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1

2011

ORAL HEALTH STERILIZING

ORIENTATION MANUAL TEMPLATE

The Oral Health Sterilizing Orientation Manual covers key areas which provide you

with a basic knowledge and understanding of safe and effective practice within

Queensland Health Oral Health facilities. The manual has been divided into the

following parts.

TABLE OF CONTENTS

PART 1 Introduction

PART 22.1. Overview of Sterilizing Services

2.2. Resources and Training

2.3. Self-Assessment

2.4. Standard Operating Procedures and Workplace Skills Assessment Sheet

2.5. Individual Learning Plan Information

PART 3 Attachments3.1. Sterilizing Services Orientation

Checklist

3.2. Manual Handling in the CSD booklet

3.3. Standard Operating Procedures and Workplace Skills Assessments

v2 March 2011 2

v2 March 2011 3

PART

1

Introduction

Your mentor for the next three months of your sterilizing orientation program within the Oral

Health Service (OHS) is INSERT NAME HERE, who will assist you during your induction

phase within your facility.

The Oral Health Sterilizing Orientation Manual has been developed for staff new to the

instrument reprocessing environment. The manual is to be used in conjunction with the

Queensland Health Orientation Program to assist new employees gain an understanding

and develop a sense of belonging in their local work area.

Oral Health Sterilizing Services Orientation Checklists have been included in part 3 for you

and your mentor to work through. Once the orientation checklists are completed this

information will be kept as part of your personnel file.

The Oral Health sterilizing orientation program contains:

The sterilizing services orientation manual

An individual self assessment form

An individual learning plan

Other specific information relating to sterilizing in Oral Health Services

v2 March 2011 4

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Recommended Resources

The table below lists additional resources for you to reference.

CHRISP website http://www.health.qld.gov.au/chrisp/default.asp

Sterilizing Services in Oral Health

Including supporting documents specifically for Oral Health services

http://www.health.qld.gov.au/chrisp/sterilising/

oral_health.asp

CHRISP website section relating to

sterilizing services


overview.asp

Queensland Health Disinfection and

Sterilization Infection Control Guidelines

http://www.health.qld.gov.au/chrisp/ic_guidelines/

contents.asp

QH Prevention and Control of Healthcare

Associated Infection - Policy, Standards,

Protocols and Guidelines

http://www.health.qld.gov.au/chrisp/

policy_framework/overview.asp

CHRISP Sterilizing Services Supporting

Documents


sterile_support.asp

PRIMEhttp://connect.health.qld.gov.au/prime/

Occupational Health and Safety http://qheps.health.qld.gov.au/safety/home.htm

Manual Handling Information Booklet –

Central Sterilising Department

http://qheps.health.qld.gov.au/safety/safety_topics/

guides/Mhb_csd.pdf

v2 March 2011 5

http://qheps.health.qld.gov.au/safety/safety_topics/guides/Mhb_csd.pdf


http://qheps.health.qld.gov.au/safety/home.htm

http://connect.health.qld.gov.au/prime/

http://www.health.qld.gov.au/chrisp/sterilising/sterile_support.asp

http://www.health.qld.gov.au/chrisp/sterilising/sterile_support.asp

http://www.health.qld.gov.au/chrisp/ic_guidelines/contents.asp

http://www.health.qld.gov.au/chrisp/ic_guidelines/contents.asp

http://www.health.qld.gov.au/chrisp/sterilising/overview.asp

http://www.health.qld.gov.au/chrisp/sterilising/overview.asp

http://www.health.qld.gov.au/chrisp/sterilising/oral_health.asp


http://www.health.qld.gov.au/chrisp/default.asp

v2 March 2011 6

v2 March 2011 7

PART

2

2.1 Overview of Oral Health, Policy, Standards and Guidelines relating to reprocessing and sterilization.

Within Queensland Health (QH), the Centre for Healthcare Related Infection

Surveillance and Prevention (CHRISP) has the statewide responsibility for the Infection

Prevention and Control program (including sterilizing). The CHRISP website has a

number of resources to assist Oral Health Sterilizing Services staff in the course of their

work, including, QH Disinfection and Sterilization Infection Control Guidelines, Easi-

Sterilise® and the Policy, Standards, Protocols and Guidelines

(http://www.health.qld.gov.au/chrisp/policy_framework/overview.asp) documents.

