So, I'm delighted to introduce Nancy Schlossberg, who is currently the Program Director of Digestive Health Services at John Muir Health in Walnut Creek, California. She has broad experience in GI and endoscopy nursing, having held positions in GI and endoscopy unit staff and leadership, as well as industry. She was the 2000-2001 president of SGNA and the 2018-2019 president of the American Board for Certification in Gastroenterology Nursing. Thank you very much. It's nice to be here this morning. So, I have a financial relationship with AMBU. I'm a speaker for them. I get speaker honoraria. That's it for me. And today, what we're going to do is identify the necessity for collaboration and coordination of reprocessing activities related to endoscope reprocessing and discuss the roles of culture, leadership, and education in approaching endoscopy reprocessing. It was a great lead-in to this talk, so thank you very much. So, we were gripped by COVID. We were hyper-focused on certain aspects of mitigating the risk of preventable endoscopy procedure-related transmission of disease. We took crash courses in donning and doffing PPE. We wore properly fitted N95 masks, which was terrible and hot and really made people… It was not a fun time. We enhanced surface-level disinfection. We lengthened room turnaround times. And for a time, we closed endoscopy units for elective procedures to protect patients and staff from the risk of COVID-19. Endoscopy staff in many hospital facilities were deployed to other areas of the institution or laid off or even terminated. And possible exposure to COVID further reduced many endoscopy staffs and scope reprocessing staffs to skeleton crews. During this time, disposable duodenoscopes and newer duodenoscopes with disposable tips hit the scene, along with the mounting evidence and heightened awareness and focus on many studies evaluating the effectiveness of endoscope processing, especially drying and storage methods and the need for cleaning verification, and very importantly, the need to consider the human factor in reprocessing endoscopes. So I ask you, while the steps of reprocessing have not changed, did COVID eclipse the need for vigilant reprocessing from pre-cleaning through the storage of endoscopes? And as we fully recover from COVID, the situation may become worse because more people are having these minimally invasive procedures and physicians are doing more complicated procedures with endoscopes that may not be clean. So I ask you again, do you know what's going on in your institution? Would you be scoped in your facility? So it's time to go back and proactively back to basics and systematically evaluate and improve endoscope reprocessing protocols, and how do you know until you look? So flexible endoscopy has become an invaluable diagnostic and therapeutic tool. For a long time, we focused on the benefits of the procedure and minimize the risks of infection. The modern geoscopes focused on improved field function and internal lumen size, but as you can see, there's a lot of technology stuffed into the tip of an endoscope, and especially the scopes with the elevator channels that you see on the right side of the screen. These more complex devices feature long, narrow interior channels, some of which are too small to permit passage of cleaning brushes and other design features where debris can be forced or become caught during use. Any deviation from the recommended reprocessing protocol can lead to survival of microorganisms and an increased risk of infection. So this is my 19th procedure manual, and there were no real reprocessing guidelines, and you can see disinfection of endoscopic equipment is desirable but must be practical in a clinical setting. The long method, which is what we know today, is more time-consuming and may not be applicable between cases in a unit. Basically, they said if you read this, you can go back and you can just kind of wipe them down with alcohol in between. They did say, though, that iodophores and glutaraldehydes have been commonly used and serial microbial cultures may be obtained according to the policy of the unit to assess the effectiveness of the technique. So we were talking about this way back when, but again, it was like kind of read the fine print. There was nothing really that was written in stone or anything that was a guideline or recommendation that was universally accepted. So today, multiple studies have shown that regardless of meticulous adherence to manufacturers' IFU, biological contamination of colonoscopes, gastroscopes, bronchoscopes, and neurologic scopes remain, no matter what guidelines were followed. No cleaning process may effectively remove bacteria. The 2021 ASGE Multisociety Guideline for Reprocessing Flexible GI Scopes and Accessories is probably the most up-to-date evidence-based document addressing the continued problems encountered with improper cleaning and reprocessing of semi-critical endoscopes since the first consensus guideline that was published in 1996 and then updated again in 2003, 2011, and 2016. In 2021, the SG&A also released safety and gastroenterology setting. In these two documents, the 2021 documents and the soon-to-be-released AIME ST91, Flexible and Semi-Rigid Endoscope Processing in Healthcare Facilities, do provide comprehensive, strong, clear, and evidence-based