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Development of an Education Plan in CSSD

Updated: Mar 10, 2022

One of the most glaring aspects of training in CSSD is the lack of an education plan. For starters, a majority of the CSSD departments don't employ an educator role. The role of an educator is usually performed by several positions in the department and is filled by management and non-management staff, often with a lack of consistency. However, to meet the standards of CMS accreditation surveys, the staff are expected to be educated and competent. To begin the development of an education plan is to put practice to paper so that no area is left uncovered.


The Joint Commission’s glossary defines orientation as "A process used to provide initial training and information while assessing the competence of clinical staff relative to job responsibilities and the organization’s mission and goals."[1] This is our obvious starting point for an education plan. With numerous subject areas to cover such as:

  • Tour of department

  • Job Descriptions

  • Job Duties

  • Performance Expectations

  • Emergency Response

  • Patient’s Rights

  • Employee Rights

  • Information Management Systems

  • Incident Reporting

  • Department Equipment

  • Infection Control

Within CSSD, there are many more areas that are job-related and must be covered, such as decontamination, preparation and packaging, and sterilization activities.


“Competence is defined in the context of particular knowledge, traits, skills, and abilities. Knowledge involves understanding facts and procedures.”.[2] As discussed in my previous article “Certification vs. Competency” departmental competencies should be completed at the time of hire while also completing a comprehensive orientation plan. They also should be completed on an annual basis. The basis of the decision of what annual competencies should be completed should fall to your annual risk assessment and needs of your department.

Risk Assessment

The Joint Commission’s Infection Prevention and Control (IC) standards require organizations to use the risk assessment process to set goals for a comprehensive infection control plan. Specifically, Standard IC.01.04.01 states, “Based on the identified risks, the [organization] sets goals to minimize the possibility of transmitting infections.”[3] The ANSI/AAMI ST:79 2017 publication recommends the use of cross functional teams to evaluate risk with regards to sterilization failures.[4]

Continued Education

Annual education is the support system for “competency” and should be based on your risk assessment. So, how do we get this accomplished? There are several ways to develop the process of delivering continued education to the staff in sterile processing. In one of my previous positions, I held the responsibility of educating and completing competency reviews at our main hospital, 4 ASC centers, and over 30 offsite Specialty Care Centers. The total number of employees was around 140 or so. I was, however, lucky enough to be allowed to hire an educator. It still was a daunting task. With the CPD Educator and our Quality Management team, we developed a process delivering the education via our mandatory education system, like a webinar process. Tests were taken online and recorded. We were able to review compliance at each site. Reports were ready to be printed at any time, and a record of education was always available upon request. Competency reviews were managed by a train the trainer process. A lead person was selected at each site and trained on the competency tool. They also had a competency completed annually on their performance. That is a large-scale approach. Not everybody has that capability. For small scale approaches the train the trainer process still works well. The utilization of computer systems is advantageous. Group education supplied by partnered industry representatives works well too. Just make sure they meet the goals of your designed education program so that you reduce the risk that you evaluated for your department.

Annual Review

Each sterile processing department should utilize a risk assessment annually, then develop education that maps to their risks. Utilization of internal and external sources will help to deliver training in a timely manner that will increase the competency of your staff, and improve the safety of items produced with CSSD.

At Evolved Sterile Processing, our consultants have a greater focus on sterile processing. With our decades of experience, we will help you develop better processes and educational resources for your staff.

[1] The Joint Commission 2019 (HR.01.04.01)

[2] Neeraj Kak, Bart Burkhalter, and Merri-Ann Cooper

Measuring the Competence of Healthcare Providers Quality Assurance Project July 2001 Volume No. 2

Issue 1 p.3

[3] Joint Commission International Accreditation Standards for Hospitals, 4th Edition. Chapter 3, p.71

[4] Association for the Advancement of Medical Instrumentation.

Comprehensive guide to steam sterilization and sterility assurance

in health care facilities. ANSI/AAMI ST79:2017

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