Many associated documents and resources relating to cleaning, disinfection and

sterilization of instruments and equipment are also available. To access the CHRISP

website go to or click on the following link: http://www.health.qld.gov.au/chrisp

CHRISP also plays an important role in representing the interests of sterilizing services

on the relevant Australian Standards committees that relate to sterilizing practice:

including:

Australian/New Zealand Standard AS/NZS 4187:2003 ‘Cleaning, disinfecting and

sterilizing reusable medical and surgical instruments and equipment, and

maintenance of associated environments in health care facilities’ (AS4187);

Australian/New Zealand Standard AS/NZS 4815:2006: ‘Office-based health care

facilities - Reprocessing of reusable medical and surgical instruments and

equipment, and maintenance of the associated environment’ (AS4815).

Your role within INSERT FACILITY HERE Oral Health Service

Staff undertaking sterilizing practices in Oral Health Services are responsible for

preparation, reprocessing, storage and distribution of sterile dental instruments and

equipment. The process of sterilization removes or destroys potentially infectious

material on reusable devices. The sterilizing role is of vital importance in ensuring that

reusable instruments are handled, cleaned, disinfected and sterilized appropriately

thereby eliminating the risk of infection transmission to patients and staff.

v2 March 2011 8

http://www.health.qld.gov.au/chrisp

http://www.health.qld.gov.au/chrisp/policy_framework/overview.asp

The Oral Health Environment

Oral Heath Services are delivered in a number of types of facilities with varying types of

instrument reprocessing areas, for example:

fixed clinics with a single room instrument reprocessing area

fixed clinics with 3 room sterilizing area

mobile dental clinics with a separate sterilizing area

Infection Prevention and Control

The role of infection control is primarily to prevent healthcare associated infections. The

ongoing use of the Easi-Sterilise Standard Operating Procedures (SOP) and Workplace

Skills Assessments (WSA) is one way of ensuring safe practice and minimising the

spread of infection to patients and staff.

In your work area it is important to take care when handling instruments to prevent

sustaining a sharps injury. Items that have been attributed to sharps injuries within a

sterilizing service include but are not limited to:

Blades that have not been removed and disposed at the point of generation,

Dental needles and fine sharp instruments such as burs, scalers, and probes.

One of the most important strategies to prevent injuries and occupational blood and

body fluid exposures whilst working in the cleaning area is wearing appropriate personal

protective equipment such as waterproof gowns/aprons, utility gloves, goggles and

masks or face shields.

Within the district there is an Infection Prevention and Control Practitioner who can be

contacted by phone on INSERT PHONE NUMBER HERE or by paging INSERT PAGE

NUMBER HERE.

For further information about Infection Prevention and Control go to the following link via

the District Intranet site: INSERT LINK HERE.

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Building Maintenance and Engineering Services (BEMS)

This information may not be relevant to your facility – delete or modify to suit your

facility.

Within this facility BEMS personnel are responsible for steam and water supply to the

large steam sterilizers, as well as the coordination of maintenance and repairs for all

equipment, machinery. If any equipment in sterilization service fails a required test (e.g.

large steam sterilizer fails the leak rate test). The failure is to be reported to your shift

supervisor. The machine is to be placed out of order until reviewed by BEMS or by the

service contractor.

Biomedical Technical Services (BTS)

Within each district there is access to Biomedical Technical Services (BTS). The scope

of services provided by local BTS may vary. Within this district BTS is responsible for

(please add or delete as required):

Instrument and handpiece maintenance and repair

Maintaining biomedical equipment

Insert details of local servicing representative

Occupational Health and Safety (OHS)

Queensland Health is committed to providing a safe, supportive and healthy

environment for its staff, volunteers and other persons at the workplace. Workplace

incidents are to be reported to the local Occupational Health and Safety Unit

(http://qheps.health.qld.gov.au/safety/communications/contact_us2.htm) as soon as

possible following their occurrence. Within each facility there are Occupational Health

and Safety Officers who can be contacted by phone on INSERT PHONE NUMBER

HERE or by paging INSERT PAGE NUMBER HERE.

