MINISTRY OF HEALTH

HUANCAVELICA REGIONAL HEALTH DIRECTORATE

HUANCAVELICA HEALTH NETWORK
SAN CRISTOBAL HEALTH CENTER

IMPROVEMENT PROJECT
CONTINUES OF QUALITY

IMPLEMENTATION OF INDICATORS TO
MONITOR STERILIZATION PROCESSES FOR
THE OPERATION OF THE AUTOCLAVE IN
THE HEALTH CENTER OF SAN CRISTÓBAL
DISTRICT AND PROVINCE HUANCAVELICA

OSNAYO QUISPE, MAGALY

PAUCAR SOTO, ALBERTO

STUDENTS OF THE FACULTY OF NURSING

NATIONAL UNIVERSITY OF HUANCAVELICA

HUANCAVELICA – PERU

2019

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 TABLE OF CONTENTS

I. GENERAL DATA.................................................................................................................3
1.1. QUALIFICATION................................................................................................................3
1.2. IMPROVEMENT TEAM......................................................................................................3
1.3. DEPENDENCE....................................................................................................................3
1.4. TARGET POPULATION.......................................................................................................3
1.5. PLACE OF EXECUTION.......................................................................................................3
1.6. DURATION........................................................................................................................4
1.7. METHODOLOGY................................................................................................................4
1.8. GENERAL OBJECTIVE.........................................................................................................4
1.9. SPECIFIC OBJECTIVES........................................................................................................4
 Train health personnel in the sterilization process...........................................................4
 Guarantee the sterility of materials and equipment........................................................5
 Promote comprehensive care for users with sterile supplies...........................................5
 Strengthen teamwork within the health facility during the continuous improvement
project process ...............................................................................................................5
II. BASIC DOCUMENTATION THAT DESCRIBES AND JUSTIFIES THE PROJECT........................5
2.1. IDENTIFICATION OF THE OPPORTUNITY FOR IMPROVEMENT..........................................5
2.2. PROBLEM STATEMENT.....................................................................................................5
2.3. DETERMINATION OF THE CAUSES....................................................................................6
2.4. DETERMINATION OF INDICATORS....................................................................................6
2.5. COLLECTION OF BASELINE DATA......................................................................................6
2.6. STATEMENT OF HYPOTHESES ABOUT CHANGES OR INTENTIONS....................................7
2.7. PRIORITIZATION OF THE ROOT CAUSE TO START YOUR INTERVENTION..........................7
2.8. FORMULATION OF THE ACTION PLAN:.............................................................................9
2.9. SCHEDULE.......................................................................................................................10

BIBLIOGRAPHY
ANNEXES

2
I. GENERAL DATA.

I.1. QUALIFICA
TION.

“IMPLEMENTATION OF INDICATORS TO MONITOR STERILIZATION

PROCESSES FOR THE OPERATION OF THE AUTOCLAVE IN THE
HEALTH CENTER OF SAN CRISTÓBAL DISTRICT AND PROVINCE
HUANCAVELICA”

I.2. IMPROVEM
ENT TEAM.

 OSNAYO QUISPE, Magaly.

 PAUCAR SOTO, Alberto.

I.3. DEPENDEN
CE.

San Cristóbal Health Center, Santa Ana Micro Network, Huancavelica

Network, Huancavelica Diresa.

I.4. TARGET
POPULATIO
N.

The target population is comprised of all health personnel, who are 66

workers, including professionals, technicians and administrative staff. And
the users who are treated at the San Cristóbal Health Center, who are
6,272 beneficiaries of the SIS.

I.5. PLACE OF
EXECUTION
.

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The San Cristóbal neighborhood is located in the district, province and
region of Huancavelica, located in the city of Huancavelica, in the micro
basin of the Icho River belonging to the Mantaro River basin; The province
of Huancavelica in relation to its neighborhoods such as San Cristóbal is
located between 503144.050 East, 8587136.291 North and Height – 3703
meters above sea level.
Establishment: San Cristóbal.
Classification: health center or medical center.
Type: no exchange
Category: 1- 3
Address: back of Plaza San Cristóbal.
Boundaries:
By the East : Antaccocha Community.
By the West : Ascension District.
For the North : Palca District.
For the South : Community of Santa Ana, Community of San
Antonio and Icho River.
Political location:
 Region : Huancavelica
 Department : Huancavelica
 Province : Huancavelica
 District : Huancavelica .