information and direction for healthcare personnel in the processing of these devices and accessories. These documents, along with others from HCPAC and the FDA and CDC and other professional organizations stress the need for education and competency-based training as keys to ensuring a safe scope for every procedure. Endoscope processing is consistently listed among the significant hazard for the last decade because endoscopes are associated with more cases of device-related patient infections than any other medical instrument. In 2018, the Joint Commission found that 72% of hospitals and critical access hospitals and 60% of ASCs were noncompliant with infection control standards. And the reasons included not following the PNP, not adhering to manufacturer's IFU, not following evidence-based guidelines, lack of validation of competency, lack of competent oversight by an area manager, and lack of involvement from infection prevention. In 2020, if you look at the list, the ECRI list of patient concerns, you can see them here too. And responding to and learning from device problems, incidents revolving around devices and equipment can occur in any setting. And the themes are fairly common with what the Joint Commission found that I just talked about. And basically, as we go down to number six, standardizing safety across the system, policies in education must align across care settings to establish a culture of safety across the system. No matter what your resources are, whether you're small or critical, large, academic institution, everyone should be held to the same standard, regardless of the circumstances. And remember, the Joint Commission and ECRI, patients can get a hold of these as well, and they're looking. So patients are getting very savvy about what's going on in the world of endoscope reprocessing and problems that have been associated with it. So infection risks related to endoscope processing are multifactorial. Other presentations today will certainly elaborate on factors listed in the left-hand column, but I'm going to concentrate on the list on the right side. Human factors and organizations culture, lack of leadership, and lack of training and education. So let's start with the seeds of the human factor. Safety risks and errors increase with the required number of manual steps. To date, a commercially available robot or fully automated production line does not exist for reprocessing endoscopes. And still, reprocessing still requires people directly involved in the actual operational tasks. And as you've heard, cleaning some scopes requires over 100 steps and subtasks to return a properly reprocessed patient-ready scope. You can't casually reprocess a scope every once in a while. I'm sure you can add to my list of Cs. So now let's move on and talk about an organization's culture, leadership, and commitment to competency. High-reliability healthcare organizations pursue zero-harm support and support a culture of consistent improvement. They have systems in place to accomplish their goals and avoid potentially catastrophic errors. Part of being a high-reliable organization means staying vigilant and proactively identifying problems. A culture of safety is driven by clear and effective leadership with an engaged team that communicates and works collectively to minimize adverse events and fosters the willingness to change and improve care delivery. Commotion, confusion, and real or perceived pressure to hurry up and reprocess that scope do not belong in a no-blame culture. And we know that happens a lot, especially as you heard, well, we had to take some of our scopes out of circulation. So could you get that one back faster to me? I need to go. We need to get moving here. According to the 2021 Multi-Society Guideline, a high-quality and safe endoscopy unit needs to have a well-defined governance structure. Clearly outlined administrative functions and responsibilities, accountability, development of policies and procedures, risk assessment, and managing and leading quality and safety improvement efforts have been identified as critical functions of an endoscopy unit leadership team. Endoscopy units should have qualified interdisciplinary and diverse leadership and a team that meets regularly. Endoscopy leadership includes designated qualified individuals who directs infection prevention plans and addresses infection outbreaks should they occur. And we have heard that they do occur. So who in your faculty is facility is paying attention? Nobody wants to be that facility that ends up on the front page of the news. Everybody needs to pay attention. And the reality is, if you think you never had a problem, you don't know what you don't know. So back to leadership. Without effective leadership and accountability for paying attention to endoscope processing, infection risks related to endoscope processing can become a deepening pit. Because infection preventionists and the infection prevention nurse where I work and who I'm going to talk about are already working across at nearly every profession within the healthcare environment, it makes sense for them to be working with people talking about reprocessing. The infection prevention person or nurse or whoever it is in your institution brings two unique pieces to the table. Surveillance and data. They know what's happening in your