Carol Hiatt, RN, LHRM, CASC, a licensed risk manager in Florida, AAAHC surveyor and consultant for Healthcare Consultants International, a subsidiary of AAAHC, shares 11 strategies to help surgery centers overcome physician and staff resistance to complying with infection control guidelines and policies.
1. Involve leadership before implementing changes. A critical mistake Ms. Hiatt has seen organizations make is trying to get everyone in a facility to comply with standards and new policies before "selling it at the top." "By that, I mean, they don't involve leadership before they start the implementation, so they don't lay the groundwork for success," she says. "It's important that they get in front of the physicians and governing body and explain the goal of needing to maintain accreditation and Medicare certification."
It is helpful to explain the need for maintaining accreditation and Medicare certification in a way that will catch the attention of leadership — by tying it to financial stability of the facility.
"By tying it to the bottom line, sometimes all of a sudden, things seem a little more important," Ms. Hiatt says. "This can be done by sharing some examples of surgery centers they have heard about that have suffered from difficult consequences as a result of not being compliant. There are a number of centers that have been closed because of a condition-level deficiency and lost revenue for a period of time. Some of these centers have been closed for months. So the last thing [leadership will want] is to find itself in that position as well."
2. Educate leadership on quality reporting requirements. In the fourth quarter of 2012, Medicare-certified ASCs will be required to begin reporting quality data to CMS. Five of the eight outcomes CMS will require for reporting (phased in through 2015) are either directly or indirectly related to infection control, Ms. Hiatt says.
Surgery centers that fail to report data to the Medicare program in 2012 will receive a 2 percent reduction in Medicare payments in 2014, and failure to report in subsequent years will affect future years' payments in the same way. While the program does not currently stipulate basing payments on performance to these quality measures, a pay-for-performance system that penalizes ASCs as low performers is "coming sooner than we think," Ms. Hiatt says.
"Hospitals already don't get paid when an infection develops that's unrelated to the patient's admitting hospital diagnosis. If a patient comes in for an appendectomy and develops a secondary infection that's unrelated to the primary diagnosis, the hospital doesn't get paid for that," she says. "This will happen to ASCs in the future. When we start having to return patients to the OR for an irrigation and debridement because an abscess developed, if we're billing it now, we won't get paid for treating the infection once this all kicks in. Educating physicians and leadership about this change is going to make it a little bit easier to get buy in from the top."
3. Appoint an infection preventionist "champion." To meet infection prevention and control standards, organizations need to appoint an infection preventionist and the governing board needs to approve the appointment. But all too often, Ms. Hiatt sees organizations relegating this role to the willing, and oftentimes it's a part-time person who doesn't work in the operating room environment.
"That person is probably not going to be respected by the doctors and the staff," she says. "I believe it's important that when you select your infection preventionist, that you select a 'champion.' They don't have to be the most knowledgeable person in the organization at the point they are selected as long as they're a member of the staff who is respected by all staff members and doctors. You can train them – that's part of this process — they're supposed to be properly trained. If you pick the right person, then staff and doctors are going to respond better when this person starts reinforcing some of the points in infection control that are important."
Ms. Hiatt says she has visited Medicare-certified organizations that have not updated their infection control program policies and procedures since the 1990s because these organizations lack such a champion.
"Someone has to own the process, show leadership how important it is, and get them to buy into it," she says. "When we miss that piece, it's destined to fail."
4. Identify and overcome obstacles to buy-in. Once selected, this infection preventionist champion needs to identify key leaders in the organization and ask them what is necessary to get their support for the organization's infection prevention and control program, Ms. Hiatt says. These are leaders such as the chief of surgery, director of anesthesia, pre/post-op leader or surgical tech leader.
"The infection preventionist needs to ask them what they need in order to comply with the standards that affect their area, and once they answer, [the infection preventionist] needs to take time to research and learn what can be done to eliminate the obstacles that stand in their way," she says. "Once you ask them and take some steps to remove the obstacles they have identify, it's a lot easier to hold them accountable in the future."
Sometimes those obstacles may require simple fixes. For example, anesthesia providers may need to take on and off gloves multiple times during the course of initiating and administering general anesthesia, and the World Health Organization (WHO) says anesthesiologists are supposed to follow certain hand hygiene practices when removing and putting on gloves in the OR.
"I'll go into an OR and guess what: There's no alcohol-based rub or hand hygiene product close to where [the anesthesiologist] is," Ms. Hiatt says. So it's impossible for him/her to be in compliance without stepping away from the patient, and they can't do that because that's not safe.
"Or you tell him/her that they have to label their syringes and yet we haven't provided labels that make this easy," she says. "These are some basic obstacles that sometimes get overlooked."
