Medical/Dental Professionals

High Risk Focus Areas for DNV GL Survey

DNV GL surveyors could arrive any day now to complete the survey for reaccreditation cmoto NIAHO standards and recertified to ISO 9001:2015. Last month, we shared some high risk areas, and below are some additional high risk areas to focus on in preparation for their visit:

Scope/Probe Reprocessing

  • Transport of contaminated scopes and probes should be identified with biohazard label
  • Storage of high-level disinfected scope/probe should ensure free from dust/debris

Sanitary Environment

  • Report general cleanliness/equipment to staff to ensure EVS is contacted
  • Keep supplies in intact packaging until use
  • If fluids are pre-spiked, must have date/time on tubing and used within 1 hour
  • Do not place tape on equipment due to inability to properly clean once tape is removed
  • Items on floor – unable to clean under
  • Report ripped/torn upholstery to staff to replace (in patient care areas)

Immediate Use Steam Sterilization (IUSS)

  • Ensure vendors honor 24 hour required delivery of vendor instruments

Surgical Attire

  • In OR, must have tie masks vs. elastic masks
  • Jackets from outside areas shouldn’t be worn inside OR

Hand Hygiene

  • Practice hand hygiene when entering and exiting rooms
  • Change gloves and practice hand hygiene using Five Moments of Hand Hygiene principles

Medication Management

  • Biologicals, including NaCl IV bags are required to be secure
  • Anesthesia carts in multiple locations unlocked and with medications on top (in unsecure areas)
  • Unsecured medications in various locations
  • Be sure all sharps are kept secure as well
  • Pain medications: orders for PRN pain meds must provide clear direction for nursing and use pain scales if appropriate. Click HERE for more details

Control of Documented Information

  • All forms should be pulled at time of use from Forms on Demand
  • Policies should be reviewed from KaleidaScope and not printed/posted
  • Management of department forms, including documents of external origin, is done via the Documented Information Log – responsibility of department manager

As always, we encourage you to share your feedback and participate in our quality improvement initiatives. Thank you for your help in ensuring a successful reaccreditation survey.

David Hughes, MD, MPH
Chief Medical Officer
Kaleida Health

Kenneth Snyder, MD, PhD
Chief Physician Quality Officer
Kaleida Health

Michael Mineo, MD
Chief Medical Officer
Millard Fillmore Suburban Hospital and DeGraff Memorial Hospital

David Pierce, MD, FACEP
Chief Medical Officer
Buffalo General Medical Center/Gates Vascular Institute

Stephen Turkovich, MD
Chief Medical Officer
Oishei Children’s Hospital