2009
STERILISING SERVICES
ORIENTATION MANUAL
The Sterilising Services Orientation Manual covers key areas
providing you with a basic knowledge and understanding of the
Central Sterilising Department enabling a transition to safe and
effective practice within Queensland Health. The manual has been
divided into the following sections.
TABLE OF CONTENTS
PART 1
PART 2
Introduction
1. Overview of Sterilising Services
2. Resources and Training
3. Self-Assessment
4. Individual Learning Plan
PART 3
Attachments
1. Orientation Checklist
2. Shift Task Lists
3. Standard Operating Procedures
4. Manual Handling Information Booklet
5. PRIME Fact Sheet
6. Information Systems Application Form
2
PART 1
Introduction
Welcome to the Central Sterilizing Department (CSD). As part of your orientation to the
Health Service District you have been booked to attend corporate orientation which
commences on the INSERT DATE HERE at INSERT VENUE HERE.
Your mentor for the next three months of your orientation program within the CSD is INSERT
NAME HERE, who will assist you during your induction phase within the work unit and
ensure that you are introduced to the staff in CSD.
This sterilizing services orientation manual (the manual) has been developed for staff new to
the sterilizing services department. The manual is to be used in conjunction with the
Queensland Health Orientation Program to assist new employees gain an understanding
and develop a sense of belonging in their local work area.
In addition to the generic QH Orientation Program Checklist, a CSD Orientation Checklist
has been included in section 6 (attachment 1) for you and your mentor to work through.
Once the orientation checklists are completed this information will be kept as part of your
personnel file.
The orientation program contains:

A welcome letter from the District Director of Nursing/ Chief Executive Officer

The CSD Orientation Manual

An individual self assessment form

An individual learning plan

Other specific information relating to CSD
Recommended Resources
The table below lists additional resources for you to reference as you transition to safe and
effective practice.
CHRISP website
http://www.health.qld.gov.au/chrisp/default.asp
CHRISP website section relating to
http://www.health.qld.gov.au/chrisp/sterilising/overvie
sterilising services
w.asp
Queensland Health Disinfection and
http://www.health.qld.gov.au/chrisp/sterilising/overvie
Sterilization Infection Control Guidelines
w.asp#
CHRISP Easi-Sterilize
http://www.chrispqld.com/easi_sterilise/easisterilise.html
CHRISP Sterilizing Services Supporting
http://www.health.qld.gov.au/chrisp/sterilising/sterile_s
Documents
upport.asp
PRIME
http://qheps.health.qld.gov.au/psc/prime/Prime_home.
htm
Occupational Health and Safety
http://qheps.health.qld.gov.au/safety/home.htm
Manual Handling Information Booklet –
http://qheps.health.qld.gov.au/safety/safety_topics/gui
Central Sterilising Department
des/Mhb_csd.pdf
5
PART 2
Overview of Sterilizing Services, Standards and Guidelines
Within Queensland Health (QH), the Centre for Healthcare Related Infection
Surveillance and Prevention (CHRISP) has the statewide responsibility for the Infection
Prevention and Control program (including sterilizing). The CHRISP website has a
number of resources to assist CSD staff in the course of their work, including, QH
Disinfection and Sterilization Infection Control Guidelines, Easi-Sterilise® and other
associated documents relating to cleaning, disinfection and sterilization of instruments
and equipment. To access the CHRISP website go to or click on the following link:
http://www.health.qld.gov.au/chrisp/default.asp.
CHRISP also plays an important role in representing the interests of sterilising services
on the relevant Australian Standards committees that relate to sterilizing practice:
including:

Australian/New Zealand Standard AS 4187- 2003 ‘Cleaning, disinfecting and
sterilizing reusable medical and surgical instruments and equipment, and
maintenance of associated environments in health care facilities’ (AS4187;

