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APSIC CSSD Center of Excellence Program Audit Checklist

Handling, Collection and Transport of Contaminated


Instruments

Item reviewed Practiced Comments Type of Reference (AAMI,


Yes/No, Observation AORN)
N/A
1 Reusable items separated from Observe ____ ST79, section 6.2
waste at point of use Interview ____
Both ____
2 Contaminated disposable items Observe ____ ST79, section 6.2
are discarded appropriately Interview ____ AORN RP: Care of
(including sharps.) Both ____
Instruments, Rec. V
3/ Gross soil is removed from Observe ____ ST79, section 6.3
M instruments at point of use if Interview ____ AORN RP: Care of
immediate transportation not Both ____
Instruments, Rec.
possible IV
4 Soiled items should be kept Observe ____ ST79, section 6.4
moist (moist towel, enzyme Interview ____ AORN RP: Care of
foam or spray product) Both ____
Instruments, Rec.
V.f.
5/ Secured, dedicated containers Observe ____ ST79, section 6.4
M are provided for soiled Interview ____ AORN RP: Care of
instruments Both ____
Instruments, Rec.
VI
6 Use of puncture resistant, leak- Observe ____ ST79, section 6.4
proof containers for soiled Interview ____ AORN RP: Care of
items Both ____
Instruments, Rec.
VI
7/ Soiled items must be contained Observe ____ ST79, section 6.5.1
M during transportation Interview ____ AORN RP: Care of
Both ____
Instruments, Rec.
VI
8/ Transportation of soiled Observe ____ ST79, section 6.5.2
M instruments avoids high Interview ____
(public) traffic areas Both ____
9/ Transportation carts should be Observe ____ ST79, section 6.5.3
M covered and should prevent Interview ____ AORN RP: Care of
items from falling over or off Both ____
Instruments, Rec.
VI
10 Dedicated elevators (or lifts) Observe ____ ST79, section 6.5.5
with direct access to Interview ____
decontamination area. Both ____
11 Policy and procedure in place Observe ____ ST79, section 6.5.6
for transportation of Interview ____
contaminated items between Both ____
buildings, if applicable

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APSIC CSSD Center of Excellence Program Audit Checklist

Cleaning and Decontamination Processes


Item reviewed Practiced Comments Type of Reference (AAMI,
Yes/No, Observation AORN)
N/A
1 Written policies and procedures Observe ____ ST79, section 7.2.1
in place for all cleaning and Interview ____ AORN RP: Care of
decontamination processes. Both ____ Instruments, Rec. XXI
2 Instrumentation is disassembled Observe ____ ST79, section 7.4.1
(according to manufacturer’s Interview ____ AORN RP: Care of
instructions) to expose all Both ____ Instruments, Rec. I
surfaces for cleaning
3 Rigid container systems Observe ____ ST79, section 7.4.2
disassembled according to Interview ____ AORN RP: Packaging
manufacturer instructions Both ____ Systems, Rec. VI.4
(filters, valves and interior
baskets.)
4/ Cleaning agents are used Observe ____ ST79, section 7.5.2
M according to manufacturer’s Interview ____ AORN RP: Care of
instructions (dilution and Both ____ Instruments, Rec. IX
temperature, etc.)
5/ Appropriate manual and Observe ____ ST79, section 7.5.3.1
M mechanical cleaning methods Interview ____ and 7.5.3.3
are used according to Both ____ AORN RP: Care of
manufacturer’s instructions and Instruments, Rec. X
IFU’s are accessible to
decontamination staff
6/ Appropriate personal protective ST79, section 7.6.1
M equipment (PPE) who are used
7 Appropriate brushes/cleaning Observe ____ ST79, section 7.5.3.2
implements designed for use on Interview ____
medical devices are used. Both ____
8 Brushes/cleaning implements Observe ____ ST79, section 7.5.3.2
are either disposable or if Interview ____
reusable, are decontaminated at Both ____
least daily.
9 Monitoring of mechanical Observe ____ ST79, section 10.2
cleaning equipment should be Interview ____
done upon installation and then Both ____
weekly (preferably daily) and
recorded
10 Appropriate manual and Observe ____ ST79, section 7.5.4 and
mechanical rinsing methods are Interview ____ 7.5.6
understood and are done Both ____ AORN RP: Care of
according to manufacturer’s Instruments, Rec. I
instructions.
11 Cleaning Agent (Enzymatic Observe ____ ST79, section 7.5.2
/ cleaner) should be compatible Interview ____
M with the medical device to be Both ____
cleaned.
12 Chemical for disinfectants and Observe ____ ST79, section 7.6.2 and
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APSIC CSSD Center of Excellence Program Audit Checklist
terminal sterilization are used Interview ____ 7.6.3
according to manufacturer’s Both ____
instructions
13 Ultrasonic cleaner solution is Observe ____ ST79, section 7.5.3.3
changed at specified frequency Interview ____
or sooner if needed Both ____

