Achieving High Reliability in High-Level Disinfection of Flexible Endoscopes at Walter Reed National Military Medical Center


The intricate design of flexible endoscopes and multi-step processes for cleaning and high-level disinfection (HLD) make the process of HLD vulnerable to human error. Missing one step or failure to complete any phase in the process can result in patient exposure to harmful contaminants which can lead to infections, increased hospital stays, increased medical costs, and even death. The clinical question explored in this project was: At WRNMMC, will an evidence-based audit process for program evaluation of HLD, compared to current practice, support a high reliability organization's (HRO) goal to achieve quality, safety, and continuous process improvement?


Graduate School of Nursing


Graduate School of Nursing



year long study


students involved


media impressions


new medication safety Practice Guidelines (ASPAN and AORN)


Donabedian’s Lasting Framework for Health Care Quality was the overarching organizing framework for this project. The CDC Program Evaluation and Audit Quality Loop frameworks guided the evaluation of data collected from 4 audit cycles, across 5 clinics, over an 11-month period of time. At the completion of data collection, variances were identified and analyzed, with evidence-based recommendations and outcome achievements disseminated based on HRO goals.


Data from 4 complete audit feedback cycles conducted across 5 clinics that perform HLD were examined for measures of adherence to 65 steps in the HLD process. The results achieved from performing recurrent audits with feedback cycles showed an improvement in HLD performance of 5.5% (91.4% to 96.9%) with the identification of 41 clinical discrepancies. These results were then used to develop 31 practice improvement initiatives, as well as, spearheaded the implementation of 22 system/process initiatives impacting over 135 areas across the organization. These initiatives included policy changes, process and organizational structure improvements, equipment standardization, and leadership buy-in that fostered a culture of safety.


Implementing recurrent audits increased compliance of HLD standards, policy, and equipment standardization across all areas conducting HLD at WRNMMC with a third order effect of decreasing patient exposure from contaminated endoscopes. The combined use of audits at prescribed intervals and leadership support created a culture that embraced both HRO goals of quality, safety, and continuous process improvement, and aligned with the Military Health System Quadruple Aim.