Australian/New Zealand Standard 4815:2006: ‘Office-based health care facilities
- Reprocessing of reusable medical and surgical instruments and equipment, and
maintenance of the associated environment’ (AS4815).
The role of CSD within INSERT FACILITY HERE
CSD is an essential department within Peri-Operative Services that is responsible for
preparing, processing, and distributing sterile and non-sterile medical and surgical
supplies and equipment. CSD is responsible for removing or destroying potentially
infectious material on reusable devices, and distributing appropriately processed items
throughout the health care facility or the district.
The CSD role is of vital importance in ensuring that reusable instruments are handled,
cleaned, disinfected and sterilised appropriately thereby eliminating the risk of infection
transmission to patients and staff.
7
Operating Theatre (OT)
The service provided by CSD extends beyond the hospital walls, with Operating Theatre
(OT) a major stakeholder. To ensure continuity of service delivery there must be a direct
relationship and open communication between CSD and Operating Suite services.
Communication between the OT and sterilizing services is a high priority and one of the
primary links. In the course of any shift it is the responsibility of the shift supervisors for
CSD and OT to communicate on a regular basis to ensure that the needs of both areas
are being met.
In order to gain an insight into the interaction between CSD and OT, you will rotate to
OT as an observer as part of your 3 month orientation program.
Infection Prevention and Control
The role of infection control is primarily to prevent healthcare associated infections.
Infection control co-ordinators and CSD staff must jointly be involved in the
development of facility sterilization and disinfection standard operating procedures to
ensure safe, quality practice.
It is important to take care when handling instruments to prevent sustaining a sharps
injury. Items that have been attributed to sharps injuries within CSD include but are not
limited to:

blades that have not been removed and disposed at the point of generation,

needles and fine sharp instruments.
There are measures to prevent injuries and occupational exposures whilst working in
the cleaning area. One of the most important strategies is wearing appropriate personal
protective equipment. Personal Protective Equipment includes wearing waterproof
aprons, gloves, goggles and masks or face shields.
Infection Control can be contacted by phone on INSERT PHONE NUMBER HERE or by
paging INSERT PAGE NUMBER HERE.
For further information about Infection Prevention and Control go to the following link via
the District Intranet site: INSERT LINK HERE.
8
Building Maintenance and Engineering Services (BEMS)
Within this facility BEMS personnel are responsible for steam and water supply as well
as the coordination of maintenance and repairs for all equipment, machinery. If any
equipment in CSD fails a required test (e.g. Sterilizer fails the leak rate test) the failure
is to be reported to the shift supervisor. The machine is to be placed out of order until
reviewed by BEMS or by the service contractor.
Biomedical Technical Services (BTS)
Within each district there is access to Biomedical Technical Services (BTS). The scope
of services provided by local BTS may vary. Within this district BTS is responsible for
(please add or delete as required):