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APSIC CSSD Center of Excellence Program Audit Checklist
Instrumentation Inspection, Preparation & Packaging
Item reviewed Practice Comments Type of Reference (AAMI,
Yes/No, Observation AORN)
N/A
Instruments:
1 Ensure instruments are cleaned Observe ____ ST79, section 8.4.3
and dried before packaging. Interview ____ ST79, section 8.4.1
Both ____
2/ Inspect instruments for flaws or Observe ____ ST79, section 8.4.3
M damage. Check for rust, pitting, Interview ____
corrosion, burrs, nicks, cracks, Both ____
chipping of plated surfaces.
Lighted magnifying glass
available for instrument
inspection.
3 cleaning verification by users Observe ____ ST79, D.1
should include visual inspection Interview ____
combined with other Both ____
verification methods (ATP) that
allow assessment of instrument
surfaces
4 Instruments: Ensure that Observe ____ ST79, section 8.4.3
-Cutting edges are sharp; Interview ____
-Moving parts move freely, Both ____
without sticking.
-Instruments needing repair are
taken out of service for repair
or replacement.
5 Follow MDMs instructions for Observe ____ ST79, section 7.5.6
instruments requiring Interview ____
lubrication after cleaning or Both ____
prior to sterilization.

Preparation and Assembly:


6 Delicate/sharp instruments are Observe ____ ST79, section 8.4.4
protected while being Interview ____
handled/assembled for Both ____
sterilization. (May use special
holders, tip guards, or foam
sleeves).
-Tip protectors should be
sterilant-permeable.
7/ Instruments that open (e.g. Observe ____ ST79, section 8.4.4
M scissors, hemostats) are held in Interview ____
unlocked, open positions. Both ____
8 Multi-part instruments are Observe ____ ST79, section 8.4.4
disassembled prior to Interview ____
sterilization, ensuring all parts Both ____
are easily accessed for aseptic
assembly.
9 Lumened devices: Observe ____ ST79, section 8.3.8
Interview ____
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APSIC CSSD Center of Excellence Program Audit Checklist
-Remove stylets/plugs, such as Both ____
catheters, needles, tubings.
-Moistening of the lumen may
be recommended; consult
device mfr.
10 Complex instruments (air- Observe ____ ST79, section 8.4.4
powered, endoscopes, having Interview ____
lumens or channels) are Both ____
prepared according to written
instructions from device mfr.
11 Non-linting absorbent material Observe ____ ST79, section 8.5.1
may be placed in trays to help Interview ____
facilitate drying. Tray liners or Both ____
other absorbent materials may
be used to alleviate drying
problems.
12 Basins: Observe ____ ST79, section 8.3.6
-Graduated basins should differ Interview ____
in diameter by one inch. Both ____
-Use nonlinting absorbent
material between nested basins.
-Wrapped basin sets should not
exceed 3 Kg (7 pounds).
13 Containerized instrument sets Observe ____ ST79, section 8.4.2
/ do not exceed 11kg (25 Interview ____ AORN RP:
pounds). Both ____
M Packaging Systems,
Rec. I.4
14 Rigid container system Observe ____ ST79, section 8.4.2
instructions are being followed Interview ____
regarding weight and density of Both ____
instrument sets.

