STERILISING SERVICES AUDIT
CRITERIA
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4. MANAGEMENT
4.1 There is a copy of AS 4187: 2003, AS 4815:2006 and associated
relevant standards such as:
 AS 1410- Pre vacuum Sterilisers
 AS 1079- Packaging of items (sterile) for patient care
 AS 1079.2 Part 2 Non-reusable papers- For wrapping of goods
undergoing sterilisation in HCF
 AS 1079.4- Part 4- Flexible packaging systems – for single use in
hospitals
 AS 1079.5- Part 5: Non-reusable, non-woven wrapping materialsfor goods undergoing sterilising in HCF
 AS 2182- Sterilisers- Steam-Benchtop
 AS 2192- Sterilisers-Steam-Downward displacement
 AS 2437- Flushers/sanitisers for bed pans & urine bottles
 AS 2478- Dry heat sterilisers
 AS 2514- Drying cabinet for medical equipment
 AS 2773.1- Ultrasonic cleaner-non portable
 AS 2773.2- Ultrasonic cleaner- benchtop
 AS 2774- Drying cabinet for respiratory apparatus
 AS 2945- Batch-type washer/disinfector
 AS 3789- Textiles for healthcare facilities and institutions
 AS 3789.2- Part 2- Theatre linen and pre-packs
 AS 3789.6- Part 6- fabric specifications
 AS 3789.8- Part 8 – recyclable barrier fabrics
 AS3836- Rack conveyor type washers
 AS4021- Non-reusable containers for the collection of sharp
medical items used in health care areas
 AS3816- Management of clinical and related wastes
 AS4146- Laundry practice
 AS4261- Reusable containers for the collection of sharp items
used in human and animal medical applications
Disinfection & Sterilization Infection Control Guidelines
4.2 CHRISP Standard Operating Procedures are operationalised to
meet the needs of the department Disinfection & Sterilization Infection
Control Guidelines
4.3 Standard Precautions and Workplace Health and Safety protocols
are applied during all stages of the cleaning, disinfection and sterilising
process Disinfection & Sterilization Infection Control Guidelines &
SOP
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RISK RATING &
ACTIONS REQUIRED
REVIEW DATE
BY WHOM
STERILISING SERVICES AUDIT
CRITERIA

4. MANAGEMENT cont.
4.4 Items designed to be reprocessed are processed to a level for their
intended use eg cleaning followed by sterilisation for all Semi-critical
and critical items Disinfection & Sterilization Infection Control
Guidelines
4.5 Manufactures instructions are provided and available to staff for
the processing of reusable medical devices Disinfection & Sterilization
Infection Control Guidelines and Easi-Sterilise Cleaning of Complex
Instruments
4.6 Material Safety Data Sheets (MSDS) are available for all cleaning
agents and chemicals which have been read and understood by staff
prior to initial use SOP1.3 & Disinfection & Sterilization Infection
Control Guidelines
4.7 Labelling on cleaning agents are to comply with any statutory
obligations and includes the following information:
 name of product
 name and addresses of manufacturer
 description & purpose of the product
 directions for dilution and use
 batch number
 expiry date
 advice not to mix cleaning agent with other chemicals
 safety & first aid instructions
 specific storage requirements SOP1.3 & Chem Alert
4.8 Chemicals used within the department are registered with the
Therapeutic Goods Association Disinfection & Sterilization Infection
Control Guidelines
4.9 Manufacturers instructions are followed in relation to load content
Disinfection & Sterilization Infection Control Guidelines
4.10 Process in place for the notification of the manager or shift
supervisor for all faults or failed processes (e.g. cleaning cycles,
sterilising loads) SOP
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RISK RATING &
ACTIONS REQUIRED
REVIEW DATE
BY WHOM
STERILISING SERVICES AUDIT
CRITERIA

4. MANAGEMENT cont.
4.11 The sterilising processing facility has standard operating
procedures for the following:
 collection of used reusable items for areas outside the sterilising
processing facility eg ward, other facilities
 cleaning items, equipment and the environment
 inspection of cleaned items
 assembly and disassembly of items
 handling and processing of specialised items
 packaging of items
 loading of items for processing
 sterilisation cycle
 process for linking steriliser cycle batch information to items that
have been sterilised to the patient
 calibration, routine monitoring and recording of sterilising
equipment and cycles
 unloading of sterilisers
 storage of sterile items
 validation of process for sterilisers
 management of deviations and faults associated with processing
of items
 distribution of sterile items
 recall of supplies or stored loads
 complaints procedure Disinfection & Sterilization Infection Control
Guidelines & SOP
4.12 Staffing profile is reviewed annually and meets the needs of the
unit Business Planning Framework
4.13 Clear professional and operational reporting structure within the
facility is evident Disinfection & Sterilization Infection Control
Guidelines
4.14 Incidents relating to the processing of reusable medical
equipment are reported, risk rated and actioned within corporate and
facility policy and the unit is provided with a summary of incidents
regularly Disinfection & Sterilization Infection Control Guidelines
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RISK RATING &
ACTIONS REQUIRED
REVIEW DATE
BY WHOM
STERILISING SERVICES AUDIT
CRITERIA
ADEQUATE
(100%)
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OVERALL COMMENTS FOR THIS SECTION:

RISK RATING &
ACTIONS REQUIRED
REQUIRES IMPROVEMENT
(>70% = 10/14)

REVIEW DATE
BY WHOM
INADEQUATE
(<70%)
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