รายงานการศึึกษาขัั้นต นlocal.moi.go.th/inception report.pdf · รายงานการศึึกษาขัั้นต น (Inception
Background - IAHCSMM · Results : lot 1-10 (1-10 Dec 2015) :criteria 4 5 6 5 8 10 20.01-21.00น....
Transcript of Background - IAHCSMM · Results : lot 1-10 (1-10 Dec 2015) :criteria 4 5 6 5 8 10 20.01-21.00น....
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