Packaging:
15 Packaging materials are held Observe ____ ST79, section 8.3.1
for a min. of 2 hrs. Prior to use Interview ____
at room temp (21°F-24°F) and Both ____
at a relative humidity ranging
from 30-60%. [This is needed
to permit steam sterilization
and prevent superheating.]
16 Packaging materials are Observe ____ ST79, section 8.3.1
/ examined regularly for defects Interview ____
(i.e. holes, warn spots, stains). Both ____
M
17 Wrappers should be kept snug, Observe ____ ST79, section 8.3.1
but not wrapped too tightly or Interview ____
strike-through could occur. Both ____
18 Paper/Plastic Pouches: Observe ____ ST79, section 8.3.2
-labeling is done on plastic side Interview ____
only. Both ____
-Double peel pouch only if
pouch is validated for this use.
19 Wrapped packs: write only on Observe ____ ST79, section 8.3.2
indicator tape or affixed labels. Interview ____

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APSIC CSSD Center of Excellence Program Audit Checklist
Both ____
20 Perforated, wire-mesh-bottom Observe ____ ST79, section 8.4.3
trays, and rigid organizing trays Interview ____
are inspected prior to each use Both ____
to ensure there are no sharp
edges, nicks, or loose wire-
mesh.
21 Tape (other than sterilization Observe ____ ST79, section 8.3.3
indicator tape) should not be Interview ____
Both ____
used to secure packages, nor
should safety pins, ropes.
paper clips, staples, or other
sharp objects

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APSIC CSSD Center of Excellence Program Audit Checklist

Sterilization and Monitoring


Item reviewed Practiced Comments Type of Reference (AAMI,
Yes/No, Observation AORN)
N/A
Follow Manufacturers’
Guidelines:
1/ Sterilizer Manufacturers’ Observe ____ ST79, section 8.6.1
M written instructions for cycle Interview ____
parameters are available. Both ____
2 Rigid Container Manufacturers’ Observe ____ ST79, Intro, page 2
instructions for cycle Interview ____
parameters are followed. Both ____
3 Medical Device Manufacturers’ Observe ____ ST79, section 7.2.2
written instructions for Interview ____ AORN RP:
sterilization cycle parameters Both ____
Sterilization, Rec.
are available/accessible for IV.a.2
items to be sterilized, including
Loaner sets

Loading the Sterilizer: ST79, section 8.5


(Follow sterilizer Mfrs. Written
instructions)
4 Group together similar items Observe ____ ST79, section 8.5.1
requiring same cycle Interview ____
parameters. Both ____
5/ Sterilizer Cart: Observe ____ ST79, section 8.5.1
M -Allow space between packs Interview ____
-Do not overload Both ____
-Packages should not touch
chamber walls
6/ Mixed Loads - Place metal Observe ____ ST79, section 8.5.1
M items on the loading cart below Interview ____
textiles and paper-plastic Both ____
pouches (to prevent condensate
from dripping onto lower
packs).
7/ Solid-bottom pans, bowls, and Observe ____ ST79, section 8.5.1
M trays are tilted on edge and Interview ____
oriented in the same direction. Both ____
8 Paper-plastic pouches – Use Observe ____ ST79, section 8.5.2
baskets to facilitate placing Interview ____
pouches on edge. Both ____
9 Rigid Containers: Stacking Observe ____ ST79, section 8.5.6
could interfere with air Interview ____
evacuation; follow container Both ____
Manufacturers Instructions.

