Failed to reduce the risk of infections associated with medical equipment, devices and supplies
Standards Interpretation Group’s infection prevention specialists Lisa Waldowski shared guidelines on how to implement a patient-first infection prevention process.
She recommends:
- Training staff who perform high-level disinfection and sterilization to ensure competency
- Assessing competency by having staff monitor high-level disinfection/sterilization
- Reviewing evidence-based guidelines and providing access to new guidelines.
She also recommends that managers ask probing questions to ensure compliance.
Failed to grant initial, renewed or revised clinical privileges to individuals who are permitted by law and the organization to practice independently
Division of Standards and Survey Methods’ Project Manager Joyce Webb shared guidelines to ensure ASCs are in compliance.
She recommends:
- Establishing a routine, standardized process to verify and grant privileges
- Obtaining a written health attestation from providers who are going through the credentialing and privileging process.
Failed to maintain fire safety equipment
Standards Interpretation Group’s Director of Engineering George Mills stressed the importance of regular fire alarm and fire plan testing. The Joint Commission requires ASCs to keep an inventory of devices to ensure all devices are tested.
More articles on accreditation:
17 outpatient facilities achieving accreditation — March 2017
The Joint Commission names top 10 challenging standards for 2016
AAAHC surveyor to know: Alicia Johnson
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