The Joint Commission: CSSD Surveys
LEARNING OBJECTIVES:
CRCST
CRCST Self-Study
Lesson Plan
LESSON NO. CRCST 122
(Technical Continuing Education-TCE)
Lesson Author
Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT
President/CEO
Seavey Healthcare Consulting, LLC
This series of self-study lessons on CSSD topics
was developed by the International Association of
Healthcare Central Service Materiel Management
(IAHCSMM). Purdue University’s Extended
Campus and IAHCSMM both offer grading
opportunities for Extended Campus points.
Earn Extended Campus Points:
Online. You can use these lessons as an in-service with
your staff, or visit www.iahcsmm.org for online grading at
a nominal fee.
Each 20 question, online quiz with a passing score of
70% or higher is worth two points (2 contact hours)
toward your CRCST re-certification (12 points).
By mail or online. From January 1 to June 30 each
year, Purdue Extended Campus offers an annual mail-in
or online, self-study lesson subscription for $75 (6 specific
lessons worth 2 points each). Call (800) 830-0269 for
details. For grading of individual lessons, send completed
20-question quiz and $15 to: PEC Business Office, Purdue
University, Stewart Center Room 110, 128 Memorial Mall,
West Lafayette, IN 47907-2034.
Each 20-question quiz with a passing score of 70% or
higher is worth two points (contact hours) toward your
CRCST re-certification (12 points). Two attempts to
achieve a passing score are permitted per examination.
IAHCSMM provides online grading service for any of the
Lesson Plan varieties. Purdue University provides grading
services solely for CRCST lessons.
For more information:
Direct any questions about online grading to IAHCSMM
at (312) 440-0078. Questions about written grading
are answered by Purdue University at (800) 830-0269.
You can also print out any current valid lesson for
grading at www.continuinged.purdue.edu/lessons.
Sponsored by
1. Explain The Joint Commission’s accreditation process and indicate helpful resources for survey
preparation.
2. Provide an overview of The Joint Commission standards and review examples of how they relate
to Central Sterile Supply Departments.
3. Define National Patient Safety Goals
4. Discuss tracer methodology and describe how the use of mock tracers can help Central Sterile
Supply Department professionals prepare for a survey by The Joint Commission.
5. Review sample survey considerations for Central Sterile Supply Departments.
The Joint Commission (TJC) accreditation processes for healthcare facilities are conducted with a focus on
safety and the quality of patient care. During the survey process, surveyors assess each department,
including the Central Sterile Supply Department, to verify that employees’ competencies and ethical and
work practices meet current published standards. Now, more than ever, decontamination and sterilization
practices have become an important focus of the accreditation survey process. This lesson provides an
overview of TJC standards that relate to sterile processing and suggests what CSSD professionals should
do to remain prepared for an accreditation survey.
Objective 1. Explain The Joint Commission’s The Association for the Advancement of Medical
accreditation process and indicate helpful Instrumentation (AAMI) recently published a new
resources for survey preparation. document, “Sterile Processing in Healthcare
TJC is an independent, nonprofit organization that Facilities: Preparing for Accreditation Surveys.”3
accredits and certifies more than 18,000 health- This guidance document helps CSSD professionals
care organizations and programs in the United prepare for an accrediting agency survey because
States. TJC offers accreditation and certification it provides guidance about the sterile processing of
for many types of facilities, including hospitals, surgical instruments and other medical devices in
doctors’ offices, nursing homes, office-based any healthcare settings.
surgical centers, behavioral health treatment
facilities, and providers of home care services. TJC
accreditation is nationally recognized as a symbol
of quality that reflects its commitment to meeting
defined performance standards.
Healthcare facilities must submit an applica-
tion, along with a fee, to request an accreditation
survey and, upon approval, TJC accreditation is valid
for a three-year period. The organization must then
be resurveyed within three years to maintain its
accreditation and certification status. In 2006, TJC
began an unannounced survey process so facilities
should remain in a constant state of readiness.6 AAMI's publication, "Sterile Processing in Healthcare
There are two main TJC resources that are essen- Facilities: Preparing for Accreditation Surveys,"
should be a priority resource for all CSSD personnel.
tial in understanding the survey and accreditation
process for hospitals and ambulatory care facilities: Objective 2. Provide an overview of The
• 2011 Comprehensive Accreditation Manual for Joint Commission standards and review
Hospitals: The Official Handbook (CAMH) 1 examples of how they relate to Central
Sterile Supply departments.