Unloading the Sterilizer:


10 Open sterilizer door properly. Observe ____ ST79, section 8.8.1
- Door may be opened slightly Interview ____
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APSIC CSSD Center of Excellence Program Audit Checklist
at the end of the cycle (for some Both ____
time) prior to removing the
load.
11 Load contents: There should be Observe ____ ST79, section 8.8.1
/ no visible signs of liquid, or Interview ____
water droplets. (Wet items are Both ____
M
considered contaminated even
if not touched.)
12 Sterilized items remain on the Observe ____ ST79, section 8.8.1
cart to cool for a minimum of Interview ____
30 minutes, and are not touched Both ____
during the cooling process.
13 Place cart in a low traffic area Observe ____ ST79, section 8.8.1
without proximity to air- Interview ____
conditioning or cold-air vents. Both ____
14 Immediate Use “Flash” Items: Observe ____ ST79, section 8.8.3,
Are used immediately and not Interview ____ and 8.8.5
stored for later use. (Assume Both ____
AORN RP:
condensate will be present.) Sterilization, Rec.
IV.f.1 and Rec. IV.a.2

Physical monitors,
Chemical indicators,
Biological indicators:
15 Verify parameters of the cycle Observe ____ ST79, section 10.5.1
have been met by reviewing Interview ____
cycle printout tapes. Circle Both ____
minimum temperature and
exposure time, initial/sign, and
date.
16 Bowie-Dick Testing is done Observe ____ ST79, section 10.7.6.1
/ daily in prevacuum sterilizers Interview ____ ST79, section 10.7.6.4
before first processed load. Both ____
M
Process Bowie-Dick at 132°-
134ºC for 3.5 to 4 minutes. One
pack per load in an empty
chamber. Record results. ISO
17 External process indicators Observe ____ ST79, section
/ (indicator tape, labels) are Interview ____ 10.5.2.2.1
Both ____
M affixed to hospital-sterilized
packages and containers.
18 Internal chemical indicator(s) Observe ____ ST79, section
/ (Class 4,5,6) are placed inside Interview ____ 10.5.2.2.2
Both ____
M every package in the most AORN RP: Packaging
challenging location for Systems, Rec. IX,
sterilant to reach. (Refer to
IX.5
Rigid Container Mfr.
Instructions for CI placement).
19 Implant Loads: Monitor with a Observe ____ ST79, section 10.6.1
/ BI PCD containing a Class 5 Interview ____ ST79, section 10.6.3
Integrating Indicator. Both ____
M AORN RP:
Implants should be quarantined Sterilization, Rec.
until BI results are known,
8
APSIC CSSD Center of Excellence Program Audit Checklist
except in emergency situations IV.h
20 Non-Implant Loads: Optional Observe ____ ST79, section 10.5.4
monitoring with a PCD Interview ____
containing either: a BI, a BI and Both ____
Class 5, a Class 5 integrating
indicator, or a Class 6
emulating indicator.
21 Routine sterilizer efficacy Observe ____ ST79, section
/ testing with a BI PCD is Interview ____ 10.5.3.2, 10.7.2.2,
Both ____
M done daily (if sterilizer run 10.7.4.2, and 10.7.3.2
daily):
Sterilizers larger than 60 Litter
–Place BI PCD in first load of
items to be sterilized, on bottom
shelf of sterilizer cart over
drain.
Table Top sterilizers: BI PCD is
ran with first load of the day
and generally placed in center
of load.
Use appropriate BI PCD
depending on type of
sterilizer:
22 Sterilizers larger than 60 Liter. Observe ____ ST79, section 10.7.2.1
/ Use commercially available Interview ____
FDA-cleared BI PCD or AAMI Both ____
M
16-towel pack. [e.g. 3M™
Attest™ Rapid 5 Steam Pack
#41382 or 3M™ Attest™ 1296
Steam Pack to monitor 132°C
Prevacuum and 121°C Gravity
Displacement cycles.] (M)
23 Table Top sterilizers. BI PCD is Observe ____ ST79, section 10.7.3.1
a user assembled challenge test Interview ____
pack which creates the greatest Both ____
challenge (e.g., BI in peel
pouch, BI in wrapped set) and
contains items normally
processed.
BI Test/Control, and Results:
24 Control BI: Incubate a positive Observe ____ ST79, section 10.7.2.3
BI control each day a test vial is Interview ____
incubated and in each Auto- Both ____
reader or incubator. The
Control BI needs to be from the
same lot number as the Test BI.
Record results.
25 Test BI: Incubate Test BI Observe ____ ST79, section 10.7.2.3
according to BI Manufacturers Interview ____
Instructions. Record results. Both ____