Instrument maintenance and repair

Maintaining biomedical equipment
Occupational Health and Safety (OHS)
Queensland Health is committed to providing a safe, supportive and healthy
environment for its staff, volunteers and other persons at the workplace. Workplace
incidents are to be reported to the local Occupational Health and Safety Unit as soon as
possible following their occurrence. Within each facility there are Occupational Health
and Safety Officers who can be contacted by phone on INSERT PHONE NUMBER
HERE or by paging INSERT PAGE NUMBER HERE.
As part of QHs commitment to ensuring staff safety the Occupational Health and Safety
Unit has developed a Manual Handling Booklet for CSD.
This booklet has been
included in part 3 of this manual and will be discussed with you by your mentor.
9
Patient Safety Officer
Within each district there is a designated Patient Safety Officer who provides advice and
resources to units/departments to assist manage patient incidents and implement
strategies to prevent reoccurrence of incidents.
CHRISP in consultation with the Patient Safety Centre have developed a fact sheet to
assist CSD and OT staff report potential and actual patient incidents. Patient incidents
are reported electronically on PRIME – refer to Part 4. Your mentor will assist you to
organise PRIME incident reporting training during your three month orientation period.
Queensland Health Information Systems
In the course of your work you will require access to the various QH Information
Systems such as HBCIS (hospital based computer information system), ORMIS
(operating room management information system), QH Novell Logon and Email access,
INSERT OTHER INFORMATION SYSTEMS REQUIRED FOR CSD HERE.
Your mentor will assist you gaining access to the systems you require and enrol you in
the relevant training programs (refer to Part 3- application forms for Novell Logon and
Email Access). To arrange access to HBCIS please go to the following link and choose
the
facility
location
and
download
the
application
form:
http://qheps.health.qld.gov.au/id/id_a_to_z_access.htm#h
Communication with Other Departments
Throughout the course of your shift there may have be instances where communication
is required with other departments (e.g. OT). Prior to contacting other departments you
should discuss the matter with the shift supervisor. It is the shift supervisor’s
responsibility to liaise with key staff within the other departments on your behalf.
As part of your orientation program your mentor will introduce you to key staff within
other departments that you may come in contact with as part of your role in CSD.
10
2.2 Resources and Training
Your mentor will assist you to complete the requirements of the Queensland Health
Orientation Program and local programs. Each week your mentor will arrange for you to
meet with your line manager INSERT NAME HERE (Nurse Unit Manager) to discuss
your transition within the department. These discussions will include your education and
training needs, workload and service expectations.
When you commence working in CSD you will be orientated to each of the work areas
within the department in a planned and systematic manner. Your mentor will assist you
by providing training and skills assessments as you move through each of the areas
and the various shifts within the department (Part 4 of this manual includes copies of
each shifts task list).
CHRISP Resources
In 2007, CHRISP launched a set of templates for standardising sterilizing practice
across QH CSDs. These resources are referred to as Easi-Sterilise® and include:
i.
Standard Operating Procedures & Workplace Skills Assessments
ii.
Sterilising Services Audit
iii.
Resources for the cleaning of complex instruments
The Standard Operating Procedures (SOP), Workplace Skills Assessments (WSA) and
instructions for the cleaning of complex instrumentation have been developed in
accordance with published guidelines and standards. They recognise the importance of
the role of sterilizing services staff and to assist them to perform their duties safely and
efficiently. Easi-Sterilise® provides a framework for the minimum set of standards for
sterilizing practice within Queensland Health facilities and are a key component in the
ensuring that staff working in sterilising units have the necessary skills, knowledge and
experience to undertake the allocated activity, task or job.
11
A hard copy of the Easi-Sterilise® (SOPS and WSA) has been provided for you in this
section. You can also access these resources on line via the CHRISP website using the
following link: http://www.chrispqld.com/easi_sterilise/easi-sterilise.html.
The sections of the SOP and WSA modules included as part of the manual includes:

Cleaning

Packaging

Sterilizing

Quality

Sterile stock
This section also includes Standard Operating Procedure & Workplace Skills
Assessment Checklist. This checklist has been designed to assist you, your mentor and
your line manager to determine which SOPs and WSA need to be undertaken during
your 3 month orientation period. On completion, this form can be included as evidence
for your performance planning and review and can be included in your personnel file.
Endoscope Reprocessing
If your role within CSD includes the reprocessing of scopes used in endoscopy services,
it is essential that you have undertaken recognised training in this area.
The Gastroenterological Nurses College of Australia Inc. (GENCA) and the Infection
Control Program of the Communicable Diseases Unit QH have collobrated in the
development of a training program for the reprocessing of flexible endoscopes and
accessories.
This
training
program
is
available
on
the
CHRISP
website
(http://www.health.qld.gov.au/EndoscopeReprocessing/) and is an educational resource
for health care professionals.
The site consists of a number of modules. Each module has review questions at the end
to assist with your learning. Once you have finished all six modules, consolidate your
knowledge by working through the final review.
An assessment of the learning obtained from this training package may be undertaken
by a practical demonstration of your skills. The Gastroenterological Nurses College of
Australia Inc. has a program for this assessment and information may be obtained from
the GENCA website.
12
Certificate III in Sterilizing Services
Queensland Health’s (QH) is committed to ongoing education and training. There is an
expectation that staff who work in CSD also undergo formal training in the reprocessing
of reusable medical devices known as Certificate III in Sterilising Services. INSERT
NAME FACILITY HERE funds the cost of enrolment within the course for all permanent
employees working in CSD.
There are numerous advantages when you undertake formal study and gain a
Certificate III in Sterilising Services, which include:

Base grade Assistants in Nursing or Operational Staff will be renumerated at
agreed higher levels when Certificate III in Sterilising Services has been
successfully completed. Your line manager or Human Resource Management
Department within the district will be able to provide you with further information
with regards to pay incentives relating to education and training.