5. Expect resistance, then educate. Change is never easy, whether the change is positive or negative. Remember, if you're asking physicians or staff members to change the way they've done something for many years, you may face resistance because they're comfortable with their outcomes and don't want to change their practices. To bring about change that will become the new norm will likely require education.
"You have to introduce them to what the current standards are, and you have to remind them that if they had a bad outcome and these were not the standards they had used at the time of surgery, it wouldn't be defensible," Ms. Hiatt says. "People don't always understand the why, and if they don't understand the why, it's hard to get them to cooperate. Make sure they have the knowledge they need to do these processes in a manner that meets these standards."
6. Train, and document the training to emphasize importance. One of the requirements of a compliant infection control program is the education of employees on infection prevention and control when they are hired and then annually thereafter. This training needs to be documented to meet requirements, but documentation performed in such a way can also help hit home the importance of the training.
"After you present on something, you should have the staff members sign for their accountability [on the presented information] or have them take a quiz at the end of that training so they realize it isn't just a talking point," Ms. Hiatt says. "Now you're having the staff understand they are accountable to what was just presented, so they may take it more seriously.
"However you do it, you have to train the staff, invest that time and help them realize it's important enough that you're investing the time to train them," she says. "If a staff member tells you they haven't been trained in infection prevention and control, you can't expect them to be in compliance with the program."
7. Catch and highlight staff members doing things right. While it is certainly important to catch non-compliant actions (see strategy #8), it can also be beneficial to catch compliance. "You should try to catch [staff members] doing things right, like complying with good hand hygiene practices," Ms. Hiatt says. "Then brag on them. Praise them for it in front of their peers and leadership. This will help make them a champion in the organization."
8. Encourage accountability in an appropriate manner. "Ask the staff to allow their peers to hold them accountable," Ms. Hiatt suggests. "If they see someone doing something that's not in compliance with the WHO good hand hygiene practices, or safe injection practices ask them to hold each other accountable at the right time, presented the right way, and it will really help an organization."
For instance, the OR circulator and the anesthesia provider can work together by monitoring hand hygiene practices, medication practices and syringe usage as a team – things that would certainly be identified during a survey, says Ms. Hiatt. "Too often, we fail to give permission to our coworkers to help us improve our infection prevention awareness by reminding us of breaches in our practice," she says. "When one member of this team fails to meet the standard, the whole team fails — and we fail the patient. When we welcome constructive observations, in regards to any infection prevention practice, I believe we demonstrate to all those around us that we are committed to best practices and best outcomes for the patient and the surgery center."
9. Create friendly competition to improve compliance. One effective way Ms. Hiatt has seen organizations improve their compliance efforts is through friendly competition between departments within an organization. For example, if a facility wants to improve hand hygiene, it could use a monitoring tool to track hand hygiene compliance by different groups within the organization, such as surgeons, anesthesia staff, RNs and scrub techs. After a period of time, the compliance rates by group can be published for everyone in the facility to see.
"This creates a little friendly competition between departments," she says. "I saw one surgery center take its hand hygiene compliance from 67 percent to over 95 percent by doing this as a contest. It was very successful and a great tool to get everyone to comply."
10. Provide the tools necessary to meet objectives. Sometimes organizations fail to ensure their staff members have the tools necessary to accomplish the mission of the infection prevention and control program while still meeting the expectations of the surgeons. This can be as simple as providing surgical techs with an additional instrument tray.
"Physicians are looking for faster turnover time — they don't want to stand around waiting between cases," Ms. Hiatt says. "They want their instruments and the patient ready to go for the next case. But if the equipment [staff members] have is not capable of what the doctors are expecting them to do, the staff feels pressures to cut corners. That's when they may fail to do something important because they feel such great pressure to not upset the surgeons.
"Sometimes it's as simple as [surgical techs] needing another instrument tray to keep up with the pace a surgeon is asking for," she says. "It's important that the ASC's leaders — the director of nursing or administrator or both — understand what it is those surgical techs that are back there in the trenches need to accomplish the goals of the organization."
11. Remind physicians and staff what infection prevention and control is about: people. "Sometimes in healthcare, we forget this is about people; we forget this is about people that come to us at our ASCs because they're sick or they have a problem, and they need our help," Ms. Hiatt says. "We forget infection control is about not adding a problem by being neglectful of something that we could have done better.
"The most recent studies show 70 percent of the infections that patients get could have been prevented by better infection prevention and control practices by healthcare workers," she says. "We don't want to be responsible for 70 percent. We want to be responsible for 0 percent. The way we do that is by improving these infection and control practices. It's not about rules. It's about saving lives and decreasing morbidity. It's about doing the best we can to give patients the best care we can."
Editor's note: Ms. Hiatt is leading a webinar titled "Tips for a Compliant and Deficiency-Free Infection Prevention Program" on Dec. 6, 2011. To learn more about the program and register, click here.
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