Central Service Policy and Procedure Manual
Central Service Policy and Procedure Manual
About this Manual
Central Service Policy and Procedure Manual is a manual containing many of our policy and procedure templates for the medical office, hospital, and other healthcare organizations. The policies cover: Joint Commission (JCAHO or TJC) • CMS • HIPAA • CDC • AAAHC and more.Want access to all our manuals? Click here
SECTION I - LEADERSHIP
1001 - Purpose and Goal1002 - Objectives1003 - Functions of Central Service1004 - Central Sterilization - Scope of Services Provided1005 - Interdepartmental Functions and Relationships1006 - Organization Chart1007 - Employee Initials - Roster1008 - Central Service Personnel Roster Form1009 - Hours of Service1010 - Supplies - Ordering from Warehouse1011 - Equipment Control1012 - After Hours Acquisition of Supplies and Equipment1013 - Selection of Disposable Products1014 - Maintenance and Service Contract Agreement - Manufacturer's Responsibility1015 - Requisitioning of Rental Equipment1016 - Revenue Recovery1017 - Central Service Equipment/Supply Distribution Form
SECTION II - IMPROVING ORGANIZATION PERFORMANCE
2001 - Performance Improvement Plan2002 - Central Service PI Monitoring and Evaluation Plan2003 - Central Service PI Trending Sheet2004 - Central Service PI Outcome Evaluation2005 - Central Service PI Volume Measures/Statistics2006 - Central Service Performance Improvement Log2007 - Performance Measure Summary Form2008 - Performance Improvement Quarterly Report Form2009 - Performance Improvement Calendar for Indicator Reporting2010 - General Guidelines for Completion of the Confidential Report of Incident2011 - Sentinel Event2012 - Incident Reporting Staff Questionnaire
SECTION III - SURVEILLANCE, PREVENTION AND CONTROL OF INFECTION
3001 - Infection Control3002 - Department Cleaning3003 - Environmental Cleaning of Central Service3004 - Central Service Physical Layout3005 - Drawing of Central Service Floor Plan3006 - Food and Smoking Policy3007 - Traffic Control3008 - Dress Code - Central Service Area3009 - Contamination Control - Responsibilities, Cleaning and Stocking3010 - Storage of Clean Supplies and Equipment3011 - Storage of Sterile Supplies3012 - Sterile Supplies in Surgical Services Department3013 - Stock Rotation3014 - Standard Precautions3015 - Asepsis3016 - Hand Hygiene3017 - Disposal of Sharps3018 - Sharps Injury Protection Plan3019 - Sharps Injury Log Form3020 - Management of Accidental Blood or Body Fluid Exposure/ Contamination3021 - Definition of Biohazardous Waste3022 - Handling of Biohazardous Waste3023 - Creutzfeldt-Jakob Disease Precautions3024 - Definitions
SECTION IV - MANAGEMENT OF ENVIRONMENT OF CARE
4001 - Central Service Safety4002 - Body Mechanics - Staff Education Handout4003 - Hazardous Chemical Communication Program4004 - Hazardous Materials and Waste - Departmental Management4005 - How to Read Safety Data Sheets (SDS)4006 - Hazardous Materials and Waste - Ordering and Receiving4007 - Hazardous Materials and Waste - Spills4008 - Hazardous Materials and Waste - Training4009 - Ethylene Oxide (EO) Sterilization Safety4010 - Ethylene Oxide Monitoring4011 - Ethylene Oxide Monitoring - Employee Training and Emergency Response4012 - New Employee Chemical Inservice Sample Memo4013 - Chemical Training Record Form4014 - Hazardous Materials and Waste - Employee Injury4015 - Hazardous Materials and Waste Departmental Reporting Form4016 - Emergency Management4017 - Emergency Supply Cart4018 - Responsibilities of Central Service in a Disaster4019 - Emergency Services4020 - Fire Safety4021 - Types of Fire Extinguishers4022 - Electrical Safety4023 - Preventive Maintenance Responsibilities - Equipment4024 - Reporting Equipment Malfunction