Qualification Testing:
26 For sterilization process failures Observe ____ ST79, section 10.7.5.1
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APSIC CSSD Center of Excellence Program Audit Checklist
/ where the cause is not Interview ____ and 10.8.1
M immediately identifiable, and Both ____
after major steam or sterilizer
repairs, run 3 empty cycles with
a BI PCD followed by 3 empty
cycles with a Bowie-Dick test if
prevacuum sterilizer.

Sterilizer Maintenance:
27 Sterilizer “drain strainers” Observe ____ ST79, section 9.4
are inspected daily for Interview ____
Both ____
debris.
28 Sterilizer external and Observe ____ ST79, section 9.4
internal surfaces are Interview ____
Both ____
routinely cleaned.

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APSIC CSSD Center of Excellence Program Audit Checklist
Sterile Storage and Distribution

Item reviewed Practiced Comments Type of Reference (AAMI,


Yes/No, Observation AORN)
N/A
STERILE STORAGE:
1 Written Policies and Observe ____ ST79, section 8.9.2
Procedures are available for Interview ____
Both ____
storage, handling, rotation,
and labeling of sterile packs.
2 Traffic in the sterile storage Observe ____ ST79, section 8.9.2
area is controlled to limit Interview ____
Both ____
access to sterile items.
3 Outside shipping containers Observe ____ ST79, section 8.9.2
and corrugated cartons are Interview ____
Both ____
not used as containers in
sterile storage areas.
4 Storage area temperature is Observe ____ ST79, section 8.9.2
generally less than (24°C) Interview ____
Both ____
and Relative Humidity
should not exceed 70%.
5 Sterile items are stored at Observe ____ ST79, section 8.9.2
least 20-25cm (8-10”) above Interview ____
Both ____
the floor, at least 45cm (18”)
below the ceiling or sprinkler
heads, and at least 5cm (2”)
from outside walls.
6 Shelving and storage carts Observe ____ ST79, section 8.9.2
have a physical barrier Interview ____
Both ____
between the bottom shelf and
the floor.
7 Medical/Surgical items, incl. Observe ____ ST79, section 8.9.2
rigid containers, are not Interview ____
Both ____
stored next to or under sinks,
under exposed water/sewer
pipes, or in any location
where they may become wet.
8 Supplies are stored only on Observe ____ ST79, section 8.9.2
designated shelving, Interview ____
Both ____
counters, and carts (not on
windowsills, floors, etc.)
9 When stacking container Observe ____ ST79, section 8.9.2
systems, ensure they are Interview ____
Both ____
firmly seated on one another.

