Joint Commission provides services designed to improve patient safety as well as to maintain compliance with the accreditation standards of TJC (Sterile Processing in HealthCare Facilities, Rose Seavey, AAMI 3rd Edition 2017, page 5-14) Endoscope Reprocessing is under scrutiny and has been identified as one of health care’s most dangerous health technology hazards.

In September 2018, The Joint Commission cited 72% of hospitals and 60% of ambulatory surgery centers for noncompliance. Reasons given included:

  • Not adhering to manufacturer’s Instructions For Use (IFU).
  • Failure to precisely follow a robust reprocessing protocol can lead to debilitating or fatal infections.
  • Improper handling and storage practices can re-contaminate previously disinfected scopes.
  • If scopes are not completely dried after high-level disinfection (HLD), any remaining viable microbes can proliferate rapidly and colonize endoscopes Inconsistencies in Endoscope-Reprocessing and Infection-Control Guidelines; The importance of Endoscope Drying; Lawrence F.Muscarella,Ph.D.2006
  • The disinfection status of endoscopes can be compromised if instruments are handled with unclean gloves or if scopes come into contact with contaminants when being transported or stored. (Tips for Avoiding Poor Compliance Grades; December 26, 2019,

Additional Joint Commission Recommendations/ Highlights of the Latest JC scoring revisions & Tips(Sterile Processing in HealthCare Facilities, Rose Seavey, AAMI 3rd Edition 2017, page 5-14)

  • Universal Precautions: wrong person, wrong site, wrong procedure
  • National Patient Safety Goals
    • Improve patient accuracy of identification
    • Improve communication among caregivers
    • Improve safety of using medications
    • Reduce harm associated with clinical alarm systems
    • Reduce the risk of health care associated infection
    • Identification of safety risk inherent to its patient population

  • Three types used by The Joint Commission
    • Individual Tracer: Patient Care experience
    • System Tracer: Interactive session with Surveyor and relevant staff
    • Accreditation Program-specific Tracer to identify risk and safety concerns

Policies Procedures should be consistent throughout the enterprise and reflect the most current standards of care. Endoscope Reprocessing Focus (Society of Gastroenterology & Associates, Standards of Infection Prevention for Endoscopes, SGNA 2018)

  • Policies for Endoscope reprocessing should be nationally recognized and follow the Instructions for Use (IFU) of the Scope Manufacturer, Endoscope Reprocessor, and National Standard chosen for use in your facility
  • Proper processing of the Endoscope:
    • Pre-clean, Leak Testing, Manual Cleaning, Rinse, Visual Inspection,
    • HLD (automated or manual)
    • Rinse thoroughly after HLD
    • Dry thoroughly (alcohol and forced air)
    • Storage
    • Ensure critical endoscope reprocessing tools remain clean and safe for each use
    • Documentation of re-use life (AAMI, 2015)
    • Assure quality program is in place and followed
    • Consistent oversite, compliance and documentation
    • Adherences to department Quality Assurance program (process monitoring and documentation)
    • (Alfa, 2016); (Standards of Infection Prevention in Reprocessing Flexible GI Endoscopes, SGNA 2018

Key Take aways

The Joint Commission serves a vital role in evaluating facilities development and implementation of processes and procedures to assure patient safety. ASP supports these patient safety goals providing products and services that specifically assist facilities in accomplishing these goals.