As part of QH’s commitment to ensuring staff safety the Occupational Health and Safety

Unit has developed a Manual Handling Booklet for Central Sterilizing Departments

(CSD). This booklet is equally applicable for use in Oral Health facilities that undertake

reprocessing activities. This booklet has been included in part 3 of this manual and will

be discussed with you by your mentor.v2 March 2011 10

http://qheps.health.qld.gov.au/safety/communications/contact_us2.htm

Patient Safety Officer

Within each district there is a designated Patient Safety Officer who provides

advice and resources to units/departments to assist manage patient incidents and

implement strategies to prevent reoccurrence of incidents.

CHRISP in consultation with the Patient Safety and Quality Improvement Service have

developed a fact sheet to assist oral health staff report potential and actual patient

incidents. Patient incidents are reported electronically on PRIME

http://connect.health.qld.gov.au/prime/.

Your mentor will assist you to organise PRIME incident reporting training during your

three month orientation period.

2.2 Resources and Training When you commence working in your facility you will be orientated to the reprocessing

and sterilizing processes in a planned and systematic manner. Your mentor will assist

you by providing training and skills assessments as you move through each process.

Your mentor will assist you to complete the requirements of the Queensland Health

Orientation Program, the Standard Operating Procedures (SOP) and Workplace Skills

Assessments (WSA). Each week your mentor will discuss and arrange for training and

supervision within the reprocessing area. These discussions will include your education

and training needs, workload and service expectations.

v2 March 2011 11

http://connect.health.qld.gov.au/prime/

CHRISP Resources

In 2010, CHRISP developed in consultation with Oral Health Staff a set of Standard

Operating Procedures and Workplace Skills Assessments. These resources are

available on the CHRISP website at Sterilizing Services, Oral Health section

(http://www.health.qld.gov.au/chrisp/sterilising/oral_health.asp).

The Standard Operating Procedures (SOP) and Workplace Skills Assessments (WSA)

have been developed in accordance with published guidelines and standards. They

recognise the importance of the role of Oral Health staff performing sterilizing and assist

them to perform their duties safely and efficiently. The Oral Health SOPs and WSAs

provide a framework for the minimum set of standards required for sterilizing practice

within Queensland Health Oral Health facilities. They are a key component in the

ensuring that staff performing sterilizing tasks have the necessary skills, knowledge and

experience to undertake the allocated activity, task or job.

Copies of the Oral Health Easi-Sterilise SOPs and WSAs have been provided for you in

part 3.3. You can also access the current version of these resources on line via the

CHRISP website using the following link:

http://www.health.qld.gov.au/chrisp/sterilising/oral_health.asp.

The sections of the SOP and WSA modules included as part of the manual include:

Cleaning Procedures Packaging and Wrapping Procedures Sterilizing Procedures Sterile Storage Area Procedures Quality Assurance

A Standard Operating Procedure & Workplace Skills Assessment Checklist has been

designed to assist you, your mentor and your line manager to determine which SOPs

and WSA need to be undertaken during your 3 month orientation period. On completion,

this checklist can be included as evidence for your performance planning and review

and can be included in your personnel file.

v2 March 2011 12



Certificate III in Sterilizing Services

Queensland Health’s (QH) is committed to ongoing education and training. There is an

expectation that staff that perform sterilizing functions will undergo formal training in the

reprocessing of reusable medical devices known as Certificate III in Sterilising Services.

There are numerous advantages when you undertake formal study and gain a

Certificate III in Sterilising Services, which include:

ability to work in other areas such as hospital Central Sterilizing Department

(CSD)

the theoretical knowledge associated with the duties you are to perform within

the facility

confidence to participate in discussions that relate to service improvements and

work environment improvements

potential to participate in the establishment of a portfolio within your role

CHRISP Forums and Training

CHRISP Sterilizing Program established DAS-Net, a Dental Assistant Sterilizing

Network in June 2010. This network provides an opportunity to communicate and

implement new initiatives and information through a network of District-based

representatives to Dental Assistants and other personnel undertaking sterilizing

activities.

Each District has a DAS-Net representative INSERT NAME OF THE DAS NET REP

whose role is to communicate information and training requirements from the Network

back through your district. Our facility communicates to the DAS NET representative

via INSERT HOW YOU CO-ORDINATE THE FACILITIES QUESTIONS/

COMMUNICATIONS TO THE DAS NET representative . e.g communication book.