I.6. DURATION.

3 months.

I.7. METHODOL
OGY.

The methodology to be used is based on the PHVA cycle, as well as on

participatory action; because it is based on critical analysis with the active
participation of the groups and actors involved that is aimed at guiding and
sustaining the practice of change and understanding the improvement that
enhances the management and use of sterilized material.

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 I.8. GENERAL
OBJECTIVE.

Implement indicators to monitor sterilization processes for the operation of

the autoclave in the health center of San Cristóbal district and
Huancavelica province.

I.9. SPECIFIC
OBJECTIVE
S.

 Train health personnel in the sterilization process.

 Guarantee the sterility of materials and equipment.

 Promote comprehensive care for users with sterile supplies.

 Strengthen teamwork within the health facility during the continuous

improvement project process .

II. BASIC DOCUMENTATION THAT DESCRIBES AND

JUSTIFIES THE PROJECT.

II.1. IDENTIFICA
TION OF
THE
OPPORTUN
ITY FOR
IMPROVEM
ENT.

Currently the San Cristóbal Health Center has a new infrastructure which
has a new Autoclave that does not come into operation due to lack of
indicators that monitor the sterilization process, it is important to have
sterile equipment and materials for medical care to avoid infections.
crusades All this with the purpose of categorizing as I-4 and being able to

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provide birth care and newborn care that require sterile materials and
equipment.
The problem arises from the need to use the autoclave with all sterilization
processes that must be controlled and monitored through physical
monitors, chemical and biological indicators.

II.2. PROBLEM
STATEMEN
T.

The main objective of a health center is to offer quality health care to the
population that comes in search of solutions to their health problems.
Within this provision of care is the prevention of the emergence of new
infectious problems derived from medical procedures. That is, avoid the
development of healthcare-associated infections (HAIs).
Sterilization and disinfection of medical items are support processes for
key processes that act directly on the patient. They have now been
universally accepted as an essential step in the control of infections
associated with health care. Its importance derives from the fact that it is
related to both ethical values by protecting users from opportunistic
infections, and economic values, since it minimizes the costs of non-
quality care.
Current knowledge of the epidemiological chain of infections and mainly of
their transmission mechanisms indicates the need to implement essential
asepsis and antisepsis practices in the entire healthcare setting (both
inside and outside the hospital) for the control and prevention of infections.
infections.
In this sense, the final objective of the sterilization and supply service is
the distribution of sterile or disinfected hospital material; already
contributing to the general process of asepsis and antisepsis in the
different procedures carried out in the institution.

II.3. DETERMIN
ATION OF

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 THE
CAUSES.

 Failure of the autoclave to function.

 Lack of input requirements by the health establishment.
 Risk of increased hospital-acquired infections.

II.4. DETERMIN
ATION OF
INDICATOR
S.

OE1 INDICATORS
 Number of meetings with the laboratory manager.
 Number of meetings with the work team.
OE2 INDICATOR
 Number of meetings to schedule the importance of indicators to
monitor sterilization.
OE3 INDICATOR
 Space to store indicators to monitor sterilization.

II.5. COLLECTIO
N OF
BASELINE
DATA.

INDICATOR START
INDICATORS  Number of Meetings with the laboratory 1
(OE1) manager
 Number of meetings to schedule the 2
importance of indicators to monitor sterilization.
INDICATORS  Number of meetings to schedule talks on the 0
(OE2) importance of using tape
INDICATORS  Space to store indicators to monitor 1

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(OE3) sterilization

II.6. STATEMEN
T OF
HYPOTHES
ES ABOUT
CHANGES
OR
INTENTION
S.

HYPOTHESIS APPROACH MATRIX FOR CHANGE

Compliance with the technical standard for sterilization and autoclave
PROBLEM
operation
Implement indicators to monitor sterilization processes for the operation of
GENERAL
the autoclave in the health center of San Cristóbal district and
OBJECTIVE
Huancavelica province.
Lack of awareness among
authorities about the Change
ROOT
importance of using hypothesi Sensitized authorities
CAUSE (1)
indicators to monitor s
sterilization.

