If a survey uncovers an issue that will take a lot of effort (time and money) to solve, always ask the surveyor if there’s an easier way to make the fix and still be in compliance. During a survey at my previous facility, a surveyor alerted us that a janitor closet needed negative pressure because it was a non-sterile space. Ours had positive pressure, which meant the contamination was being pushed out into the OR hallway. That would’ve meant replacing the HVAC system. Before we dumped that kind of money into a solution, we asked the surveyor if there anything else we could do. “As a matter of fact, there is,” he told us. If the closet was a sterile storage space, the positive pressure wouldn’t be an issue, he said. So, before he left for the day, we removed the janitorial supplies, terminal cleaned the closet and replaced everything in the space with sterile supplies such as drapes and gauze. Because we made the fix while he was on site, the incident was wiped from the report on the spot. Lesson learned. You should always ask for alternatives to giant fixes before you opt to go the overhaul route.
Alfonso del Granado, BHCM, CASC
Covenant High Plains Surgery Center
Lubbock, Texas
[email protected]