CHRISP also liaises with medical industry when coordinating statewide inservice

programs. Information is distributed by INSERT NAME OF SDA to all staff within the

department as these programs become available within your department.

v2 March 2011 13

What’s Next: After your three month orientation program

Once you have completed your three month Oral Health sterilization orientation

program you will now plan your ongoing learning needs with your manager in line with

the Workplace Skills Assessments (WSA).

2.3 Self Assessment

This tool has been designed to assist you to assess your level of knowledge and skills

in key functions of sterilization. It is important that your self assessment is completed on

or before day 1 of your sterilization orientation as we believe this process assists us to

streamline your training needs.

The idea of the self assessment is to identify your specific learning needs.

Step 1: Please complete the following questions to assess (1) your current level of

knowledge and (2) your current skill level by circling the most appropriate response. It

is expected for new staff members who have never reprocessed oral health instruments

to self assess as ‘Nil’ or ‘Limited’.

Step 2: You are to discuss the results of your self assessment with your

mentor/manager and the results will be used to develop your individual learning plan for

the next 3 months.

v2 March 2011 14

2.3 Self Assessment cont.

Cleaning

Knowledge in sorting instruments prior to cleaning Nil Limited Some Extensive

Skills in sorting instruments prior to cleaning Nil Limited Some Extensive

Knowledge in Chemical & Detergent Mixtures Nil Limited Some Extensive

Skills in replacing and checking Chemical & Detergent Mixtures

Nil Limited Some Extensive

Knowledge in pre & post rinsing of dental instruments Nil Limited Some Extensive

Skill in pre and post rinsing Nil Limited Some Extensive

Knowledge of manual cleaning processes Nil Limited Some Extensive

Skill in manual cleaning including cleaning of complex and cannulated instruments (handpieces)


Knowledge of how Batch Type Washer Disinfector Machines operate (where present)


Skill in operating Batch Type Washer Disinfector

Machines (where present)


Knowledge of how Ultrasonic Cleaners operate Nil Limited Some Extensive

Skill in operating Ultrasonic Cleaners Nil Limited Some Extensive

Knowledge of De-Staining instrument processes Nil Limited Some Extensive

Skill in De-Staining instruments Nil Limited Some Extensive

Knowledge of how and when to use an air pressure gun Nil Limited Some Extensive

Skill in Operating the air pressure gun Nil Limited Some Extensive

Knowledge of how a Drying Cabinet operates (where

present)


Skill in operating a Drying Cabinet (where present) Nil Limited Some Extensive

v2 March 2011 15

Preparation and Packaging

Knowledge in general practice dental instruments Nil Limited Some Extensive

Knowledge in Periodontal set ups Nil Limited Some Extensive

Knowledge of handpieces and ultrasonic scalers Nil Limited Some Extensive

Knowledge in Endodontic set ups Nil Limited Some Extensive

Knowledge in Crown and Bridge set ups Nil Limited Some Extensive

Knowledge in Oral surgery set up Nil Limited Some Extensive

Knowledge of orthodontic and implant technology Nil Limited Some Extensive

Knowledge in how to organise preparation and packaging

work area


Skill in organising the preparation and packaging work

area


Knowledge of how to set up instrument trays/cassettes Nil Limited Some Extensive

Skill in setting up instrument trays/cassettes Nil Limited Some Extensive

Knowledge of packaging and wrapping techniques used in

the department


Knowledge of how to load and use a batch label gun Nil Limited Some Extensive

Skills in loading and using a batch label gun Nil Limited Some Extensive

Skills in packaging and wrapping techniques Nil Limited Some Extensive

Knowledge of how the heat sealer operates (where

applicable)


Skill in operating a heat sealer (where applicable) Nil Limited Some Extensive

v2 March 2011 16

Sterilizing

Knowledge in the requirements for batch labelling and

recording of a load prior to sterilization


Skill in batch labelling and recording of a load prior to

sterilization


Knowledge of loading a trays/trolley for steam sterilization Nil Limited Some Extensive

Skill in loading a trays/trolley for steam sterilization Nil Limited Some Extensive