institution and they have the knowledge of what needs to be done to prevent infections. They bring up failures and opportunities that some would rather avoid or ignore. But the infection preventionists, as my infection preventionist always says, they have responsibility for everything and oversight over everything, but authority over nothing. So the IPs, I'm just going to call them that, are tasked with collaborating and working with SPD and by extension all areas that reprocess endoscopes. And what they found is there's often a gap in knowledge or training as to the actual inner workings of this complex environment. So the real experts are the people who take care of GI and endoscopy patients and the equipment. The IP is dependent on that expertise and working together to mitigate infection, create realistic surveillance plans, and effectively investigate any outbreaks or issues. So pre-COVID in my institution, we had an addition of many new gastroenterologists and available block time. So our endoscopy volume took off. And the resulting number of GI scopes requiring delayed reprocessing triggered our look at all of our scope reprocessing, which in turn triggered the creation of a formal reprocessing oversight committee, co-chaired by our infection prevention nurse and actually myself. And so this is what came out of, if you don't know what happens, if you're not looking, it was that one event, it's like, man, we got a lot of scopes that are in delayed reprocessing. So here's what we created, and here's the formal charter, and it became our roadmap for cleaning up existing problems and methodically mitigating future problems. The learned wisdom has been particularly insightful during the now post-COVID normal times. The first thing we did was we created a multidisciplinary team, which included representatives that you can see listed on the left-hand side of the slide. A big part of the process is relationships. If you have them or develop them, finding stakeholders becomes easier because everybody gets the same agenda. Our leader was key in utilizing the art of delegation so that everybody completed their assigned tasks and pulled their weight, and as she likes to say, people even volunteered. So in order to take advantage of the talent in the room, though, we had to leave egos and personal agendas at the door, and we agreed that our table was a safe space. We established up front that we were going to find issues, but they're nobody's fault, but it was everybody's job to fix this. Again, in a high-reliability organization, there's a culture that is fostered, a culture of no blame is fostered, and we arrived at a collective mindset to accomplish our common goal. So this is what we proposed to accomplish. Again, demonstrating a just culture is important in our healthcare system, and so it was when it came to the table to accomplish our customer and patient safety-focused goals. It's nobody's fault when something is wrong, but it is our fault when we don't do anything about it. The committee functioned to ensure that patient safety associated with the growing body of issues, evidence-based reprocessing guidance, and changing manufacturers' instructions for use that our team identified. The right people also needed access to the findings in order to take accountability for progress in addressing issues that had been identified. So our information regularly gets reported up to senior leadership, and we never want senior leadership to be blindsided in the case of a potentially preventable outbreak or an accreditation surveyor who cites your endo lab for a gap in process. It is a very happy day when senior leadership learns about evidence-based processes that were proactively implemented to prevent endoscope-related infections. So where to start? After assembling our multidisciplinary team, we followed the disciplined scientific plan-do-check-adjust methodology to guide us through our assessment, evaluation, and improvement of reprocessing-related processes and workflows. And again, you know, some people talk about plan-do-check-act. I'd like to make that A, an adjust, because that is what you're doing. You're taking a look and saying, where did we come from? Where should we go? What should we do better? Let's put the process in place, new process in place, and let's go from there. So where did we start? We had a roadmap, but needed to agree on our first destination and how to get there. We started with a facility-wide scavenger hunt. And if you've done this, no surprise, scopes are all over the place. They were outdated. We had outdated and current IFU that were still in shipping containers, drawers, and cabinets. Each site had different, rather outdated, reprocessing policies and procedures. And they all stated they followed various professional society recommendations. So as a system, we needed to develop a standardized policy and procedure to ensure a safe scope for every patient for every procedure. After we found the scopes, which took a while, in order to update and standardize policies and procedures across the institution, we need to agree on whose standards, professional guidelines, and best practices aligned with our hospital and endoscopy units. And you know, we had, of course, you know, we had SG&E people there, we had ORN people there. So you think it's easy, but things were