You will gain the theoretical knowledge associated with the duties you are to
perform within the department

You will have the confidence to participate in discussions that relate to service
improvements and work environment improvements

Potential to participate in the establishment of a portfolio within your role

Contribute to points for higher learning
CHRISP Forums and Training
CHRISP conducts Sterilising Services Forums across the state. These forums are
designed to communicate the activities of the Statewide Sterilizing Program, update
knowledge and skills relating to CSD and to provide opportunities for you to network
with other staff working in other facilities.
Information regarding the forums is forwarded to the INSERT NAME OF NUM and to
those who have registered to be part of the Sterilizing Services Network.
13
If you want to become a member of the CHRISP Sterilizing Network, register your email
address (either work or home email) with CHRISP via email: chrisp@health.qld.gov.au.
Everyone is welcome to join the CHRISP Sterilizing Network.
In addition to the forums, CHRISP also liaises with medical industry and the manager of
CSD when coordinating statewide inservice programs. Information is distributed by
INSERT NAME OF NUM to all staff within the department as these programs become
available within your department,
CSD Inservice Program
Within CSD there is also an inservice program that is designed to complement your
work area. This inservice program is linked to the overall staff performance planning
and development, inservice needs analysis and work unit planning.
The inservice program provides you with local information in relation to the reprocessing
of reusable medical devices so that we can address local hazards and reduce the risk
of injury or infection to patients and staff.
The department’s inservice program is managed by INSERT NAME HERE and a
schedule for the program can be found in/on INSERT LOCATION HERE.
What’s Next: After your three month orientation program
Once you have completed your three month orientation program this is not the end of
the transition in CSD. As part of your professional development you will now plan your
additional learning needs with your manager.
In your role in CSD it is planned that you undertake other training that is provided within
the health service district such as Human Error and Patient Safety (HEAPS) training
which is provide by the Patient Safety Officer. Your mentor and manager will assist you
to determine your training needs.
14
2.3 Self Assessment
This tool has been designed to assist you to assess your level of knowledge and skills in key
areas within CSD. It is important that your self assessment is completed on or before day 1 of
your orientation as we believe this process will assist you to transition easily and safely to
sterilizing practice. Do not be concerned if you have “limited” in many of your responses. The
idea of the self assessment is to identify your specific learning needs.
Step 1: Please complete the following questions to assess (1) your current level of knowledge
and (2) your current skill level by circling the most appropriate response.
Step 2: You are to discuss the results of your self assessment with your mentor/manager and
the results will be used to develop your individual learning plan for the next 3 months.
1. Cleaning
Knowledge in sorting instruments prior to cleaning
Nil
Limited
Some
Extensive
Skills in sorting instruments prior to cleaning
Nil
Limited
Some
Extensive
Knowledge in Chemical & Detergent Mixtures
Nil
Limited
Some
Extensive
Skills in replacing and checking Chemical & Detergent
Nil
Limited
Some
Extensive
Knowledge in pre & post rinsing of surgical instruments
Nil
Limited
Some
Extensive
Skill in pre and post rinsing
Nil
Limited
Some
Extensive
Knowledge of manual cleaning processes
Nil
Limited
Some
Extensive
Skill in manual cleaning including cleaning of complex
and cannulated instruments
Nil
Limited
Some
Extensive
Knowledge of how and when to use of a water
Nil
Limited
Some
Extensive
Skill in operating a pressure water gun
Nil
Limited
Some
Extensive
Knowledge of Ophthalmic & Micro-Instruments
Nil
Limited
Some
Extensive
Skill in cleaning of Ophthalmic & Micro-Instruments
Nil
Limited
Some
Extensive
Knowledge of cleaning of powered tools, air hoses and
batteries
Nil
Limited
Some
Extensive
Mixtures
pressure gun
15
1. Cleaning cont.
Skill in cleaning of powered tools, air hoses and
Nil
Limited
Some
Extensive
Knowledge of how Batch Type Washer Disinfector
Machines operate
Nil
Limited
Some
Extensive
Skill in operating Batch Type Washer Disinfector
Nil
Limited
Some
Extensive
Knowledge of how Index Machines operate
Nil
Limited
Some
Extensive
Skill in operating Index Machine
Nil
Limited
Some
Extensive
Knowledge of the operation of Tunnel/ Continuous
Nil
Limited
Some
Extensive
Skill in operating Tunnel or Continuous Washers
Nil
Limited
Some
Extensive
Knowledge of how Ultrasonic Cleaners operate
Nil
Limited
Some
Extensive
Skill in operating Ultrasonic Cleaners
Nil
Limited
Some
Extensive
Knowledge of De-Staining instrument processes
Nil
Limited
Some
Extensive
Skill in De-Staining instruments
Nil
Limited
Some
Extensive
Knowledge of how and when to use an air pressure
Nil