DISTRIBUTION:
10 Supplies are handled Observe ____ ST79, section
11
APSIC CSSD Center of Excellence Program Audit Checklist
carefully. Interview ____ 8.10.1
Both ____
11 Packaging is inspected Observe ____ ST79, section
visually for integrity, and Interview ____ 8.10.1
Both ____
labeling, prior to using items.
11 Transport carts should have a Observe ____ ST79, section
physical barrier between the Interview ____ 8.10.2
Both ____
bottom shelf and the floor.
-Reusable covers should be
cleaned after each use.
13 Carts are decontaminated/ dried Observe ____ ST79, section
before reused for transporting Interview ____ 8.10.2
sterile supplies. Both ____

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APSIC CSSD Center of Excellence Program Audit Checklist
Documentation
Item reviewed Practiced Comments Type of Reference (AAMI,
Yes/No, Observation AORN)
N/A
EQUIPMENT & CYCLE
DOCUMENTATION:
1 Documentation for each Observe ____ ST79, section 10.2
mechanical washer is Interview ____
Both ____
maintained: Monitor and
verify cleaning processes
(e.g. digital readouts, and
cycle printouts)
2/ Documentation for each Observe ____ ST79, section 9.7 and
M sterilizer is maintained, and Interview ____ 10.3.2
Both ____
includes results from each AORN RP:
load. (e.g monitoring results; Sterilization, Rec.
sterilizer repair records) IV.c.1 - IV.c.3
3 For each cycle printout tape: Observe ____ ST79, section 10.5.1
*Verify cycle start was Interview ____ AORN RP:
Both ____
initiated Sterilization, Rec.
*Ensure cycle selected was IV.c.1
appropriate for load contents
*Verify correct Time &
Temp. was met
*Ensure there were no cycle
aborts or warnings
4/ Record for each cycle: Observe ____ ST79, section 10.3.2
M *Lot number; Interview ____ AORN RP:
Both ____
*Load contents; Sterilization, Rec.
*Exposure time/temp; XIV
*Name/initials of sterilizer
operator;
*Results of BI testing, if
applicable;
*Results of Bowie-Dick
testing, if applicable;
*Results of CIs in test packs;
reports of non-conclusive or
non-responsive CIs found in
the load
PRODUCT RECALLS:
5/ *Policies & Procedures are Observe ____ ST79, section 10.11.1
M clear and concise Interview ____ AORN RP:
Both ____
*Records are maintained Sterilization, Rec.
* Lot control labels are used, XVI, IVI.d
to include: Sterilizer ID, lot
number, sterilization date,
expiration date, name of
13
APSIC CSSD Center of Excellence Program Audit Checklist
pack and initials.
6/ Sterilization Process Failure: Observe ____ ST79, section 10.7.5
M – When cannot immediately Interview ____ AORN RP:
Both ____
identify cause of failure (e.g. Sterilization, Rec.
selected incorrect cycle XVI.c.1
setting), reprocess the load
and recall/reprocess all items
dating back to last load in
sterilizer with negative BI
results.

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APSIC CSSD Center of Excellence Program Audit Checklist
Facility Design
Item reviewed Practiced Comments Type of Reference (AAMI,
Yes/No, Observation AORN)
N/A
1 All instrumentation Observe ____ ST79, section 3.1
reprocessing is centralized Interview ____
Both ____

2 If centralized reprocessing is Observe ____ ST79, section 3.1


not possible, consistent Interview ____
Both ____
policies and procedures
between locations are in
place.
3 CSSD department size is Observe ____ ST79, section 3.2.2.1
appropriately designed with Interview ____
Both ____
regard to anticipated volume

4 Decontamination area Observe ____ ST79, section 3.3.7.1


facilitates proper workflow Interview ____
Both ____
and provides adequate space
for necessary equipment
5 Decontamination area has Observe ____ ST79, section 4.5.2
space dedicated to donning Interview ____
Both ____
and removal of PPE.

