The Normalization of Deviance

By Renae N. Battié, RN, MN, CNOR

Normalization of deviance is, well, normal. That’s why infection preventionists (IP) and perioperative leaders must continue to team up to address it.

Normalization of deviance works like this: when we first get our learner’s driving permit, we bring the car to a complete halt at every stop sign. Every few blocks, we check whether we are following the speed limit. But over time, as we gain confidence, we might slide through familiar stop signs or inch over the speed limit. If nobody catches us – or we don’t wreck – we are lulled into believing our behavior is okay.

The same is true for many of the complex, time-consuming, detail-oriented sterile processing tasks. As we add more personnel and expand to satellite facilities, not every perioperative team member may clean devices the same way. We may also fall short in cleaning every device - especially the rarely used ones - according to manufacturers’ instructions.

Unfortunately, it took seeing well-respected hospitals on the front page of newspapers to reawaken us to the importance of remaining vigilant in the face of normalized deviance.

At my facility, CHI Franciscan Health, our gastroenterological and perioperative team – including our IP - began to examine duodenoscope reprocessing closely in early 2015 as part of our broader focus on preventing healthcare-acquired infections. Our GI service line staff are the experts in our organization around flexible endoscopes and the competencies in processing them. They have helped us standardize these competencies across the organization.

Processing duodenoscopes – and all flexible endoscopes – involves many steps that are guided by complex regulations, standards and guide-lines. While perioperative personnel, especially scrub persons, are responsible and accountable for the care and cleaning of instruments, the main responsibility for processing reusable devices lies with sterile processing personnel or specialized GI personnel, depending on the organization.

Led by the IP, our interdisciplinary team examined whether all team members were cleaning and processing medical devices the same way in all of our satellite facilities; whether we were using the same solutions everywhere; and whether there was a conflict between manufacturers’ instructions and standards from national organizations. 

We learned that we were not processing every single scope the same way, nor that every person was completing the very complex process correctly.

Then, in a great example of teamwork, our perioperative IP convened a meeting of all stakeholders for this issue - from processing personnel to the GI leadership and physicians to the perioperative director – to talk about patient safety. We brainstormed how to give our processing personnel the right amount of time, education, training and equipment to adhere to these important standards. We asked if we were properly equipped to perform the number of procedures we would like to each day, and if we needed to purchase more scopes. We also talked about competency verification.

While our facility was undergoing this self-examination, on a national level, AORN last year was also updating its guideline for endoscope processing. With APIC,

IAHCSMM, ACS, ASA and SHEA as liaisons on the advisory board that approved the revised guideline, Guideline for Processing Flexible Endoscopes was released Feb. 1, 2016 to guide endoscopy, perioperative, and sterile processing personnel.

Interestingly, and further underscoring the importance of the IP/periop partnership, two of the guideline’s top takeaways emphasize multi-disciplinary teamwork, particularly between IP and perioperative services.

The new guideline acknowledges that the current evidence about the maximum safe storage time for processed endoscopes is inconclusive. As well, it notes that safe storage times may be affected by factors unique to the facility. Given this, the guideline provides an extensive evi-dence review and recommends that the facility team use the helpful evidence provided in the review, as well as the variables unique to their facility, to determine their own policy.  The team, again, is IP and periop.

Another top takeaway concerns whether or not to implement a program to regularly culture flexible endoscopes and mechanical processors.  When AORN’s lead author looked closely at the evidence for and against culturing, it was mixed. Again, AORN’s guideline provides an extensive evidence review and recommends that the IP/periop team make the decision.

Additionally, the new guidelines recommend that flexible scopes be manually cleaned and then mechanically cleaned and processed with a high-level disinfectant or a liquid chemical sterilant, or that they are mechanically cleaned and sterilized. In addition, perioperative services should implement a process to audit manual cleaning to help ensure the manual cleaning has been done correctly. This is an area where IP, in collaboration with sterile processing and other team members, can routinely observe for consistency with optimal practice.

All told, the new guideline again proves that IPs can be tremendous collaborators and resources for the periop department. Because of IPs’ competence in performance improvement and implementation science, they are ideally suited to examine whether basic prevention practices are being reliably and consistently implemented. Because IPs are adept at root cause analysis of existing or potential infections, they are a great resource for determining the human and other factors most directly associated with a (possible) sentinel event and the systems related to it. Finally, because of IPs’ understanding of science, they are well suited to partner with all  processing personnel to ensure adequate policies are in place to address potential processing failures and to help assess whether new devices purchased by the facility can be safely and effectively processed.

The good news is that we have begun to realize that endoscope processing is an enormously complex task. It is not like driving a car, where a few miles above the speed limit will probably not harm you. It’s one where normalization of deviance can risk a patient’s life. To keep processing personnel vigilant, IP and periop must continue to work as a team.

Renae N. Battié, RN, MN, CNOR, is president of the Association of periOperative Registered Nurses (AORN).