• 2011 Comprehensive Accreditation Manual for
Ambulatory Care (CAMAC) 2 TJC uses standards, rationale statements and
The accreditation standards for ambulatory care elements of performance (EP) to provide guidance
about what to expect as a survey is conducted.
facilities are organized similarly to those for
The standards are the performance objectives and
hospitals, with slight modifications that take into
each objective has rationale statements to describe
account the different settings.
the importance of the objectives. Each standard
Copies of the resources should be available in the also has applicable EPs that specify how the
administration department of any facility applying standard or objective should be met. The EP
to be surveyed. Much of the information is scores determine the overall compliance with the
applicable to CSSDs, and it is a “must read” for standard. Facilities must receive a minimum of
CSSD professionals. score of 90% on every EP on the survey.
 IAHCSMM CRCST Self-Study Lesson Plan
For hospitals, TJC standards are grouped into the
following chapters1:
• Environment of Care (EC)
• Emergency Management (EM)
• Human Resources (HR)
• Infection Prevention and Control (IC)
• Information Management (IM)
• Leadership (LD)
• Life Safety (LS)
• Medication Management (MM)
• Medical Staff (MS)
• National Patient Safety Goals (NPSG)
• Nursing (NR)
• Provision of Care, Treatment, and Services (PC)
• Performance Improvement (PI)
• Record of Care, Treatment, and Services (RC)
• Rights and Responsibilities of the Individual (RI)
• Transplant Safety (TS)
• Waived Testing (WT)
The standards that most affect CSSDs are in the
Environment of Care, Human Resources, Infection
Prevention and Control and Leadership chapters.
Each TJC standard has at least one very specific EP
that the surveyor reviews. For example, consider
standard HR.01.06.01: “Staff are competent to
perform their responsibilities.” This standard has
numerous EPs that impact sterile processing such as: 1,2
EP 1. The hospital defines the competencies it
requires of its staff who provide patient care, treat-
ment, or services.
EP 2. The hospital uses assessment methods to
determine the individual’s competency in the skills
being assessed.
Note: Methods may include test taking, return
demonstration, or the use of simulation.
EP 3. An individual with the educational back-
ground, experience or knowledge related to the
skills being reviewed assesses competency.
Surveyors look for three types of staff competen-
cies: demonstration, certification and involvement
with professional associations. They want to see
job descriptions that match responsibilities,
documented skill check lists, and training-based
annual evaluation forms.4
Another example of a standard directly applicable
to CSSDs is LD.04.01.11: “The hospital makes
space and equipment available as needed for the
provision of care, treatment, and services.
EP 2. The arrangement and allocation of space
supports safe, efficient and effective care, treat-
ment, and services.
EP 5. The leaders provide for equipment, supplies
and other resources.
Sterilization is a complex process requiring
environmental controls (examples: for controlled
air changes, exhaust ventilation, temperature, and
humidity); appropriate equipment and supplies;
adequate space; qualified, competent personnel
who are provided with ongoing training and
personal protective equipment (PPE); and monitor-
ing for quality assurance.
TJC surveyors include an engineer who, more than
likely, will visit the CSSD to review environmental
concerns, such as temperature and humidity
controls, water quality, the presence of eyewash
stations, and appropriate ventilation (air exchanges
and positive and negative air flows). The sepa-
ration of clean and dirty areas, traffic control,
absorbability of surfaces (such as unpainted
shelves or pegboard), and holes in smoke/
fire walls, especially after removing/replacing
equipment, are assessment concerns.
Objective 3. Define National Patient Safety
Goals
In 2002, TJC established the National Patient Safety
Goals (NPSG)1. These are targeted goals that the
surveyors address regarding problems known to
create significant challenges. The NPSG that is
most important for CSSD is NPSG.07.05.01: Im-
plement evidence-based practices for preventing
surgical site infections (SSI). There are two priority
EPs that this NPSG addresses:
EP 3: Implement policies and practices aimed at
reducing the risk of surgical site infections. These
policies and practices meet regulatory requirements
and are aligned with evidence-based guidelines
[for example, the Centers for Disease Control and
Prevention (CDC) and/or professional organization
guidelines].
