STERILISING SERVICES AUDIT

CRITERIA
RISK RATING &
ACTIONS REQUIRED
REVIEW
DATE
BY WHOM
3. EDUCATION
3.1 100 % of staff in the sterilising facility that have undergone an
annual performance appraisal process which includes review of each persons job description
 review of annual CHRISP workplace skills assessment
 review of the staff members training needs
 mandatory training (as per district policy) QH ICG
3.2 70% of staff within the sterilising facility that have undertaken
formal training (certificate 3) in sterilisation practice QH ICG
Section 3
3.3 100% of newly employed staff within the sterilising facility t
have (including casual and agency staff) undergone a formal
orientation process
 preceptoring with a suitably qualified staff member
 complete the orientation package (which is reviewed annually)
 workplace skills assessments
 information is provided on how to access the sterilising
services instructions QH ICG Section 3
3.4 There is a formal in unit in-service program which is routinely
evaluated QH ICG
3.5 In-service is provided to all staff when new instrumentation or
equipment is procured QH ICG Section 3
ADEQUATE
(100%)

OVERALL COMMENTS FOR THIS SECTION:

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REQUIRES IMPROVEMENT
(>70% = 4/5)

INADEQUATE
(<70%)

STERILISING SERVICES AUDIT
CRITERIA

4. MANAGEMENT
4.1 There is a copy of AS 4187 (2003) 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
materials- for 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
QH ICG Section 3
4.2 CHRISP Standard Operating Procedures are operationalised to
meet the needs of the department QH ICG Section 3
4.3 Standard Precautions and Workplace Health and Safety
protocols are applied during all stages of the cleaning, disinfection
and sterilising process QH ICG Section 3 & SOP



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 critical
items QH ICG Section 3
4.5 Manufactures instructions are provided and available to staff for
the processing of reusable medical devices QH ICG Section 3 and
Cleaning Resources
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 & QH ICG Section 3
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 QH ICG
4.9 Manufacturers instructions are followed in relation to load
content QH ICG Section 3
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
4.11 Staffing profile is reviewed annually and meets the needs of
the unit Business Planning Framework
4.12 Clear professional and operational reporting structure within
the facility is evident QH ICG Section 3
4.13 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 QH ICG Section 3
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RISK RATING &
ACTIONS REQUIRED
REVIEW
DATE
BY WHOM
STERILISING SERVICES AUDIT

CRITERIA
RISK RATING &
ACTIONS REQUIRED
REVIEW
DATE
BY WHOM
4. MANAGEMENT cont.
4.14 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 QH ICG Section 3 & SOP
ADEQUATE
(100%)

OVERALL COMMENTS FOR THIS SECTION:

REQUIRES IMPROVEMENT
(>70% = 10/14)

INADEQUATE
(<70%)

STERILISING SERVICES AUDIT

CRITERIA
RISK RATING &
ACTIONS REQUIRED
REVIEW
DATE
BY WHOM
5. CONSULTATION
5.1 There is a formal communication process established between
the sterilising facility and operating theatre for the following:
 purchasing of instrumentation
 changes to configuration of instrument trays
 operating theatre scheduling
 development and review of instrument count sheet QH ICG
Section 3
5.2 There is a clearly defined relationship between sterilising
services and other services within the district/facility, including but
not limited to:
 infection control
 maintenance department
 patient safety officer
 peri-operative and surgical services
 clinical procurement officer QH ICG Section 3
5.3 There is a formal consultation process with the manager of the
sterilising facility for the purchase of all reusable medical devices
QH ICG Section 3
5.4 The design and workflow supports designated areas for
cleaning, packaging, sterilising and storage of sterile items Building
& Refurbishment
5.5 Operation manuals for the sterilisers are readily available for
maintenance and sterilising staff to access QH ICG Section 3
5.6 Each steriliser and associated equipment has a preventative
maintenance program (monthly, quarterly, annually) QH ICG
Section 3
5.7 Medical records departments are consulted about the
management of sterilising records that are to be archived QH ICG
Section 3
ADEQUATE
(100%)

OVERALL COMMENTS FOR THIS SECTION:







REQUIRES IMPROVEMENT
(>70%= 5/7)

INADEQUATE
(<70%)