6 Decontamination sink is of Observe ____ ST79, section 3.3.7.1


adequate size and has three Interview ____
Both ____
compartments (for soaking,
cleaning and rinsing)
7 Handwashing sinks/hand Observe ____ ST79, section 3.3.6.8
hygiene facilities are Interview ____ AORN RP: Care of
Both ____
appropriately located in Instruments, Rec. VII
department
8 Emergency eyewash stations ST79, section 3.3.8
(required by OSHA) located ST79, 3.3.7.1, AORN
within 10 seconds travel time RP: Care of
of all chemical usage Instruments, Rec. VII
locations, with a continuous
flush for at least 15 minutes.
E.g., Decontamination area.
9/ Functional workflow pattern: Observe ____ ST79, section 3.2.3
M clear distinction (ie physical Interview ____ AORN RP: Care of
Both ____
wall) between dirty and clean Instruments, Rec. VII
10 Functional workflow pattern: Observe ____ ST79, section 3.3.7.1
pass–through window Interview ____
Both ____
available to avoid hallways,
and is not propped open
11 Temperature and humidity Observe ____ ST79, section 3.3.6.5
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APSIC CSSD Center of Excellence Program Audit Checklist
monitoring controls in Interview ____ and 3.3.6.6
decontamination and clean Both ____
areas
12 Temperature and humidity Observe ____ ST79, section 3.3.6.5
monitoring is recorded daily Interview ____ and 3.3.6.6
Both ____

13 Appropriate traffic control. Observe ____ ST79, section 3.2.4


Written policy and procedure Interview ____
Both ____
in place for authorized entry
and movement and attire.
14 Floors and walls are Observe ____ ST79, section 3.3.6.1
constructed from materials Interview ____
Both ____
that can withstand frequent
cleaning

15 Ceilings are flush surfaces Observe ____ ST79, section 3.3.6.2


and not of materials that are Interview ____
Both ____
of a particulate or fiber-
shedding composition.
16 Doors close freely and do not Observe ____ ST79, section 3.3.6.4
have thresholds. Interview ____ AORN RP: Care of
Both ____
Instruments, Rec. VII
17 Appropriate positive (clean Observe ____ ST79, section 3.3.6.4
areas) and negative (soiled Interview ____ AORN RP: Care of
Both ____
areas) pressure ventilation Instruments, Rec.
systems in place, VII.c
18 Lighting adequate for all Observe ____ ST79, section 3.3.6.7
work areas Interview ____
Both ____

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APSIC CSSD Center of Excellence Program Audit Checklist
Personnel Considerations
Item reviewed Practiced Comments Type of Reference (AAMI,
Yes/No, Observation AORN)
N/A
1 CS supervisory personnel meet Observe ____ ST79, section 4.2.1
minimum recommended Interview ____
qualifications Both ____
2 CS supervisory personnel Observe ____ ST79, section 4.2.1
maintain competency and Interview ____
participate in departmental Both ____
continuing education
4 CS technicians meet minimum Observe ____ ST79, section 4.2.2
recommended qualifications Interview ____
Both ____
5 All new CS personnel receive Observe ____ ST79, section 4.3.1
initial and comprehensive Interview ____
facility and department Both ____
orientation.
6/ All CS personnel receive a Observe ____ ST79, section 4.3.1
M minimum annual training on Interview ____
department policies and Both ____
procedures All CS personnel
demonstrate competency
annually.
7 Written policy on personal Observe ____ ST79, section 4.4
hygiene. Interview ____
Both ____

8 Written policy and adherence to Observe ____ ST79, section 4.5.1


appropriate CS personnel attire. Interview ____
Both ____

9 Written policy and adherence to Observe ____ ST79, section 4.5.2


appropriate PPE in Interview ____
decontamination area. Both ____

M: Mandatory

Source Documents:
1. Association for the Advancement of Medical Instrumentation. Comprehensive guide to steam sterilization and sterility assurance
in health care facilities. ANSI/AAMI ST79:2010 & A1:2010 & A2:2011 (Consolidated Text).
2. Association of periOperative Registered Nurses (AORN): Perioperative Standards and Recommended Practices 2012 Edition.
AORN Recommended Practices for Cleaning and Care of Surgical Instruments and Powered Equipment (RP: Care of
Instruments)
3. Occupational Safety & Health Administration. OSHA’s Medical and First Aid Standard (29 CFR 1910.151)

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