How difficult is it to develop an audit tool for AS/NZS 4187:2014 Reprocessing of reusable medical devices in health service organizations ?

Ms Joe-anne Bendall, Ms Sharon Woods, Ms Kerrie Crossie, Ms Tracey Worthington, Ms Lynne Norring, Ms Georgina Rees

1Clinical Excellence Commission, Haymarket, Australia

Health facilities that perform reprocessing (sterilization and disinfection of reusable medical devices) that are undergoing accreditation require compliance with AS/NZS 4187:2014 Reprocessing of reusable medical devices in health service organizations.

The Australian Commission of Safety and Quality in Health Care released an Advisory in May 2017 which articulates the minimum requirements for accreditation. They have recommended a five year implementation plan of this Standard due to its alignment with ISO Standards, quality management system requirements, risk management framework and its lack of prescriptive procedures.  Health Service Organisations that are unable to meet the requirements of the Advisory (including progress against an implementation plan) will not pass accreditation.

NSW Health provided an audit tool to assist facilities meet the requirements of the two previous editions of this Standard. In late 2016, the Clinical Excellence Commission (CEC) formed a working party to develop a two-step self-assessment and audit tool that enables the users to identify their gaps and write an implementation plan. The self-assessment and audit tool provides a gap analysis of governance, quality management systems and staff knowledge and skill.

Following successful trials, the self-assessment and audit tool has been entered into the CEC’s Quality and Audit Reporting System (QARS) which health facilities can access.  QARS can also track actions.

The presentation will provide an overview of how:

  1. the self-assessment and audit tool is assisting NSW public health facilities meet their accreditation requirements
  2. the CEC will support NSW public health facilities meet common gaps with the Standard


Joe-Anne Bendall has worked in various nursing, management and consultancy positions since 1977. Her infection control career commenced in 1990 and has enabled her to work in private and public hospitals, public health and NSW Ministry of Health.

 Joe’s current role in the Clinical Excellence Commission enables her to use her passion for patient quality and safety.

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