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We’ve Always Done It This Way
By Sara Freiberg

One of the most dangerous phrases in business is “we’ve always done it this way,” and this phrase extends to healthcare, as well. Organizational routines are patterns of behaviour that are followed repeatedly, but are subject to change if conditions change.1 We can all relate to routines and predictability, whether in our personal or professional lives. With the ongoing changes, updates, and technological advances in the healthcare arena, today’s healthcare staff face multiple demands and must also review multiple guidelines, as they are constantly evolving to contribute toward improved patient safety. Therefore, shouldn’t we learn and evolve with the most current practices, as well? “We’ve always done it this way” does not always equate with best practices and evidence-based guidelines. We sometimes become so accustomed to our routines that we have no idea where they actually originated from or why we continue to do what we do. When we hear feedback from staff such as, “New people come in with different ideas, we like things the way they are,” or the dreaded, “We’ve always done it this way,” it may be time to question the status quo.

We may ask if our current practices could be outdated or if there are recent publications that either support or refute our current practices. If so, what do the studies and literature suggest and what does the data tell us? In healthcare, we follow the regulatory, manufacturer, and best practice guidelines to remain current in the industry, maintain our accreditation, and most importantly, for patient safety. While outdated routines may be traced back from prior training or existing department policies, they are uniquely capable of being updated to mirror current best practices. How do we know for certain if we are performing outdated or incorrect practices? The first step involves reviewing the most current guidelines.

The CDC says to follow the guidelines published by government agencies and professional organizations.2 Sterile processing and OR staff would benefit greatly by following the current standards and guidelines set forth by regulatory and professional organizations such as AAMI, AORN, IAHCSMM, SGNA, AST, manufacturer’s IFUs, FDA, TJC, APIC, OSHA, etc.

The Joint Commission states that “…standards are developed with input from healthcare professionals, providers, subject matter experts, consumers, and government agencies (including the Centers for Medicare & Medicaid Services). They are informed by scientific literature and expert consensus. New standards are added only if they relate to patient safety or quality of care, have a positive impact on health outcomes, meet or surpass law and regulation, and can be accurately and readily measured.”3

A new standard is currently in process for AAMI-ST91 2015 Comprehensive guide to flexible and semi-rigid endoscope processing in health care facilities. AAMI committees prepare draft standards using input from technical advisory panels, experts and other stakeholders. These draft standards are distributed for review and made available for comments. Following input, standards are reviewed and approved by members within the committees. The approved standards are published for healthcare facilities and ongoing feedback is continually captured for the purpose of continuous improvement to these standards. If you would like to participate in updates and modifications to a standard, join a committee.

The importance of following current guidelines
Referring to and following the regulatory and manufacturer guidelines is important, and remaining current to these periodic updates is even more crucial. Remember when time-out in surgery became a requirement for all accredited hospitals, ambulatory care centers, and office-based surgery facilities? Originally introduced by AORN and defined by The Joint Commission in 2003 as an immediate pause by the entire surgical team and a universal protocol for preventing wrong site, wrong procedure, and wrong person surgery. When a time-out is practiced in a step-by-step manner, with true involvement of all members of the team led by the surgeon, checklists are extremely effective as they contribute to improved patient outcomes. We still have to make some progress; however, incorporating a time-out has reduced errors and contributed to better processes and better patient outcomes.4

This month, for example, The Joint Commission published Additional Revisions Announced for Hospitals and Critical Access Hospitals including the release of Standards Revisions for Organizations Providing Fluoroscopy Services.5 Hospitals should review the capability of their fluoroscopy equipment and whether it can capture radiation exposure metrics. Older equipment, legacy units, may not have the capability to capture radiation exposure in the required metrics; therefore, if a facility owns older equipment that cannot capture the required metrics, it will need to document the fluoroscopy time and the number of images captured. (See Prepublication Standards Revisions.)

Manufacturer IFUs are also updated periodically. If facilities use a platform such as OneSource, they will find at the top of the homepage a Recent Revisions icon, entailing weekly revisions to various manufacturers’ IFUs. It is our responsibility to remain current to any changes and incorporate and train our staff accordingly.

How we can improve
Most facilities have replaced paper policies and procedure manuals with electronic policy libraries available on the organization’s intranet. This enhances staff ease of access and provides a library containing the policy name, subject, and department.

Create an electronic archive for storing retired or prior versions of policies. Immediately remove a policy that has been officially retired or replaced from the active database and transfer it to a designated archive.

  • Have access to current guidelines (AAMI, AORN, SGNA, OSHA, manufacturer IFUs, APIC, etc.). Designate a leader to oversee policy development, approval, and periodic review by the appropriate policy owner(s).
  • Train department managers in their use.
  • Train staff on guidelines and compliance for new employee orientation programs,including floating, part-time, weekend, and traveling employees. Employees should review new or revised policy prior to its effective date, sign it, and it should be kept on file.
  • Implement a feedback mechanism so staff can report situations to management that result in a near miss event or necessitate some form of workaround.
  • Create a tracking mechanism that will identify when each department policy’s periodic review is due, issuing advance notice to the policy owner to assure a timely response.
  • Create a system-level policy and procedure oversight committee and subcommittees for each department (OR, SPD, infection control, biomedical engineering, etc.).
  • Review guidelines and policies periodically to uncover any new practices and guidelines.
  • Failure to do so may cause a staff member to follow an outdated policy, possibly compromising patient care and leading to allegations of corporate negligence.6

We must continually evolve and keep pace in the healthcare arena to improve in all aspects of what we do. We owe it to our patients, ourselves, and our organizations to incorporate the necessary changes that improve patient safety, workflow, and our business. In place of hearing the antiquated term “we’ve always done it this way,” our patients, departments, and facilities will thank us if we have the mindset that we can do better. We can always do better. Patient safety depends on it.


  1. https://ir.stthomas.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1029&context=ocbopmtpub
  2. https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html
  3. https://www.jointcommission.org/facts_about_joint_commission_accreditation_standards/
  4. http://bulletin.facs.org/2017/06/time-outs-and-their-role-in-improving-safety-and-quality-in-surgery/
  5. https://www.jointcommission.org/standards_information/prepublication_standards.aspx
  6. https://www.psqh.com/analysis/policies-and-procedures-for-healthcare-organizations-a-risk-management-perspective/






Sara Freiberg, CST, CBSPDT, CER, has more than 15 years experience working as a certified surgical technologist, with five of those years spent traveling to various operating rooms across the U.S. Following Sara’s time in the clinical arena, she worked as a surgical technology didactic and lab instructor at Rasmussen College. Sara holds bachelor degrees in science and business and marketing, which led to her work with various medical device companies as a clinical specialist, product manager, and clinical training manager. She has experience working on quality and regulatory teams, monitoring patient-adverse events, and postmarket surveillance activities.

Sara currently works for Northfield Medical as a clinical education manager where she provides education which is based on current manufacturer and regulatory guidelines regarding various healthcare topics for SPD, OR, and GI staff. Training entails the care and handling of medical devices to ensure patient safety, as well as targeted education addressing departmental cost concerns. Her passion is working with SPD, OR, and GI departments; providing assessments; and sharing best practices with respect to patient and staff safety, surgical instruments, and medical devices. Sara is a voting member of the AAMI ST/WG84, ST91 flexible endoscope committee, and she has developed several CEU presentations approved through CBSPD, CBRN, NCCT, and IAHCSMM. Sara also authors a biweekly healthcare article for Ultra Clean Systems.

Sara is currently studying for the Certification Infection Control (CIC) exam through APIC.

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