What surveyors look for, and where hospitals get cited most

Sterile processing is not a “behind-the-scenes” function, it is one of the most visible indicators of patient safety, operational reliability, and regulatory readiness during accreditation surveys.  Joint Commission data makes the scope of the issue clear: in 2018, more than 50% of hospitals surveyed were found noncompliant with high-level disinfection and sterilization under Infection Control standard IC.02.02.01, EP2 (American Nurse Today, 2019). These findings reflect not isolated missteps, but systemic challenges in how sterile processing is resourced, monitored, and documented.

The consequences extend beyond survey outcomes. A direct-observation study published in BMC Surgery found surgical instrument errors in 26% of observed cases, with failures tied to inspection, identification, function, or bioburden accounting for 88.6% of all errors. In cases where delay data was available, more than half experienced operative delays, averaging 10.16 minutes per case, translating to an estimated $6.75M–$9.42M in annual lost chargeable OR minutes at a single healthcare campus (Nichol et al., 2024).

 At the same time, workforce instability continues to amplify risk. A 2025 Surgical Directions report warns that chronic sterile processing staffing shortages and underinvestment are driving delays, cancellations, compliance exposure, and patient harm—highlighting that up to 5% of surgical patients experience surgical site infections, many associated with improper instrument sterilization (Surgical Directions, 2025). Together, these data points explain why accreditation surveyors increasingly focus on sterile processing as a leading indicator of organizational safety and reliability.

How Hospital and ASC Accreditation Works

Accreditation surveys are typically unannounced, on-site evaluations conducted on a recurring cycle (often every three years for The Joint Commission). Surveyors assess compliance with infection prevention, sterilization, equipment maintenance, and documentation standards by observing workflows, reviewing records, and interviewing staff.

Surveyors frequently use tracers, following an instrument or patient through the continuum of care. This almost always brings them into the Sterile Processing Department. Their goal is not just to “check boxes,” but to confirm that safe, repeatable processes are in place every day—not just during survey week (OR Today, 2025).

What Surveyors Look for in Sterile Processing

1. Instrument Traceability and Documentation

One of the most common and consequential survey findings involves instrument traceability. Facilities must be able to demonstrate what was processed, how it was processed, when it was processed, by whom, and for which patient.

AAMI ST79 recommends that each sterilized tray or pack include a lot control identifier that captures:

  • Sterilizer identification
  • Cycle or load number
  • Date of sterilization
  • Person who assembled the set
  • Patient or case identifier when applicable

This level of traceability is essential for recalls, infection investigations, and patient notifications (AAMI ST79; 3M Healthcare, 2017).

The Joint Commission has explicitly cited facilities when they cannot produce sterilization logs, BI results, or documentation linking instruments to patients, noting that poor documentation makes outbreak response extremely difficult (Joint Commission, Quick Safety Issue 33).

2. Validated Sterilization Processes

Surveyors closely review whether sterilization processes are:

  • Validated
  • Documented
  • Consistent with IFUs

Facilities must demonstrate that sterilizers are run using the correct cycle parameters (time, temperature, and pressure) and that every load includes appropriate chemical and biological monitoring.

According to Joint Commission guidance, surveyors routinely review:

  • Sterilizer printouts or electronic cycle records
  • Load contents and identifiers
  • BI and CI results
  • Evidence that staff review and sign off on records

There is no mandated format (paper vs. electronic), but records must be complete, accurate, and readily available (Joint Commission Standards FAQ).

Failure to follow manufacturer IFUs, such as using the wrong cycle type or incorrect exposure time, is one of the most common reasons hospitals receive citations (Joint Commission, Quick Safety Issue 64).

3. High-Level Disinfection (HLD) and Endoscope Reprocessing

Flexible endoscope reprocessing has become one of the highest-risk areas during accreditation surveys. Numerous outbreaks have been linked to improperly disinfected scopes, prompting increased scrutiny by The Joint Commission and CMS.

Surveyors evaluate whether facilities:

  • Follow manufacturer IFUs and AAMI ST91 guidance
  • Perform point-of-use pre-cleaning
  • Document each step of manual cleaning and HLD
  • Track scopes to patients
  • Validate staff competency

In fact, Joint Commission data showed that 72% of hospitals surveyed in early 2018 were cited for sterilization or HLD noncompliance, most often due to failure to follow IFUs, lack of competency validation, or missing documentation (AAMI Array, 2019).

