when resolving the recall. To demonstrate this process to an auditor, we run the Recall Information by Load report. This report can be used to view information including recalled loads, recall reasons, and all products that were recalled.

For our second audit challenge, we want to show that all of the products used on a specific case were processed correctly and delivered safe for use on a patient case. SPM allows us to take case information such as doctor, time and date, find the case and then view all of the items linked to the case. We can then look at each item and see the reprocessing history in order to confirm that they were reprocessed correctly.

If you would like more information on the SPM application we invite you to view our demo or contact us for a live demo. For our current customers only, if you would like to see the detailed step by step process for running the analysis we mention above, click here (PDF document download).