just a little bit different in each one. So we had to come to the table and say, what are we going to take out of all of these that we're going to reference back to that's going to become our policy and procedure? So often individuals have varying opinions, as I said. And there are so few regulatory requirements that are established as state or federal laws that regulatory agencies depend on specialty organizations' expertise to guide practice. However, when you include standards or recommendations in your policy, it becomes regulatory, because if you don't do what you say you're going to do, that's when you get in trouble. So here's some of the standards, and you can go back through those in your syllabus. I'm not going to read through them, but you can see there's regulatory, voluntary, and endoscopy-related regulatory standards. As I showed you earlier in the presentation, these Professional Society Guidelines continue to be updated to ensure that recommendations reflect the most currently available evidence. And again, stay tuned for AIME ST91 and the AORN guidelines, which, even though they have 2021 guidelines out, the reprocessing recommendations have not really been updated since 2016. So stay tuned. That's on the horizon, I believe, for this summer. So there are certain rules for developing P&P. And if a regulation exists, follow its direction. Infection prevention policies cannot conflict with law and regulation. In our institution, we depend on our infection preventionists to interpret state law related to reprocessing. If a facility is deemed accredited to qualify for CMS, policies must not conflict with CMS. And where do you find these? Again, our infection preventionists directed us to the Haystack, but it behooves everybody in endoscopy and SPD leadership to keep current in order to make changes in practice to ensure the delivery of safe patient care. Healthcare organizations have to follow manufacturers' IFUs. In the absence of clear requirements and recommendations provided by state regulations, CMS or IFUs review evidence-based guidelines or national standards. but be prepared to discuss with CMS or other accrediting agencies and surveyors why you chose that and where that comes out and where is it documented. PNP have to resolve any disagreement if they got all it has to be consistent and standardized and make sure that there's a system in place to update the PNP so that they remain current. Again, all the evidence and the documentation and research that's coming out, you can update your policies and procedures to reflect that. So we did a mock tracer. We walked through, I walked through with the infection preventionist as a second pair of eyes so that they can understand the full spectrum of disease transmission through the lens of health care, through the lens of health care from disinfection to sterilization, PPE utilization, patient movement and transport, and risk of medical devices and procedures. So typically you can contact your original equipment manufacturer to retrieve some copies of specific instructions that you're supposed to be using to clean and reprocess your scopes and many times they're accessible online, but if you have, if you've ever gotten into subscription services like OneSource, you can get in there and you can find the most up-to-date IFU from manufacturers and it really is amazing how things change. I know certainly with our scopes, it seems like we keep getting, well here's the most updated one and here's the most updated one, so you really have to keep up with that and sometimes they land on somebody's desk and they don't get opened, so you really got to keep your eyes open. So as we did our mock tracer, we had, we can use various checklists because you need to go through, are they doing this, are they doing this, and why are they doing it? And I found when I was walking through with our infection prevention nurse and you can see here, and I don't know if my pointer is working, the pictures, this is from an old, an ARN guidance, but it was really an ARN guidance, but it was really nice because it had every little picture there. This is what we're supposed to be looking for and I actually happen to be a very visual person, so this helped me a lot too and it certainly helped her because at least I'm familiar with the stuff, but she was not, so this was extremely helpful. Then we did a gap analysis and we wanted to see what we were doing versus what we should have been doing and we identified several areas of concern in order to prioritize a plan, which helped us prioritize our action plan. And you can see this, these were the steps and again in your syllabus, I'm not going to read them to you, but here they are and this is what we did as part of our gap analysis. And at the end of the day, we identified several issues and our reprocessing charter empowered us to develop and evaluate action plans to ensure a safe scope for every patient every time. So we found that pre-cleaning was not routinely performed, especially in many of the OR settings. This required education, hands-on training with return demonstration of competency. Also, as part of our product standardization initiative, we took the opportunity to conduct a value analysis of the cost and efficacy of our pre-cleaning kits. We wanted to make sure that they were the same across