2103 - Gemba Walk to Sustainable High-level Disinfection Compliance

Session Description: Effective high-level disinfection is critical to reducing the risk of transmission of pathogenic material from flexible endoscopes. The manufacturers' instructions for use, national standards, and consensus documents are complex, contradictory at times, and intimidating, creating barriers to adherence monitoring and process improvement. The Gemba Walk is a tool that can proactively problem-solve challenges, barriers, identify redundancies, and elucidate current practices and processes in high-level disinfection that could contribute to productivity and safety issues. The Gemba Walk and the Healthcare Infection Control Practices Advisory gap analysis and auditing tools will support Infection Preventionists with resources and techniques to confidently assess current workflows and practices crucial to reducing the risk of outbreaks associated with flexible endoscopes (bronchoscopes, endoscopes, endoscopic retrograde cholangiopancreatography, and duodenoscopes). Organizations with a multi-departmental oversight and physical separation where reprocessing occurs introduce variation and incomplete adherence to high-level disinfection with the hierarchical approach. We will describe how to prioritize, communicate, adopt, and implement process changes to address findings from the gap analysis necessary for sustainable adherence to endoscope reprocessing. The importance of integrating high-level disinfection audits into the Infection Preventionists' workflow will be discussed to promote improved compliance and sustained standardized improvement under inter-organizational oversight. Motivating change management may require staff in-services from representatives, purchasing supplies, and stakeholder buy-in of new equipment necessary to effectively implement Association for the Advancement of Medical Instrumentation ST91 2021 guidelines. The Gemba walk, gap analysis, and routine audits are essential for operationalizing the high-level disinfection process and standardization of multi-departmental oversight.