Accreditation

Sample policy and procedure for vendors in the operating room

Accreditation Connection, February 6, 2006

Editor's note: The following sample policy and procedure is reprinted with permission by Joann L. Gillaspie, quality coordinator at Spring Park Surgery Center in Davenport, Iowa.

Purpose:
To provide guidelines for visitors and sales representatives in the Spring Park Surgery Center in order to reduce the chance of infection and provide patient privacy.  This policy will be enforced at all times.

Procedure:


A. Patient visitors

1. Visitors are allowed only in the admit area.
2. Prior approval by the attending physician is obtained if a visitor is allowed into the operating room for reason of translation, interpretation, or consolation of an unruly pediatric patient.
3. Only personnel and visitors in proper surgical attire will be allowed in the operating room.
4. Proper surgical attire includes all of the following: surgical scrub pants and shirts, surgical hair and beard coverings, surgical shoe covers, and masks.
5. Cover gown/lab coats will not be worn inside the operating room.

B. Sales representatives/Service repair personnel/Other representatives


1. Visitor notification forms will be at the front desk to inform staff of previous approval.
2. Visitors must have prior approval from the attending physician to enter the operating room for any reason. 
3. If there has not been prior approval, the sales representative will report to the receptionist who will notify the clinical coordinator and, if possible, arrangements will be made through the nurse and physician.
4. The clinical coordinator must be informed ahead of time of visitation to the operating room and approved by him/her.
5. The sales representative will wear a name badge at all times.
6. Sales representatives will never scrub in or become part of the sterile field in any way.
7. Sales representatives will never touch the patient or operative equipment and will participate by only providing verbal guidance.
8. The patient's permission/acknowledgment must always be obtained before allowing sales representatives, visitors, or residents in the operating room during their procedure. Patient privacy must be maintained at all times
9. As the patient's advocate, the RN responsible for the patient's care during the procedure is accountable for maintaining the patient's safety, privacy, dignity, and confidentiality.
10. The specific area that the sales representatives were involved needs to be documented in the medical record in the area it pertains to (steps 1-5 in Section A will be followed).
11. In the event that a service/repair person needs to enter the operating room/vicinity around the operating room, all efforts must be made to schedule their work time at the end of the day's schedule.

C. Equipment

1.  All new equipment or equipment for trial purposes must be electrical safety check by bio-tech. Sufficient amount of time must be allowed to make arrangements for this service
2.  Literature must be provided for the proper processing of instruments. No instrument is to be put in use until the instrument-processing technician has reviewed the process.
3.  To facilitate no disruption in the daily surgical schedule time is allowed for the staff to be inserviced on the instrument/equipment.

 

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