Limited
Some
Extensive
Skill in Operating the air pressure gun
Nil
Limited
Some
Extensive
Knowledge of how a Drying Cabinet operates
Nil
Limited
Some
Extensive
Skill in operating a Drying Cabinet
Nil
Limited
Some
Extensive
batteries
Machines
Washers
gun
16
2. Preparation and Packaging
Knowledge in general surgical instruments
Nil
Limited
Some
Extensive
Knowledge in orthopaedic instruments
Nil
Limited
Some
Extensive
Knowledge in gynaecology and obstetric instruments
Nil
Limited
Some
Extensive
Knowledge in ear nose and throat instruments
Nil
Limited
Some
Extensive
Knowledge in neurosurgical instruments
Nil
Limited
Some
Extensive
Knowledge in cardiac surgery instruments
Nil
Limited
Some
Extensive
Knowledge in INSERT surgical instruments
Nil
Limited
Some
Extensive
Knowledge in INSERT surgical instruments
Nil
Limited
Some
Extensive
Knowledge in INSERT surgical instruments
Nil
Limited
Some
Extensive
Knowledge in INSERT surgical instruments
Nil
Limited
Some
Extensive
Knowledge in how to organise preparation and
packaging work area
Nil
Limited
Some
Extensive
Skill in organising the preparation and packaging work
Nil
Limited
Some
Extensive
Knowledge of how to set up instrument trays
Nil
Limited
Some
Extensive
Skill in setting up instrument trays
Nil
Limited
Some
Extensive
Knowledge of packaging and wrapping techniques
used in the department
Nil
Limited
Some
Extensive
Skills in packaging and wrapping techniques
Nil
Limited
Some
Extensive
Knowledge of how the heat sealer operates
Nil
Limited
Some
Extensive
Skill in operating a heat sealer
Nil
Limited
Some
Extensive
area
17
3. Sterilizing
Knowledge in the requirements for batch labelling and
recording of a load prior to sterilization
Nil
Limited
Some
Extensive
Skill in batch labelling and recording of a load prior to
sterilization
Nil
Limited
Some
Extensive
Knowledge of loading a trolley for steam sterilization
Nil
Limited
Some
Extensive
Skill in loading a trolley for steam sterilization
Nil
Limited
Some
Extensive
Knowledge of loading a Hydrogen Peroxide Plasma
Sterilizer
Nil
Limited
Some
Extensive
Skill in loading a Hydrogen Peroxide Plasma Sterilizer
Nil
Limited
Some
Extensive
Knowledge in identifying and operating the appropriate
steam sterilizer cycle
Nil
Limited
Some
Extensive
Skill in steam sterilizer operation and ability to select the
correct cycle
Nil
Limited
Some
Extensive
Knowledge in Hydrogen Peroxide Plasma Sterilizer
operation
Nil
Limited
Some
Extensive
Skill in Hydrogen Peroxide Plasma Steriliser and ability to
select the correct cycle
Nil
Limited
Some
Extensive
Knowledge of required parameters when releasing a
Sterilizer load
Nil
Limited
Some
Extensive
Skill in assessing and inspecting all parameters when
releasing a Sterilizer load
Nil
Limited
Some
Extensive
Knowledge of the requirements when cooling a Sterilizer
load
Nil
Limited
Some
Extensive
Skill in managing items following sterilization that require
cooling prior to release
Nil
Limited
Some
Extensive
Knowledge of reporting requirements when a Sterilizer
load fails
Nil
Limited
Some
Extensive
18
4. Quality Assurance
Knowledge in cleaning efficiency testing
Nil
Limited
Some
Extensive
Skill in performing clean efficiency testing
Nil
Limited
Some
Extensive
Knowledge of test/s required to determine ultrasonic
machine efficiency
Nil
Limited
Some
Extensive
Skill performing ultrasonic machine testing
Nil
Limited
Some
Extensive
Knowledge of mechanical washer cycle monitoring for
thermal disinfection
Nil
Limited
Some
Extensive
Skill in interpreting and documenting mechanical washer
cycle monitoring for thermal disinfection
Nil
Limited
Some
Extensive
Knowledge of routine cleaning and checking of
mechanical washers
Nil
Limited
Some
Extensive
Skill in performing routine cleaning and checking of
mechanical washers
Nil
Limited
Some
Extensive
Knowledge of internal and external chemical indicators
and when they are used
Nil
Limited
Some
Extensive
Skill in determining the appropriate internal and external
chemical indicator for their use
Nil
Limited
Some
Extensive
Knowledge of biological and enzymatic indicators and
when they are used
Nil
Limited
Some
Extensive
Skill in the use of biological and enzymatic indicators
Nil
Limited
Some
Extensive
Knowledge of requirements of leak rate test fro prevacuum sterilizers
Nil
Limited
Some
Extensive
Skill in setting the appropriate steam steriliser cycle for
leak rate test and interpreting and documenting the
sterilizer printout
Nil
Limited
Some
Extensive
Knowledge of the requirements of a Bowie Dick test and
interpreting the results
Nil
Limited
Some
Extensive
Skill in undertaking Bowie Dick testing and interpreting
and documenting the results
Nil
Limited
Some
Extensive
Knowledge of routine cleaning and checking of
sterilizers
Nil
Limited
Some
Extensive
Skill in performing routine cleaning and checking of
sterilizers
Nil
Limited
Some
Extensive
Thank you for taking the time to complete your self assessment.
19
2.4 Easi-Sterilize: Standard Operating Procedures &
Workplace Skills Assessments
The Standard Operating Procedures (SOP) provides a framework for the minimum set
of
standards
for
sterilising
practice
within
Queensland
Health
facilities
(http://www.chrispqld.com/easi_sterilise/easi-sterilise.html). This resource can be used:

As a resource for you within sterilising services

Help you recognize areas in which they are competent and those in which they
still need to improve

Identify problem areas where you may require further assistance and training
The SOP’s are divided into 5 sections:
Section 1 Cleaning Procedures
Section 2 Packaging & Wrapping Procedures
Section 3 Sterilising Procedures
Section 4 Sterile Storage Area Procedures
Section 5 Quality Assurance
Workplace Skills Assessments (WSA)
A key component in the implementation of SOP’s is ensuring that you have the
necessary skills, knowledge and experience to undertake the allocated activity, task or
job.
Within each SOP criteria for the WSA are included and are designed to be used as part
of CSD’s orientation program and for your ongoing professional development. The
rating criteria for the WSA are based on the Benner Scoring Legend (refer to table 1). A
template for WSA sheet (included in this section) is to be used as your personal record.
20
To undertake a WSA the following conditions need to be applied:


When undertaking the WSA you are able to:

Completes the task on your own

Locate equipment used in the process without delay;

Use unit equipment according to manufacturers instructions; and

Completes the WSA within the boundaries of legislation and the SOP’s
Each step within the SOP has a box to be ticked (√) for achievement and (X) if
the performance criteria is not achieved

The rating criteria for the WSA are based on the Benner Scoring Legend (refer to
table 1).