the system and we actually saved a little money standardizing that. After many months, we finally did draft our policy and procedure, but I will say, and I don't know if others have had this issue as you go through looking at your scopes, the TEE probes took on a life of their own and ultimately we decided they needed their own PMP. We discovered that some of the smaller, shorter scopes like cystoscopes and bronchoscopes that were compatible with STERAD were being high level disinfected and we know if you can sterilize something, you should be sterilizing it. So they are now being put through STERAD. We also found that our AER capacity or our automated endoscope reprocessor capacity and reprocessing staff could not keep up with busy endo and OR days and many scopes required extended soaps. Remember, that's what started this whole thing. So we actually hired some reprocessing staff and added some AERs and we put a system in place that documents the time pre-cleaning was completed and when manual cleaning began and scopes that now require delayed reprocessing or manual high-level disinfection are track-trended and guess what, reported up the ranks at the big infection control meetings and whenever they show up, I'm going, well, why did that happen? Why did that happen? And people need to document the reason why. Storage cabinets did not meet current evidence-based guidelines and I will say COVID set us back with site visits and options of what to purchase. We had many evidence-based discussions about hang time and we did end up using seven days, but more importantly, a process was put in place to proactively identify and reprocess the scopes that were likely to exceed hang times. COVID has delayed our final decision on what cleaning verification to use. We currently use ATP, but I keep saying we need to run a head-to-head on the carbohydrate, protein, and hemoglobin tests to make sure that they're coming out the same way, that if ATP says less than 200, we should not be finding protein, carbohydrate, or hemoglobin on those scopes. We're still using scopes. We're still in the process of deciding a routine endoscope, especially duodenoscope surveillance. We're using scopes with the disposable tips and we're trialing disposable scopes, but we still haven't quite figured out what we're going to do about that. And importantly, we've got to talk a little bit about repair tracking, especially the workhorse gastroscopes, colonoscopes, and in interventional units, we do a lot of EUS and duodenoscopes. Those scopes can be damaged. The more you use scopes and the more you put them through high-level disinfection, the more chance there is that they're going to have a repair that you may or may not know about. Biofilm can attach anywhere and tracking and trending helps us paint a picture of common avoidable repairs. So again, if you start seeing some cracked tips and you see a trend for that, that often comes from knocking the scopes against stainless steel sinks. And our scopes are processed remotely in SPD, so I don't know what happens when they get down there oftentimes if someone just kind of plunks them in the sink and goes, okay, no problem. But again, things you have to look for. Angulation repairs often result from storing scopes with control levers in the locked position. So every time I walk through, I go, hmm, are they hanging there? You know, I said, there's always one that I've got to put in the neutral position. So after you've gone through this, and we have, it's great. You can celebrate. We did a lot of great things, but guess what? Just when you think you're finished, it's time to start again. And we will do scheduled and unscheduled audits through the reprocessing area to determine if staff is following our new policy and procedure and correct performance of reprocessing steps is baked in all of the time, not just when somebody is watching. So remember the Hawthorne effect, observation changes behavior. If someone knows you're watching, they're going to do the right thing. But how do you train and educate staff to want to do the right thing the right way all of the time? So let's talk about the importance of education, training, and competence. Since the majority of training is OTJ or on the job, many organizations neglect consistent education and proper training. Facility policies and procedures need to address regular didactic and hands-on return demonstration competency-based education and training, whether it's a tech or an RN who reprocesses the scopes. And remember, I just told you that our scopes get processed in sterile processing. However, the nurses who are working up in the rooms need to do the pre-cleaning. And we were actually cited by the Joint Commission because we didn't have their competencies checked off. But it's critical that everybody who touches those scopes demonstrates hands-on knowledge and skills necessary for pre-cleaning, testing, decontamination, inspection, disinfection, transport, storage, in accordance with industry standards, guidelines, and regulations, and manufacturer's instructions for use. The 2021 Multi-Society Guidelines stresses the importance of staff training and demonstration of competency. But the how is just as important as the what. That's the what. How do you remember? Remember back to the human factor. How do you get there? And how do