Process Improvement Quality Control in CSSD1

incomplete/incorrect

Backgroundoccurrence report 2014

sharp Outof

explossure Quantity amount3% 1%

lostdramage 7%

instrument10% incorrect/inco

mplete 43%

not readyto use35%

No instrument

1%

CSSD provide disinfection and sterilization instrument & medical

devices for the whole hospital follow international standard guideline.Cleaning is important process after

that inspection process for malfunction and damage instrument

before packing .

Item amount %

10

7 7

5

3

Jan-15 Feb-15 Mar-15 Apr-15 May-15

incomplete/incorre ct

2

incorrect/incom plete

67 43.23 12

10

not ready to use 54 34.848

dramage instrument

15 9.68 6

lost 11 7.10 4

sharp explossure

5 3.23 2

Out of Quantity 2 1.29 0

No instrument 1 0.65

Value stream mapping : Internal Process

PRE -WASH

Scan wash Check list

RETURN

SCANWASH

SCANWASH

TAG

WASH Post- Wash Pre-Pack Pack

Pre-BatchBatchPost-BatchStorageDispatchUse

Packingand

label

SCAN Basket

for loadinginto

Sterilizer

SCAN Batch

for SterilizerScan Approve

afterSterile

StorageScanDispatch

foeuser

Checkand

tracking

3

Validation QC staff :lab test

Objective project: improve competency CSSD staff for patient safety

Target >80%

Result inspector test pass8 :17 persons

4

Results : lot 1-10 (1-10 Dec 2015) : criteria

45

6

58 10

20.01-21.00น.

19.01-20.00น.

9.01-10.00น.

8.01-9.00น.

Reject period 1-10

5

Bata dine

blood

Bone cement0

45

11

0

2

4

6

8

10

12

manualcleaning washer disinfector

0 0

ultrasonic cleaner

rash instrument washed clean instrument

0 2 4 6

Reject from cleaning process

RCA: Cause & Effect Diagram :

6

Water qualityLook a like:

Pre wash vs.rash removal

Brush is appropriate

Auto washer fan obstructLoad check

not pass

Waste & Solution : cleaning incomplete

Dirty instrument

clean not pass

Training arrange

instrument

Water pressure not

enough

Check Fan of auto washer

and assessor every morning

before start machine

Water quality

Approve water quality every

morning before start machine

7

Results : lot 1-30 (1-30 Dec 2015)

8

16

1412

10

86

4

20

deformed instrument rash instrument deteriorate

0

4

16

0

3

9

00 0

2

8

0

lot1-10

washed instrument

lot11-20 lot21-30

Compare type of reject Lot 1-30

Next Action Plan

Pack to Sterilize

Return +Dirty

Cycle time for Sterilize

Packing

PostBatch

PackingArea-Returned PreBatchArea-PackingArea PostBatchArea-PreBatchArea

Returned to Pack

Sterilize

Return Packing PreBatch

9

1

2