SECTION V - MANAGEMENT OF HUMAN RESOURCES
5001 - Position Description/Performance Evaluation - Central Service Manager5002 - Performance Evaluation - Age-Related Competency - Central Service Manager5003 - Annual Competency Skills Assessment - Central Service Manager5004 - Position Description/Performance Evaluation - Central Service Chief Technician5005 - Performance Evaluation - Age-Related Competency - Central Service Chief Technician5006 - Annual Competency Skills Assessment - Central Service Chief Technician5007 - Position Description/Performance Evaluation - Lead Central Service Technician5008 - Performance Evaluation - Age-Related Competency - Lead Central Service Technician5009 - Annual Competency Skills Assessment - Lead Central Service Technician5010 - Position Description/Performance Evaluation - Certified Central Service Technician5011 - Performance Evaluation - Age-Related Competency - Certified Central Service Technician5012 - Annual Competency Skills Assessment - Certified Central Service Technician5013 - Position Description/Performance Evaluation - Central Service Technician5014 - Performance Evaluation - Age-Related Competency - Central Service Technician5015 - Annual Competency Skills Assessment - Central Service Technician5016 - Position Description/Performance Evaluation - Central Service Assistant Technician5017 - Performance Evaluation - Age-Related Competency - Central Service Assistant Technician5018 - Annual Competency Skills Assessment - Central Service Assistant Technician5019 - Responsibility and Accountability of Personnel5020 - New Employee Orientation5021 - New Hire Processing Checklist5022 - Orientation Schedule for New Employees Form5023 - Pre-Employment Physical Examination5024 - Staff Competency5025 - Education and Training5026 - Cardiopulmonary Resuscitation Certification5027 - Education Profiles5028 - Departmental Inservice Programs5029 - Staffing Patterns5030 - Employee Work Assignments5031 - Light Duty Assignment5032 - Work Schedule5033 - Central Service Work Schedule Form5034 - Time Card5035 - Sleeping on Hospital Premises
SECTION VI - GENERAL POLICIES AND PROCEDURES
Decontamination, Cleaning, Packaging
6001 - Decontamination - Receiving and Handling6002 - Operation of the Utensil Washer6003 - Sterilization of Items from Isolation6004 - Disposable Versus Nondisposable Items6005 - Instruments - Care and Cleaning6006 - Steps for Cleaning and Processing of Instruments and Supplies6007 - Cleaning of Equipment and Instrument Trays6008 - Processing of Instrument and Procedure Trays6009 - Prepared Trays6010 - Reusable Trays and Accessories - Cleaning and Processing6011 - Separation of Sterile from Nonsterile6012 - Wrapping6013 - Wrapped Specifications for Sterile Processing6014 - Envelope Wrapping6015 - Oblong Wrapping6016 - Proper Packaging of Articles for Sterilization6017 - Cleaning and Care of Air-Powered Drills6018 - Cleaning of Anesthesia Supplies6019 - Catheters and Tubing - Cleaning and Processing6020 - Cleaning of Endoscopic Instruments6021 - Fiberoptic Endoscopes - Care and Cleaning6022 - High-Level Disinfection of Endoscopes6023 - Gomco Suction Equipment (Portable) - Care and Maintenance6024 - Heat Pad (K-Pad) Module - Equipment Care and Maintenance6025 - Hypo/Hyperthermia Units - Equipment Care and Maintenance6026 - Infusion Pumps - Equipment Inspection, Care and Maintenance6027 - Needles - Special Procedure, Cleaning and Processing6028 - Crash Cart - Responsibility for Maintaining Integrity