you validate? How do leaders, remember we talked a lot in the beginning about how do leaders in the pre-processing staff understand that we're all stakeholders? It's not just our patients. You, your colleague, your friend, your family member could be at the other end of the scope. Remember, I started out with the question, would you be as scoped in your own institution? So here are some strategies that I've put in place or observed as best practice over many years. First, be a ring leader, if you're the leader. Like a ring, the leaders can be too loose or too tight, and the best ones are there when the staff needs them and gone when they don't. You need to be open, understanding, and support staff, especially when they tell you, I'm stressed out because they're telling me to hurry up, and I know I'm not supposed to be hurrying up because I'm going to miss one of those hundred steps. So designate reprocessing staff, and I can't tell you, you know, not everybody wants to touch these scopes, and just because you rotate people around doing procedures or anything else, dedicated reprocessing staff, when you have that, your scopes show, actually show less repairs, and because they care about their scopes, and they do these scopes every single day, you can't reliably reprocess an endoscope every once in a while. So while not easy in these days of barebone staffing, you need to carve out sufficient time for instruction and hands-on return demonstrations. It's like see one, do one, teach one. One and done is not. You have to leave time for this. New staff needs to receive instructions, training, and have competency documented before being assigned to perform high-level disinfection or sterilization of endoscopes on their own. Additionally, competency evaluation should be performed and documented for personnel that reprocess endoscopes on the schedule defined by the organization. It is time and dollars well spent when you avoid repairs because leak testing was not done appropriately, or the joint commission cites you for having, for not documenting pre-cleaning competencies from the endoscopy staff. Original equipment manufacturers are required to commit time and resources to training, and you need to, if they haven't, if they're not coming in there and doing that on a regular basis, you can call, and you can call them and certainly contact them, and they should be there when you need them, when you get new scopes, when something's a problem, when you get new staff, and it's important that they're there. And probably some of you know on the newer, the newer duodenoscopes with the disposable caps, the manufacturers would not, would not put that, let you put them into use until they had trained staff to use them. So use competency-based training lists for every, every model of every endoscope to validate hands-on demonstration of reprocessing steps. Now, where do you get those? Again, you have to get them back, some, some of the manufacturers are better than others about being very specific in those competency-based steps. However, if you look at that, all of a sudden you have this thick packet of papers with 15 steps on every page times 10 pages. It's a lot of steps. So collaborate with your infection prevention nurse to routinely audit staff for compliance with all steps involved in reprocessing. In a high reliability organization culture, blame-free staff feedback is sought. I'm sorry, you know, I can't do this. They're moving me too fast. How can we all improve this situation? And I will say endoscopy unit leaders have no excuse not to keep up to date because ultimately that's where the responsibility lies, but you can't be available 100% of the time. So one thing to do is to consider signing up for the SG&A Infection Prevention Champion Program, which provides the tools and the knowledge to analyze the current infection prevention practices and identify opportunities for improvement or change based on the most current regulation standards and practices. They kind of feed the champion exactly what's new on an ongoing basis. Champions also work with the hospital's Infection Prevention Nursing Committee to review processes, education, and training. Carve out time. Put infection prevention in services on your educational calendar. And if you don't have one, put together an educational month by month or however you want to do it, but put it down and get it there so people will know to attend and know what's coming next. Vendors offer a lot of free contact hour, approval live, and video educational courses. And finally, encourage staff to become certified in endoscopy reprocessing. And I'm sorry I flipped the slide too fast, but really encourage staff to become certified. There's ISHM and CVSPB. And the certifications are designed to recognize individuals who have demonstrated the knowledge and skills necessary to pre-clean, test, decontaminate, inspect, disinfect, transport the scopes in accordance with industry standards, guidelines, and regulations, and manufacturers IFU. And even studying for that test, the study manual for the ISHM that I had was a great refresher in everything that you're supposed to do. So share that around. And really, if you study, it really brings great gratification personal and professional to get that certification. So in summary, infection prevention is critical to the