II.7. PRIORITIZA
TION OF
THE ROOT
CAUSE TO
START
YOUR
INTERVENT
ION.

PRIORITIZATION MATRIX
No OPPORTUNITY FOR FREQUENCY IMPORTANCE FEASIBILITY TOTAL

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. IMPROVEMENT
01 Material shortage 5 5 5 15
(witness tape)
02 Inadequate 5 5 5 15
guarantee of
sterilized material
and/or equipment
03 Health personnel 3 4 4 11
are not
compromised by the
use of witness tape
04 The system and 5 3 4 12
flow of handling the
witness tape to
sterilize is not a
priority in the
sterilization area
05 Health personnel do 3 3 5 11
not know how to
handle the witness
tape to sterilize

HIGH MEDIUM LOW

PUNCTUATION 5 3 1
SOURCE: RM N°. 095 2012 MINSA

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 II.8. FORMULATION OF THE ACTION PLAN:

GENERAL OBJECTIVE SPECIFIC OBJECTIVES ACTIVITIES TASKS RESULT/ PRODUCT GOALS RESPONSIBLE

Lic.
-Train health personnel in Responsible for
Train health Commit health
the management and -Health personnel work as a -100% staff trained in the macro
personnel in the personnel to use process.
use of chemical team. sterilization processes.
sterilization process chemical indicators
indicators
UNH students

Use of appropriate
IMPLEMENT THE packaging with
- Create a stand for the
INDICATORS TO Ensure the sterility of double wrapping Work team.
MONITOR THE materials and safeguarding of chemical -Meeting to train and -100% sterile supplies CS San
plus indicators carry out teamwork
STERILIZATION equipment indicators Cristobal
PROCESSES FOR
THE OPERATION
OF THE
AUTOCLAVE OF Promote
THE HEALTH 100% of prioritized communities Work team.
comprehensive care User attention using -Using family folders -Prevention of cross
CENTER OF SAN with family folders CS San
for users with sterile appropriate materials infections .
CRISTÓBAL Cristobal
DISTRICT AND
supplies.
PROVINCE
HUANCAVELICA .
Strengthen
Raise awareness among
teamwork within the 100% of family folders Work team.
health personnel for the
health facility during Engage health Health personnel work implemented in the CS San
proper management and
the continuous personnel as a team. determined time within the Cristobal
conservation of family
improvement project schedule
folders.
process.

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 II.9. SCHEDULE.

July
Activities 19 20 21 22 23 24 25 26 27 29 30 01 02

Formation of x
improvement team.

Project planning x x

Improvement plan x
analysis meetings.

Implementation of x x
action plan
Presentation of x x
improvement plan
proposal
Plan feedback x

Delivery of x x x
improvement plan to
the health
establishment
Delivery of final x
report.

BIBLIOGRAPHY

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1. MINSA, Ministerial Resolution N º 095-2012/MINSA that approves
Technical Document 2 Guide for the development of improvement
projects and the application of techniques and tools for quality
management”
2. MINSA, RM N° 1472-2002-SA/DM/MINSA Hospital disinfection and
sterilization manual.
3. MINSA, TECHNICAL STANDARD N° 015-MINSA/DGSP-V.01 biosafety
manual.
4. MINSA, RM N° 179-2005/MINSA Technical standard for Epidemiological
Surveillance of hospital-acquired infections.
5. https://es.slideshare.net/PaulaPrez14/20-los-equipos-y-el-material-de-
esterilizacin

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ANNEXES

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 IMAGE Nº 01
CHEMICAL INDICATORS - PROCESS INDICATORS – CLASS I ADHESIVE TAPE

The different process indicators for Pupinel, autoclave and EO are observed.

IMAGE Nº 02
CHEMICAL INDICATORS - MULTIPARAMETRIC INDICATOR - CLASS IV

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 IMAGE Nº 03

RMN°616-2003-SA/DM that approves the hospital model technical standard

015-minsa/dgsp-v01 Biosafety Manual
IMAGE Nº 04

Technical Standards Filing Cabinets

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