Peel Packs: Achieving a Highly Reliability Through a Best Practice Tool
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Speakers: Richard Schule, MBA, BS, FAST, FCS, AAMIF, Sharon Sutherland, MD, MPH
A large U.S. health system underwent preparation for a major accreditation survey. A consulting firm identified deficiencies in the handling of reusable instruments. Examples included poor condition of instrument tape, inadvertent reprocessing of single-use instruments, and packaging errors, such as closed hinges and missing sterile indicators. Subject matter experts in sterile processing, infection control and prevention, nursing and process improvement collaborated to create a Best Practice Tools. Clinical leaders engaged all unit managers to conduct a 'sweep' of their clinical areas to identify and correct deficiencies, and then educated those at point of use to prevent future deficiencies.
Tool:Peel Pack Sweeps Workflow: attached
Problem:1) Describe the exact nature of 'right' and 'wrong' elements when evaluating a peel pack. 2) Enable managers and teams to conduct peel pack sweeps and to correct deficiencies.3) Enable bedside caregivers to inspect a peel packed instrument just prior to use and enable stopping the line when necessary.
Tool Selection: The multidisciplinary team developed a tool to educate caregivers about best practices and to empower each caregiver to take action when a deficiency is identified. The 'sweep' tool is a novel step-by-step guide developed by subject matter experts. The workflow allows participation by non-clinical caregivers for an 'all-hands-on-deck' approach.
Usage: To determine feasibility, the tool was piloted in four offices or inpatient units. After content was finalized, subject matter experts collaborated with clinical leaders to define a strategy for implementation. Managers and teams conducted peel pack sweeps over a 4-week period with in-person and remote support by subject matter experts.
Results: With over 500 clinical units (inpatient, procedural and outpatient), it was not feasible for subject matter experts to round in all locations. Empowering local teams to identify deficiencies and implement corrections fostered local ownership and enhanced sustainability. There were no significant findings related to peel packs at time of survey.