success and safety of any endoscopy unit. Close adherence to established guidelines for reprocessing all endoscope equipment is essential to preventing transmission of pathogens and providing safe GI endoscopic procedures. Culture, leadership, and competency are key to fostering a philosophy of competency-based training for every person who processes endoscopes. And proactively implementing methodical, multidisciplinary, programmatic approach will ensure a patient-ready scope every time. So I thank you for your time and for being part of this faculty today. Thank you so much again for that wonderful talk. Really appreciate you giving that fantastic overview of sort of how we should think about our leadership teams and the training of our staff. I had one or two questions. First, I was curious, you know, and you have a lot of experience in going to various endoscopy units across the country. I'm curious, when you go to visit them, how do you begin approaching when you're examining those endoscopy units, when looking at training and their leadership teams? Kind of what is your approach and what are you looking for? Well, one thing that I've learned over the years is you can never walk in anybody else's shoes. And just because you think, oh, I'm here, you're always a threat to people when you walk through the door. But you just kind of have to hang in and kind of figure out where the biggest trouble spots are. I usually just walk around and I'm just here to follow you. And we're just going to kind of compare what's going on. And this is a really good thing, because when you do things right, people need to be congratulated for doing things right. And I've often said that the person who gets the least recognition are the techs. And those are the people that you really need to kiss, give candy, whatever you need to do, because that is the weakest link in the chain. So I think whenever you go in, again, you can't walk in other people's shoes, is just to say, I understand what you're doing. And I'm just going to take a look to figure out, you know, maybe just to figure out if there's anything that's new and different. And I will say that there's pluses and minuses to having a self-contained unit that has your own reprocessing within the unit. But when you start having distant reprocessing, and people are doing surgery scopes, as well as your flexible end scopes, there's usually a fairly big gap. And I have to always go in and say, I appreciate what you do here, because I'm not a sterile processing queen. I don't have blue hair. I don't, you know, all day long. But I hope that answers your question. You just have to appreciate the culture of where you are, and then how the individuals who are there and where they're coming from. Thank you for that, Nancy. The last question I have, and you spoke eloquently about it, was really, it's important to have a strong and competent infection control leadership team, and the leadership team within the endoscopy unit. And I really liked how you sort of outlined that and discussed it into some greater detail. I'm wondering, how do you think about the leadership team? Like, who do you really feel should be on it? And then, how do you recruit for that? Like, how do you make sure? Because a lot of times in institutions, people may get selected for and may not want the position. So, who are you looking for? Kind of, what are the qualities? And how do you kind of recruit and retain them to do it and continue it? Great question. You know, you always want somebody from endoscopy in there with you, and hopefully, and I don't want to say the nurse manager should be part of the team, but they're not always the ones who are the real hands-on experts to go, no, no, no, we don't do it that way. It's like, oh, you know, we've got a problem here. But so, you need, in our institution, remember, I said we process remotely. We needed the sterile processing people on. We needed, and then, one of the unit nurses on. We had the nurse manager on. It's all about the relationships and who you think is going to be able to really contribute. The other people who need to be on, depending on what your circumstances are, and I'm finding more and more that, for better or for worse, endoscopy units fall under the purview of the O.R. So, the O.R. directors really need to be there. We have people come on and off. You know, as I said, senior leadership, we often have a person on from there, but they're sort of on the as-needed basis, especially when you go to get something approved. You know, can we really do this in our institution? And I just think it's your key stakeholders, but that infection prevention, you know, you hope that you have a very proactive infection prevention nurse because they're the ones who actually can kick it up, you know, because when infection prevention talks like, we've got some problems here with our scopes, people start listening. But again, I continually kind of go, here's a great presentation, or did you see these guidelines, or whatever, because they need to know because that's who will kick it upstairs, and people will listen and go, any risk of infection in the hospital is not good, as everybody in the audience knows.

collaboration

leadership

education

endoscope reprocessing

COVID-19 impact

patient safety

training

healthcare-associated infections