4 Key Steps for ASCs to Ensure Infection Prevention Programs Meet Survey Requirements

At the 20th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 25, infection prevention consultant Marcia Patrick, RN, MSN, CIC, and Accreditation Association for Ambulatory Health Care Associate Director Marsha Wallander, RN, discussed how ASCs can craft strong infection prevention programs.

1. Create a customized prevention program. ASCs must create infection prevention programs that address their unique issues, rather than simply borrowing someone else's policy, Ms. Wallander said.

"You've got to know what your own inherent risks and challenges are," she said. "Your risks are different than the guy down the street."

Surgery centers can create a customized policy by conducting a risk assessment. Ms. Patrick said the assessment should be collaborative because infection prevention permeates the entire organization. She said ASCs should consider factors such as the population they serve, the types of procedures they perform, their personnel and their geographic area (which can present unique risks such as earthquakes).

Once they've documented their risks, surgery centers should prioritize them based on the level of risk and the likelihood of occurrence. They can then set measurable goals.

2. Make infection prevention a visible part of quality assurance/performance improvement. The infection prevention program should line up with the center's overall QAPI initiative, according to Ms. Patrick. The infection prevention and QAPI goals and objectives should mesh concerning hand hygiene compliance, safe injection practices, surgical site infection prevention and other practices.

3. Delegate program responsibilities. The next step is to identify who's in charge of the infection prevention program. CMS requires providers to assign a designated healthcare worker to this task.

"It really should be someone who's licensed and has received training in infection prevention and control," she said.

ASCs should formally document who the designated infection prevention worker is to comply with CMS regulations, she said.

4. Avoid common survey deficiencies. Once the infection prevention program is established, ASCs should work to avoid common deficiencies cited in surveys. These include deficiencies with cleaning and disinfection, non-adherence to chosen or required guidelines, manufacturer instructions for supplies not readily available and inadequate or incorrect supplies.

Overall, Ms. Patrick said ASCs need to have solid evidence backing their practices, something more than "We've always done it that way."

"That is not a good rationale," she said.

More Articles on ASC Infection Control:
Patient Safety Tool: Ambulatory Surgery and Surgical/Procedural Checklists 
Blame Game at Play in WHO Protocol Hand Hygiene Inaction 
Healthcare Literacy: Infographic from AHRQ 

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