Darling Downs Health Reprocessing Compliance and Governance project

Overview

Initiative type

Service Improvement

Status

Deliver

Published

June 2025

Summary

Meeting AS5369:2023 Compliance across the district gave rise to multiple challenges in information gathering, transparency and maintenance to ensure compliance with the relevant commission notifications.

Dates: 1 December 2023 -

Implementation sites

Toowoomba Hospital

Aim

To implement, maintain and monitor compliance with AS5369:2023.

Outcomes

AS5369 Audit Tool

  • Complete gap analysis tool
  • Results and mitigation section
  • Automated Action reminders

DDH Reprocessing Equipment Register

  • Validation of equipment register
  • Maintenance of equipment record register
  • Automated validation reminders

DDH Water Quality Application

  • Out of Specification automated emails
  • Automated out of specification reminders for outstanding actions.
  • Centralised Teams Portal for the District.
  • Private channel for Auditing
  • Private Channel for Policy and Procedures

Background

The project was initiated to address significant gaps in compliance with the Australian standards AS4187 and the newly introduced AS5369. Prior to this project, there was no district-wide system or centralised register for information critical to these standards. Instead, data was stored in isolated Excel spreadsheets, which contained limited information and did not provide a comprehensive gap analysis for the new standard. This fragmented approach hindered the ability to ensure compliance and posed risks related to the transmission of infections through the reprocessing of reusable medical devices.

The central question addressed by this project was: How can we create a centralized, transparent, and ongoing register of data and information to ensure compliance with AS5369?

To align with the requirements outlined by the Australian Commission on Safety and Quality in Healthcare, the project aimed to develop and implement applications that would consolidate data on equipment, water quality, and gap analyses. These applications were designed to provide a comprehensive and accessible register, facilitating continuous monitoring of compliance, hence minimising the risk of healthcare associated infection transmission. By centralising this information, the project sought to enhance the transparency and effectiveness of compliance efforts across the district.

Methods

Establishment of the Team
To address the compliance issues, we established the DDH Reprocessing Compliance and Governance Team. This team consisted of the ADON Clinical Redesign and the NUM Reprocessing Compliance Manager. Our initial step involved conducting site visits to gather baseline data and assess the level of compliance using the newly developed AS5369 Audit Tool.

Initiatives Developed and Implemented
We created a Central MS Team for DDH Reprocessing Compliance and Governance. This team facilitated the distribution and access of information to district-wide site responsible officers and subject matter experts. The implementation process included site visits and education sessions to ensure the effective use of the tools and their ongoing application.

Implementation Process
Audit Tool:
The Audit tool was created in Power Apps utilising a SharePoint List for the detailed questionnaire aligning to all aspects of the new Standard AS5369. Audits are conducted at each site by DDH Reprocessing Compliance and Governance team to ensure constancy of audit process. All Action items appear in APP to the Site Responsible officers for population of mitigation and corrective strategies. Audit results are immediately available including a dashboard displaying site and district wide compliance.

DDH Reprocessing Equipment Register
Data collection was performed manually for each piece of equipment, which was then entered into an equipment register supported by a SharePoint List. Upon completing all site visits, we established a comprehensive register of all reprocessing equipment, including SAID numbers, serial and model details, and photos of each item. Automated reminders are sent at 60/30/1 days for upcoming Validations to ensure items are maintained within the 12 months as per the standard. Expired items are flagged as not for use.

Water Quality
Water quality testing results are also recorded in a SharePoint List. Automation is achieved through collaboration with an external provider responsible for collecting, measuring, and reporting to DDH Reprocessing Compliance and Governance Generic account where through Power Automate out of specification notifications are sent including their recommendations. 3 daily automated reminders are sent for incomplete action items.

Improvement Methodology
We employed Clinical Redesign Methodology to guide our improvement efforts. This approach ensured a systematic and structured process for enhancing compliance and governance across the district.

Discussion

What was necessary for the project to succeed - environment / context?

  • It was necessary to create a single data repository that can easily be accessed by users and shared as required either directly or within applications.
  • Ensuring Subject Matter Expertise within the Compliance and Governance Team
  • Support from Executive throughout the district and Digital Health Teams.

What were the lessons learnt and limitations?

  • Essential communication outlining key requirements ensuring engagement with key stakeholders.

What were the Strengths, Weaknesses and Opportunities?
Strengths

  • Transparency, ease of access to data
  • Automation ensuring continues compliance and engagement.
  • Alignment to Standards and requirements
  • Scalability and ability to share.
  • Adaptability of the team to pursue different approaches to ensure engagement.
  • The project has the potential for broader implementation in all reprocessing facilities statewide within Queensland Health.

Weakness

  • Small two-person team with one Subject Matter Expert and one clinician/ application developer
  • Change fatigue and reluctance to engage due to previous repeated attempts resulting in limited actions.

Opportunities

  • There are opportunities to refine and upscale the solution to enhance its effectiveness and reach.

What Would Be Done Differently:

  • Expanding the team to include more subject matter experts and clinicians would distribute the workload more effectively and bring diverse perspectives to the project.
  • Implementing a robust change management strategy to address change fatigue and increase stakeholder engagement from the outset.
  • Adopting an incremental approach to implementation, allowing for adjustments based on feedback and ensuring smoother transitions.

Next Steps:
The next steps involve refining and upscaling the solution to ensure it meets the evolving needs of the district and continues to support compliance and governance efforts effectively. Steps have begun to investigate the opportunities for the use of the Audit Tool across Queensland through Statewide AS5369 Working Group. Two additional Regions have adopted the Audit tool for completion of their own audits.

References

Standards Australia. (2023). Reprocessing of reusable medical devices and other devices in health and non-health related facilities (AS 5369:2023)

Australasian Health Facility Guidelines (AusHFG). (2025). Part D - Infection Prevention and Control.

Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019)

Key contact

Craig Harrower

Assistant Director Of Nursing, Clinical Redesign

Darling Downs Hospital and Health Service

Email: craig.harrower@health.qld.gov.au

Last updated: June 2025

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