CDC guidance emphasizes that documentation of scope identifiers, patient linkage, disinfectant concentration testing, and equipment maintenance is essential to patient safety (CDC HICPAC).

4. Preventive Maintenance and Equipment Oversight

Sterilizers, washer-disinfectors, ultrasonic cleaners, and automated endoscope reprocessors must be maintained according to manufacturer and regulatory requirements.

Surveyors expect to see:

  • A documented preventive maintenance (PM) program
  • Routine calibration and servicing
  • Maintenance logs and service records
  • Evidence that staff are trained to operate and monitor equipment

The Joint Commission and CMS both cite facilities when PM is overdue or undocumented, viewing it as a system-level failure that puts patients at risk (Auxo Medical, 2024).

5. Instrument Cleaning, Inspection, and Packaging

Surveyors will physically inspect instruments and trays. They look for:

  • Visible debris or staining
  • Corrosion, pitting, cracks, or damage
  • Improper wrapping or compromised packaging
  • Inappropriate reuse of single-use devices

Joint Commission guidance warns that instruments in disrepair may not be able to be adequately cleaned or sterilized and should be removed from service immediately.

Cleaning failures such as dried bioburden, improper disassembly, or skipped inspection steps are frequently cited and often indicate broader process breakdowns rather than isolated mistakes.

Common Reasons Hospitals and ASCs Get Cited

Across surveys, the most frequent sterile processing citations fall into three categories:

  1. Incomplete or missing documentation
     Missing sterilization logs, BI results, maintenance records, or training documentation.
  2. Failure to follow IFUs or standards
     Incorrect sterilization cycles, improper HLD processes, or skipped cleaning steps.
  3. Lack of staff competency validation
     Inadequate training records or inability of staff to explain or demonstrate correct processes.

The Joint Commission has repeatedly emphasized that these issues are often long-standing and reflect systemic gaps, not one-time errors (Quick Safety Issue 33).

How Ascendco Health’s Sonar Platform Supports Compliance

Ascendco Health’s Sonar platform was built specifically to address the areas surveyors scrutinize most.

End-to-End Instrument Traceability

Sonar tracks instruments and trays from decontamination through sterilization, storage, and use, linking assets directly to patients and procedures. This supports immediate recall response and full survey-ready traceability.

Real-Time Audit Trails

Every action is time-stamped and tied to a user, creating defensible audit records for sterilization cycles, HLD, quality checks, and corrective actions without relying on paper logs.

Quality Checkpoints and Workflow Enforcement

Sonar embeds required quality steps into daily workflows, helping prevent skipped inspections, incomplete documentation, or IFU deviations before they reach the OR.

Preventive Maintenance Oversight

The platform tracks PM schedules, overdue equipment, and service history helping facilities demonstrate proactive compliance with Joint Commission and CMS expectations.

Staff Competency and Accountability

Training records, competencies, and performance data are centralized, supporting survey discussions around staff readiness and oversight.

Conclusion

Accreditation surveys are an opportunity to validate patient safety systems. For sterile processing professionals and hospital leaders, success depends on consistent adherence to standards, complete documentation, and strong operational visibility.

With platforms like Sonar, Ascendco Health helps hospitals and ASCs move from reactive survey preparation to continuous compliance, reducing risk, improving efficiency, and protecting patients every day, not just during survey week.

References 

  • American Nurse Today. High-Level Disinfection and Sterilization. July 2019.
  • Nichol PF, Saari MJ, et al. Surgical instrument errors and operating room delays. BMC Surgery. 2024.
  • Surgical Directions. Report warns sterile processing staffing crisis threatens surgical safety. September 2025.
  • The Joint Commission. Quick Safety Issue 33: Improperly sterilized or HLD equipment.
  • The Joint Commission. Quick Safety Issue 64: Ensuring critical instruments are appropriate for reuse.
  • The Joint Commission. Standards FAQs: Sterilization and documentation requirements.
  • AAMI. ANSI/AAMI ST79: Steam Sterilization and Sterility Assurance.
  • AAMI. ANSI/AAMI ST91: Flexible Endoscope Processing.
  • CDC. Guideline for Disinfection and Sterilization in Healthcare Facilities.
  • AAMI Array. “The Joint Commission Provides Guidance for Meeting Infection Control Standards,” 2019.
  • Auxo Medical. “Preventive Maintenance Requirements for Sterilizers,” 2024.
  • OR Today. “Stay Ready for Accreditation Surveys,” 2025.