At the completion of each assessment your mentor/assessor undertaking the
assessment will discuss with you the assessment outcomes
Table 1: Benner Scoring Legend
SCORING LEGEND
NOVICE (1)
Requires guidance: performs within set
parameters
ADVANCED BEGINNER
(2)
Performs routine functions: requires some
assistance in complex situations and setting
priorities
COMPETENT (3)
Prioritises and completes functions
independently: can adapt practice to
manage complex situations.
PROFICENT (4)
Demonstrates speed and flexibility in
decision making: can predict outcomes
independently and plan for contingencies.
WSA RATING
Requires immediate action
by manager to manage risk.
Inadequate
Requires reassessment in
one (1) week.
Improvement
Required
Adequate
Requires reassessment
within one (1) month.
Meets current best practice
requirements.
Review annually.
Adequate
Meets current best practice
requirements.
Review annually.
21
STANDARD OPERATING PROCEDURES
WORKPLACE SKILLS ASSESSMENT SHEET
Staff Member Name:
Competency
Assessor Assessment & Signature
Title
Date
Adequate
Improvement required
Inadequate
CLEANING
1.1
Standard Precautions
1.2
Soiled Pick-Up Schedule
1.3
Sorting Prior to Cleaning
1.4
Chemical & Detergent
Mixtures
1.5
Pre & Post Rinsing
1.6
Manual Cleaning
1.7
Operating the Water Pressure
Gun
1.8
Cleaning of Ophthalmic &
Micro-Instruments
1.9
Cleaning of Powered Tools,
Air Hoses and Batteries
1.10
Ultrasonic Cleaner
1.11
Use of Blue Food Dye
Technique
1.12
Washer Disinfector Machines
1.13
De-Staining
1.14
Operating the Air Pressure
Gun
1.15
Drying Cabinet
22
STANDARD OPERATING PROCEDURES
WORKPLACE SKILLS ASSESSMENT SHEET
Assessor Assessment & Signature
Competency
Title
Date
Adequate
Improvement required
Inadequate
PREPARATION
2.1
Unloading Mechanical
Washer Disinfector Machines
2.2
Unloading of Drying Cabinet
2.3
Organisation of Packaging
Table
2.4
Equipment Set Ups
2.5
Wrapping / Packaging /
Labelling
2.6
Operation of Heat Sealer
2.7
Stock Replacement
STERILISING
3.1
Batching & Recording of a
Load Prior to Sterilisation
3.2
Loading and Recording of
Items for Steam Sterilisation
3.3
Hydrogen Peroxide Plasma
Sterilisation
3.4
Releasing and Unloading a
Sterile Load
3.5
Emergency Shutdown of
Steam Steriliser
23
STANDARD OPERATING PROCEDURES
WORKPLACE SKILLS ASSESSMENT SHEET
STERILE STORAGE
Assessor Assessment & Signature
Competency
Title
Date
4.1
Dedicated Area for Sterile
Goods
4.2
Stock Rotation
4.3
Loading a Dedicated Trolley
& Container for Delivery of
Sterile Stock
Adequate
Improvement required
Inadequate
QUALITY ASSURANCE
5.1
Water Quality
5.2
Cleaning Efficiency Test
5.3
Ultrasonic Machine Testing
5.4
Mechanical Washer Cycle
Monitoring
5.5
Internal and external
Chemical Control
5.6
Biological & Enzymatic
Indicators
5.7
Leak Rate Test
5.8
Bowie Dick Test
5.9
Mechanical Washer &
Sterilizer Routine Cleaning
and Checking
24
2.5 Individual Learning Plan
Performance Appraisal and Development Plan template - HR Policy G9
October 2008
Note: This template is provided as an example. Districts or professional groups may choose other
preferred templates. Guidelines on Performance Appraisal and Development for Managers, Supervisors
and Employees are on the HR Branch Learning and Development Unit webpage.
NAME:
EMP. ID:
POSITION:
CLASSIFICATION:
FACILITY/WORK UNIT:
Supervisor
Initiate Agreement
6 Month Review
12 month Appraisal
Date Completed
Date to be conducted
Date to be conducted
__/__/__
__/__/__
__/__/__
Initials
Initials
Initials
Supervisors Comment – 6 Month Review
Employees Comment – 6 Month Review
Performance Results (please circle appropriate response):
12 Month Appraisal
Exceeds requirements
Meets all requirements
Meets some
requirements
Does not meet
requirements
Conduct/Queensland Health Values (please circle appropriate response):
12 Month Appraisal:
Satisfactory
Unsatisfactory
Supervisors Comment – 12 Month Appraisal
Employees Comment – 12 Month Appraisal
UPON COMPLETION
6 MONTH REVIEW
12 MONTH APPRAISAL
25
EMPLOYEE
REPORTING OFFICER
Name:
Name:
Signature:
Signature:
Name:
Name:
Signature:
Signature:
DATE REVIEW COMPLETED
Supervisor to retain original. Employee to retain copy.
26
PART 1:
PERFORMANCE PLAN
The business plan objectives should reflect your role Description and link to Queensland Health/Local
Unit’s plans and goals. You should consider including technical and interpersonal job characteristics in
this section.
Role Description Summary