Sterilization Processes
6101 - Sterilization6102 - Sterilization Control - Hand Labeler6103 - Sterility Code System for Surgical Services6104 - Lot Load - Central Service Monitoring6105 - Biological Monitoring6106 - Biological Indicator Use6107 - Biological Indicator Incubation6108 - Steam and Ethylene Oxide Sterilization Failure Checklist6109 - Bowie Dick Test6110 - Sterility Testing - Random Sample6111 - Flash Sterilization6112 - Steam Sterilization - Definitions6113 - Steam Sterilization - Guidelines6114 - Malfunctioning Sterilizer6115 - Ethylene Oxide (Gas) Sterilization6116 - Ethylene Oxide Sterilization Operation6117 - Emergency Leak of Ethylene Oxide6118 - Daily ETO Gas Testing6119 - Daily Testing of ETO Gas Form6120 - Record Keeping Sterilization6121 - Sterilizer Graph/Printed Readout Recording Sheets6122 - Sterilizer Graph/Printed Readout Recording Sheets - Maintenance of6123 - Cleaning of Sterilizers6124 - Chemical Disinfectants6125 - FDA Approved Sterilants and Disinfectants6126 - Use of Glutaraldehyde Solution for Disinfection of Instruments6127 - Glutaraldehyde Precautions6128 - Recall Policy6129 - Recall of Hospital Sterilized Items6130 - Product Recall Procedures and Product Retrieval6131 - Sterilization of Implantable Items6132 - Reprocessing of Single-Use Devices6133 - Advantages of Sterile Linen Processing in Central Service6134 - Processing of Sterile Linen6135 - Outdates6136 - Implementation Program for Event-Related Shelf Life6137 - Checklist - Steps of Event-Related Implementation Program6138 - Event-Related Shelf Life and Sterile Packaging
SECTION VII - INSTRUMENT TRAYS AND PROCEDURE CARTS
Instrument Trays Count Sheets
7001 - Angiogram Tray Count Sheet7002 - Angiogram Tray X-Ray Count Sheet7003 - Burr Hole Tray Count Sheet7004 - C-Section Tray Count Sheet7005 - Chest Tray Count Sheet7006 - Circumcision Tray Count Sheet7007 - Cut Down Tray Count Sheet7008 - Dilatation and Curettage Tray Count Sheet7009 - Eye Tray Count Sheet7010 - Gallbladder Tray Count Sheet7011 - GI Tray Count Sheet7012 - Hysterectomy Tray Count Sheet7013 - Incision and Drainage Tray Count Sheet7014 - Intubation Tray Count Sheet7015 - Kidney Tray Count Sheet7016 - Knee Tray #1 Count Sheet7017 - Knee Tray #2 Count Sheet7018 - Laparoscopy Tray Count Sheet7019 - Liver Biopsy Tray Count Sheet7020 - Lymphangiogram X-Ray Tray Count Sheet7021 - Major Instrument Set Tray Count Sheet7022 - Mediastinoscope Tray Count Sheet7023 - Muscle Biopsy Tray Count Sheet7024 - Nasal Tray Count Sheet7025 - Pelvic Tray Count Sheet7026 - Plastic Instrument Tray Count Sheet7027 - Rectal Tray Count Sheet7028 - Sigmoidoscopy Tray Count Sheet7029 - Thoracentesis or Paracentesis Tray Count Sheet7030 - Thyroidectomy Tray Count Sheet7031 - Tonsil Tray Count Sheet7032 - Tonsil Hemorrhage Tray Count Sheet7033 - Tracheotomy Tray Count Sheet7034 - "Surgery" Tracheotomy Tray Count Sheet7035 - Large Vascular Tray Count Sheet7036 - Small Vascular Tray Count Sheet7037 - Micro Vascular Tray Count Sheet
Procedure Carts and Supply Carts
7101 - Supply Cart Maintenance7102 - Procedure Cart #_____7103 - Bronchoscopy Cart7104 - Urology Cart7105 - Immuno-Suppression Unit Supply Cart7106 - Medical Unit (Includes OB and Pediatrics) Supply Cart7107 - Telemetry Unit Supply Cart7108 - Critical Care Unit Supply Cart7109 - Orthopedic Unit Supply Cart7110 - Ambulatory Care Unit Supply Cart7111 - Surgical Unit Supply Cart7112 - Rehabilitation Unit Supply Cart