Surveyors determine whether the facility is following
national and local standards. The Comprehensive
guide to steam sterilization and sterility assurance
in health care facilities, ST79, is the reference guide
used for the survey, and CSSD professionals should
ensure that their departments follow the procedures
described in the most current edition. 3, 5
EP 4: As part of the effort to reduce surgical site
infections:
• Conduct periodic risk assessments for surgical
site infections.
• Select surgical site infection measures using
best practices or evidence-based guidelines.
• Monitor compliance with best practices or
evidence-based guidelines.
• Evaluate the effectiveness of prevention efforts.
TJC surveyors consider CSSD personnel to be the
subject-matter experts who set the reprocess-
ing standards for the facility. These standards,
including record-keeping, should be the same in
all areas, such as labor and delivery suites and
endoscopy suites within the healthcare system, or
facility where reprocessing is performed.
Objective 4: Discuss tracer methodology
and describe how the use of mock tracers
can help prepare CSSD professionals prepare
for a TJC survey.
TJC’s survey process includes tracer methodology,
a process in which surveyors select a patient and
use his or her record as a roadmap to evaluate the
facility’s compliance with specific standards. The
objectives of a tracer are to assemble proof of
compliance with policies and procedures, identify
process problems, and establish accountability by
observing and speaking with staff.
Use of a mock tracer related to surgical instru-
ments is a great way for CSSD personnel to evalu-
ate compliance with current policies and proce-
dures. Mock survey tracers should be conducted
routinely with staff from the operating room (OR),
infection prevention and control, and the CSSD.
For example, identify a patient who recently had
surgery. Select a specific instrument set used for
that patient’s procedure and trace it through all
the reprocessing steps while looking for compli-
ance with every applicable policy and procedure.
This self-survey should also include equipment
monitoring and objectively evaluating the facility’s
physical spaces, such as sterile storage and clean
and decontamination areas, to ensure they comply
with recommended design standards.
The tracer process can include an evaluation of
numerous issues including:
• How were the instruments packaged?
• How were the instruments sterilized?
• If there were implants, were they quarantined
until the results of the biological indicator were
available?
• How were the instruments stored?
• How was the sterile instrument set transported
to the OR?
• How were the instruments decontaminated
after their use?
• Are these steps spelled out in the facility’s
policies and procedures?
• Are the manufacturers’ written instructions for
use available?
 IAHCSMM CRCST Self-Study Lesson Plan
• Documentation for the specific competencies
and orientation, training, education, and
other activities enabled CSSD personnel to
consistently perform to the required standards
demonstrated during the mock tracer.
• Are equipment maintenance records available
and up-to-date?
• Is the department clean?
• Can each instrument be traced to the patient
selected for the mock survey?
The processes used for each step being traced
should comply with the requirements of the
facility’s applicable policies and procedures.
Likewise, all processes actually used should
be those explained and/or evaluated in facility
training and competency assessment activities.
Objective 5. Review sample survey
considerations for Central Sterile Supply
departments.
Endoscope cleaning and CSSD processing areas
and work protocols are high priority TJC
inspection concerns. Transportation of clean/
sterile and contaminated items to/from clinics
and compliance with required dress codes in all
processing areas are also a special focus during
the on-site visit.
Surveyors review equipment cleaning and main-
tenance records, and they are interested in the
type of maintenance—not just when it was
performed. CSSD housekeeping procedures are
reviewed, and surveyors evaluate the results of
daily and deep cleaning activities. For example,
they look behind closed doors, under racks, in
hidden corners, and at high-level flat spaces in all
areas of the CSSD.
Advisory Committee and Authors For Self-Study Lessons
Scott Davis, CMRP, CRCST, CHMMC
Materials Manager, Surgical Services
University Medical Center of Southern Nevada
Las Vegas, NV
Susan Klacik, ACE, CHL, CRCST, FCS, CSS
Manager
St. Elizabeth Health Center
Youngstown, OH
Patti Koncur, CRCST, CHMMC, ACE
Corporate Director, CSPD
Detroit Medical Center • Detroit, MI
Natalie Lind, CRCST, CHL, FCS
IAHCSMM Educational Director,
Moorhead, MN
David Narance, RN, CRCST
Nurse Manager, Sterile Reprocessing
Med Central Health System • Mansfield, OH
Storage areas are a certain priority, including
security concerns. No corrugated cardboard box-
es or shipping containers should be in clean areas.