Knowledge in identifying and operating the appropriate

steam sterilizer cycle


Skill in steam sterilizer operation and ability to select the

correct cycle


Knowledge of required parameters when releasing a

Sterilizer load


Skill in assessing and inspecting all parameters when

releasing a Sterilizer load


Knowledge of the requirements when cooling a Sterilizer

load


Skill in managing items following sterilization that require

cooling prior to release


Knowledge of identifying and reporting requirements when

a Sterilizer load fails


Skill in identifying and reporting requirements when a

Sterilizer load fails


v2 March 2011 17

Quality Assurance

Knowledge in cleaning efficiency testing Nil Limited Some Extensive

Skill in performing clean efficiency testing Nil Limited Some Extensive

Knowledge of test/s required to determine ultrasonic machine

efficiency


Skill performing ultrasonic machine testing Nil Limited Some Extensive

Knowledge of mechanical washer cycle monitoring for thermal

disinfection


Skill in interpreting and documenting mechanical washer cycle

monitoring for thermal disinfection


Knowledge of routine cleaning and checking of mechanical

washers


Skill in performing routine cleaning and checking of mechanical

washers


Knowledge of internal and external chemical indicators and

when they are used


Skill in determining the appropriate internal and external

chemical indicator for their use


Knowledge of biological indicators when they are used Nil Limited Some Extensive

Skill in the use of biological and enzymatic indicators Nil Limited Some Extensive

Knowledge of requirements of leak rate test for pre-vacuum

sterilizers


Skill in setting the appropriate steam sterilizer cycle for leak rate

test and interpreting and documenting the sterilizer printout


Knowledge of the requirements of a Bowie Dick type test and

interpreting the results


Skill in undertaking Bowie Dick type testing and interpreting and

documenting the results


Knowledge of routine cleaning and checking of sterilizers Nil Limited Some Extensive

Skill in performing routine cleaning and checking of sterilizers Nil Limited Some Extensive

v2 March 2011 18

2.4 Standard Operating Procedures & Workplace Skills Assessments

The Standard Operating Procedures (SOP) provides a framework for the minimum set

of standards for Oral Health sterilizing practice within Queensland Health facilities

(http://www.health.qld.gov.au/chrisp/sterilising/oral_health.asp). These resources can

be used:

As a resource for you are undertaking sterilizing services within Oral Health

Help you recognize areas in which they are competent and those in which they

still need to improve

Identify problem areas where you may require further assistance and training

The SOP’s are divided into 5 sections and can be found at

http://www.health.qld.gov.au/chrisp/sterilising/oral_health_SOP.asp

Section 1 Cleaning Procedures

Section 2 Packaging & Wrapping Procedures

Section 3 Sterilizing Procedures

Section 4 Sterile Storage Area Procedures

Section 5 Quality Assurance

v2 March 2011 19



Workplace Skills Assessments (WSA)

A key component in the implementation of SOP’s is ensuring that you have the

necessary skills, knowledge and experience to undertake the allocated activity, task or

job. Each SOP criteria is aligned with a WSA and is designed to be used as part of the

Oral Health Services sterilizing orientation program and for your ongoing professional

development.

The WSA’s are divided into 5 sections and can be found at


The rating criteria for the WSA are based on the Benner Scoring Legend (refer to table

1). A template for WSA sheet (included in this section) is to be used as your personal

record.

To undertake a WSA the following conditions need to be applied:

When undertaking the WSA you are able to:

Complete the task on your own

Locate equipment used in the process without delay;

Use unit equipment according to manufacturers instructions; and

Completes the WSA within the boundaries of legislation and the WSA’s

Each step within the WSA has boxes which can be used as a prompt and ticked

(√) for achievement and (X) if the performance criteria is not achieved at this

stage.

The rating criteria for the WSA are based on the Benner Scoring Legend (refer to

table 1).

At the completion of each assessment your mentor/assessor undertaking the

assessment will discuss with you the assessment outcomes

Table 1: Benner Scoring Legend

SCORING LEGEND WSA RATING

NOVICE (1) Requires guidance: performs within set parameters

Inadequate

Requires immediate action by manager to manage risk.

Requires reassessment in one (1) week.