Plan objectives
Key Responsibilities
Performance Targets
Timeframe
















PART 2:
PERFORMANCE PLAN
The four Queensland Health values should be evident in the way we go about our day to day work.
Discuss what good performance will look like for your work in relation to each of these values.
Queensland Health
values
Performance
Outcomes/Expectations
Comments – Mid
Cycle Review
Comments – Annual
Review
Caring for people

Supporting a safe
quality health care
Ensuring patients are
treated with
consideration and feel
valued


<insert here>
<insert here>


<insert here>
<insert here>
High standards of
behaviour in line with
these values and code
of conduct
Understanding
responsibilities
Taking on challenges
Listening and being
responsive


<insert here>
<insert here>


<insert here>
<insert here>
Developing healthy
professional
relationships
Respecting dignity,
rights and personal
views of others


<insert here>
<insert here>


<insert here>
<insert here>
Building mutual trust
Provision of quality
advice based on sound
research


<insert here>
<insert here>


<insert here>
<insert here>
Demonstrating
commitment and

consideration for people
in the way we work.
Leadership

Regardless of level we
all have a role in
communicating a vision,

taking responsibility and
colleagues.


Respect

building trust amongst
Showing due regard for
the feelings and rights
of

others.
Integrity
using official positions
and power properly.


27
PART 3:
DEVELOPMENT PLAN
Outline your development needs including skills and knowledge required.
Skills and Knowledge
Required
Developmental
Activities
Comments –
Comments –
Mid Cycle Review
Annual Review
















OPTIONAL – CAREER ASPIRATIONS
List any career aspirations you have. What training and development will assist you in achieving this
career goal?
Developmental
Activities
Progress –
Progress –
Mid Cycle Review
Annual Review












Career Goal
Sign off of Performance and Development Plan (initial agreement).
EMPLOYEE
Name:
Signature:
__/__/__
REPORTING OFFICER
Name:
Signature:
__/__/__
28
29
PART 3
1. CSD Orientation ChecklistCSD Orientation Checklist
Activity
Date
Mentor Signature
Day 1
Tour CSD and introduce to staff
Meeting with Manager
Completed self assessment
Scheduled weekly meeting with manager
Week 1
Organise corporate orientation
Read Manual Handling Information Booklet- CSD
Week 2
Facility tour
Introduced to key staff within organisation
1 Month
Navigate the CHRISP website
Observer in Operating Theatre
2 Months
Undertake endoscope reprocessing module (CHRISP
website:
http://www.health.qld.gov.au/EndoscopeReprocessing/
30
Activity
Date
Mentor Signature
3 Months
Enrol in Certificate 111 Sterilisation Services
Complete Individual Learning Plan- PA&D
Complete and sign off all relevant WSA
CSD Rotation (Week 1 to 3 months)
Cleaning area
Inspecting and tray set-up
Wrapping and packaging
Sterilizing
Dispatch
Sterile stock
31
2. Shift Task Lists
Insert a copy of Shift Task lists here
32
3. Standard Operating Procedures
Download standard Operating Procedures and insert here:
http://www.chrispqld.com/easi_sterilise/easi-sterilise.html
33