If an event-related shelf life plan is in use there
should be notices about “not using packages
that are open or damaged” on the sterilization
sticker. Staff should recognize and understand
universal symbols found/located on the packag-
ing of purchased items, such as for “single use”
or “sterilized," and there are documented train-
ing activities that address them.
Common facility citations include those for
frequent use of immediate-use steam steriliza-
tion (IUSS) for the same items, failing to fol-
low the manufacturers’ written instructions
for use, and inadequate instrument cleaning.
Other problems that are often identified include
failing to use monitoring devices appropriately,
and transporting uncovered instruments to the
point of use. 7
In Conclusion
TJC accreditation procedures are designed to
help CSSD professionals use a systems approach
to evaluate their processes and to improve them
when necessary. Understanding the accreditation
standards and reviewing supporting documents
that relate to their department can help CSSD
professionals remain ready for an unannounced
survey.
Endnotes:
1. 2011 Comprehensive Accreditation
Manual for Hospitals: The Official
Handbook (CAMH)
2. 2011 Comprehensive Accreditation
Manual for Ambulatory Care (CAMAC)
Carol Petro, CNOR, CRCST, RN, BSN
O.R. Room Educator for Surgical Services
IU Health North Hospital • Carmel, IN
Technical Editor:
Carla McDermott, RN, ACE, CRCST
Clinical Nurse III
South Florida Baptist Hospital, Plant City, FL
Series Writer/ Editor:
Jack D. Ninemeier, Ph.D.
Michigan State University • East Lansing, MI
Sponsored By:
3. Association for the Advancement
of Medical Instrumentation. Sterile
Processing in Healthcare Facilities:
Preparing for Accreditation Surveys.
Arlington, VA: Association for the
Advancement of Medical Instrumentation,
2011. In press.
4. John E. Eiland. “IAHCSMM and the
Joint Commission” Presentation at the
2011 Annual IAHCSMM Conference.
(Mr. Eiland is a TJC Surveyor, Hospital
Accreditation Programs.).
5. Association for the Advancement of
Medical Instrumentation. Comprehensive
guide to steam sterilization and sterility
assurance in health care facilities. ANSI/
AAMI ST79:2010. Arlington (VA): AAMI,
2010.
6. Adapted from: http://www.jointcommission.
org/about_us/about_the_joint_
commission_main.aspx
7. A position statement supported by several
associations including IAHCSMM is
available at: www.aami.org/publications/
standards/ST79_Immediate_Use_
Statement.pdf
Earn Continuing Education Points:
You can use these lessons as an in-service with your staff,
or visit www.iahcsmm.org for online grading at a nominal
fee.
Each lesson plan graded online with a passing score of
70% or higher is worth two points (2 contact , hours).
You can use these points toward your , re-certification
of CRCST (12 points).
Mailed submissions to IAHCSMM will not be graded
and will not be granted a point value.
Purdue mail-in, self-study lesson subscription,
(6 lessons/2 points each) for $75. Call (800) 830-0269.
For grading of individual lessons, send completed quiz
and $15 to: PEC Business Office, Purdue University,
Stewart Center Room 110, 128 Memorial Mall,
West Lafayette, IN 47907-2034.
Each 20-question quiz with a passing score of 70% or
higher is worth two points (contact hours) toward your
CRCST re-certification (12 points). Two attempts to
achieve a passing score are permitted per examination.