ADVANCED BEGINNER (2) Performs routine functions: requires some assistance in complex situations and setting priorities

ImprovementRequired

Requires reassessment within one (1) month.

COMPETENT (3) Prioritises and completes functions independently: can adapt practice to manage complex situations.

Adequate Meets current best practice requirements. Review annually.

v2 March 2011 20


WORKPLACE SKILLS ASSESSMENT - ORIENTATIONWORKPLACE SKILLS ASSESSMENT - ORIENTATION CHECKLISTCHECKLIST

Staff Member Name:

Competency

Title Date

Assessor Assessment & Signature

Adequate Improvement required Inadequate

CLEANING

1.1 Standard Precautions

1.2 Soiled Pick-Up Schedule

1.3 Sorting Prior to Cleaning

1.4 Chemical & Detergent Mixtures

1.5 Pre cleaning

1.6 Manual Cleaning for immersible items

1.7 Manual Cleaning for non-immersible items

1.8 Handpieces, Ultrasonic Scalers and Triplexes

1.9 Ultrasonic Cleaners

1.10 Washer Disinfector Machines

1.11 De-staining

1.12 Air Pressure Gun

1.13 Drying Cabinet

PREPARATION

2.1 Organisation of Packing Area

2.2 Assembly of Instrument trays and Hollowware

2.3 Wrapping / Packaging / Labelling

2.4 Using and reloading Batch Label Gun

v2 March 2011 21

2.5 Restocking Consumable Materials

v2 March 2011 22

Competency

Title Date

Assessor Assessment & Signature

Adequate Improvement required Inadequate

STERILIZING

3.1 Batching & Recording of a Load Prior to Sterilization

3.2 Loading and Recording of Items for Steam Sterilization

3.3 Releasing and Unloading a Sterilized Load

3.4 Managing a failed sterilizer cycle and load

STERILE STORAGE

4.1 Dedicated Area for Sterile Goods

4.2 Stock Rotation

4.3 Delivery of Sterile Stock

QUALITY ASSURANCE

5.1 Water Quality

5.2 Cleaning Efficacy Test (Optional)

5.3 Ultrasonic Machine Testing

5.4 Mechanical Washer Cycle Monitoring

5.5 Internal and external Chemical Indicators

5.6 Biological Indicators

5.7 Leak Rate (Vacuum) Test

5.8 Bowie Dick Type Test

5.9 Routine Cleaning of Reprocessing Equipment

v2 March 2011 23

2.5 Individual Learning Plan

Note: Performance Appraisal and Development information for managers, supervisors

and employees can be found on the Human Resources web page and include up-to-

date Performance Appraisal and Development templates

http://www.health.qld.gov.au/hrpolicies/g_learndevperf.asp

v2 March 2011 24

http://www.health.qld.gov.au/hrpolicies/g_learndevperf.asp

v2 March 2011 25

v2 March 2011 26

PART

3

3.1 Oral Health Sterilizing Services Orientation Checklist Staff Member Name:

Activity Date Mentor Signature

Day 1

Introduction to reprocessing and sterilizing

environment

Meeting with key staff

Completed self assessment

Scheduled weekly meeting with line manager

Week 1

Organise District orientation

Read Manual Handling Information Booklet- CSDhttp://qheps.health.qld.gov.au/safety/safety_topics/guides/Mhb_csd.pd f Navigate the CHRISP website

1 Month

2 Months

3 Months

Complete Individual Learning Plan- PA&D

Complete and sign off all relevant WSA

v2 March 2011 27


Staff Member Name:

Activity Date Mentor Signature

Sterilization Services Rotation where applicable(Week 1 to 3 months)

Cleaning area

Inspecting and tray set-up

Wrapping and packaging

Sterilizing

Dispatch

v2 March 2011 28

3. 2. CSD Manual Handling booklet

Insert/provide a copy of CSD Manual handling booklet found at


v2 March 2011 29


3.3 Standard Operating Procedures and Workplace Skills Assessment

Insert copies of the current Standard Operating Procedures and Workplace Skills

Assessments here or provide direction as to where they are located in the clinic

Go to http://www.health.qld.gov.au/chrisp/sterilising/oral_health.asp

v2 March 2011 30
