IHEEM audit tool update - mandatory template 5 – version 12.1

The IHEEM audit tool has been reviewed and revised by the AEDs within the IHEEM platform led by John Prendergast and supported by Sarah Marshall as the BSGdecontamination and TSE advisor, and Helen Griffiths as JAG Lead Nurse. We will now be moving to version 12.1.

You can access the updated version here

Update changes

• Executive Summary is now at the front of the Audit Tool

• All COVID references have been removed

• The summary review in section 13 gives a rating and actions to each individual process e.g EWDs, Storage, environment etc. This will help assessors see clearly where issues lie

• All references to remote audit have been removed, all audits must be undertaken in person

• AEDs now have to give their registration details. This follows non authorised engineers attempting to obtain contracts to undertake the JAG audit without the relevant qualifications

• Checks now made as to whether Labs undertaking rinse water tests are accredited to UKAS

• Email address for JAG has been added for the AED to escalate significant concerns immediately

• Transportation section now requires greater scrutiny if off site Decon is in place, or is carried out at a different site within the hospital

• Reference to cassette systems has been removed as these are no longer in use

• There has been a review of the section on vacuum packing to clarify current questions

• Adherence to 3-hour rule – question has been added to ask if providers adhere to this, mitigations if not (e.g moist bags) and how this is traced and recorded? This follows concerns around Increasing transportation times which do not meet the recommended 3 hour reprocessing rule and associated risks. 

• Drying of endoscopes – addition of extra questions to ensure greater scrutiny for testing and management of drying cabinets/systems

If you have any questions or require any additional support in relation to the IHEEM audit tool, please contact ask.jag@rcp.ac.uk