IAHCSMM acknowledges the assistance of the
following two CSSD professionals who reviewed this
quiz:
Lisa Huber, BA, CRCST, ACE, FCS,
Sterile Processing Manager,
Anderson Hospital, Maryville, IL
Paula Vandiver, CRCST, CIS
CS Technician, Orthopedic Specialist,
Anderson Hospital, Maryville, IL
,

Quiz No. CRCST 122 (CIRCLE THE CORRECT ANSWER)

Lesson 122 • January 2012 • Lesson expires January 2015
CRCST

Objective 1 8. Every standard used by The Joint 14. Who are the subject-matter experts that
1. The accreditation from The Joint Commission Commission has at least ________ specific should set reprocessing standards for a
is valid for how many years? elements of performance that are facility?
a. Two reviewed by surveyors. a. Surveyors from The Joint Commission
b. Three a. One b. The facility’s infection control committee
c. Four b. Two c. CSSD professionals
d. Five c. Three d. CDC experts
d. Four
2. The Joint Commission offers accreditation and Objective 4
certification for doctor’s offices and providers 9. Which staff competencies are reviewed by
surveyors from The Joint Commission? 15. Which is not an objective of tracer
of home care services.
a. Demonstration methodology?
a. True
b. Certification a. Assemble proof of compliance with
b. False
c. Involvement with professional associations policies/procedures
3. Which is true about accreditation d. All the above b. Determine if all patient costs have been
standards for ambulatory care facilities assessed
compared to those for hospitals? 10. Which member of The Joint Commission
c. Identify process problems
a. They are the same team is likely to visit the CSSD to review
d. Establish accountability
b. They are organized in a similar way environmental concerns?
c. There are slight modifications a. The team leader 16. Personnel from which department(s) should
d. B and C are correct b. An engineer be involved in mock survey tracers?
e. All of the above are correct c. A maintenance specialist a. Operating room
d. An architect b. Infection prevention and control
4. Which organization has published a
document that helps CSSD professionals Objective 3 c. Central Sterile Supply Department
prepare for an accrediting agency survey? d. All the above
11. The National Patient Safety Goal (NPSG)
a. CDC that is most important for CSSD relates to: 17. Which should be used to trace through all
b. FDA a. Implementing evidence-based practices for reprocessing steps for a patient’s procedure
c. AAMI preventing surgical site infections when a mock tracer is used?
d. AORN b. Safe guarding the rights and a. Loaner instrumentation
Objective 2 responsibilities of individuals b. One specific instrument
c. Developing contemporary information c. A specific instrument set
5. Standards developed by The Joint management systems
Commission are: d. A basin set, if applicable
d. Increasing professionalism of CSSD
a. Statements of facts personnel Objective 5
b. Performance objectives
12. Policies and practices aimed at reducing 18. Which is a high priority inspection
c. Rationale statements
the risk of surgical site infections must: concern of The Joint Commission?
d. Long-term strategies
a. Meet all regulatory requirements a. Distribution cart cleaning
6. Facilities must receive a minimum score of b. Be aligned with evidence-based guidelines b. Endoscope cleaning
________ on every element of c. Be implemented at lowest possible cost c. Facility loading dock
performance on The Joint Commission d. A and B above d. Distribution of mobile equipment
surveys to be accredited. e. All the above 19. Shipping containers ________ be in clean
a. 80% areas.
b. 85% 13. Which procedures should be followed to
reduce surgical site infections? a. Should
c. 90% b. Should not
d. 95% a. Conduct periodic risk assessments
b. Monitor compliance with best practices 20. The frequent use of immediate-use steam
7. Which standard does not affect most CSS c. Evaluate the effectiveness of prevention sterilization (IUSS) for the same item
departments? efforts ________ a common facility citation.
a. Environment of care d. All of the above
b. Infection prevention a. Is
b. Is not
c. Transplant safety
d. Human resources

REQUEST FOR PAPER/PENCIL SCORING (please print or type information below)

REQUEST FOR ONLINE SCORING (payment and scoring made directly online at www.iahcsmm.org using either online check or credit card)

q I have enclosed the scoring fee of $15. (Please make checks

payable to Purdue University. We regret that no refunds can be Name
given.)
Mailing Address (Be sure to include apartment numbers or post office boxes)
q Check here if you have a change of address

q Check here if you wish to have your results emailed to you City State Zip code
( )
Detach quiz, fold, and return to:
Daytime telephone IAHCSMM Membership Number
Purdue University
PEC Business Office
Stewart Center, Room 110 • 128 Memorial Mall Email Address
West Lafayette, IN 47907-2034 If your name has changed in the last 12 months, please provide your former name
(800) 830-0269 Purdue University is an equal access/equal opportunity institution