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6 Vital Steps to a More Compliant Surgery Center

Pamela Dembski Hart, CHSP, BS MT (ASCP), principal  and founder of Healthcare Accreditation Resources LLC, discusses key steps surgery centers should take to increase compliance with current infection prevention and control standards so successful accreditation may be achieved.

1. Understand accreditation consultants are there to assist you with the process — but cannot do all the work. Ms. Dembski Hart recommends that in order to position the organization for a successful accreditation survey, most ASCs should hire experts in the field to help them to develop and manage an effective and compliant infection prevention program. However, she cautions ASC leaders to remember that accreditation consultants and all staff must partner together to get the job done. "A consultant is there to assess your facility for infection prevention and control compliance and help the organization interpret the process and/or help with written protocols," she says. "The organization should not assume that the outside person is able to get the whole job done."

She says accreditation consults are there to guide the center through the process, interpret the latest regulations or standards and provide the tools and resources necessary to meet those standards. The key is that the organization has to utilize the tools — including training, policies, procedures and documentation forms — provided by the consultant and routinely implement the processes and protocols.

2. Increase staff education. Ms. Dembski Hart emphasizes that compliant surgery centers must have robust education programs for their staff members. This means education should be site-specific and conducted by an individual proficient in the course content, and the training must address specific procedures the center performs. Training must be provided annually, as well as for all new hires and whenever new procedure is introduced that may present new or additional hazards.

Specifically, education on Hazard Communication Standard and Accreditation Infection Prevention standards is required at least annually for all at risk employees to meet OSHA's Bloodborne Pathogen requirements. There are limitations to the acceptability of web-based training. Additional in-services and other continuing education can be supplemented by other professional associations, such as APIC, AORN or the CDC, which provide seminars specific to the infection prevention and control industry.

3. Appoint a clinical leader to oversee accreditation.
Ms. Dembski Hart says ASC administrators should make sure accreditation supervisors have a clinical background and knowledge of infection prevention. If the facility needs to implement staff training on infection prevention protocols, she says CMS prefers a training leader with additional credentials in the infection prevention and control area. "It's not required that you have a CIC credential, but it is highly recommended that you have some other credential that sets you above and beyond the other staff members," she says. "For example, I'm a clinical laboratory scientist, not an RN, but I'm certified as a healthcare safety professional."

4. Review policies annually — at a minimum. Ms. Dembski Hart says ASC administrators should check up on processes and policies "annually at a minimum." If the ASC introduces a new procedure or hires a new staff member, the ASC leaders should review policies related to the new procedure and go over orientation materials to make sure information is up-to-date.

She also recommends reviewing policies and processes when case volume increase or when the ASC identifies an adverse event. "If an adverse event occurs, leader should go back to the cause and figure out how the ASC can prevent the event from reoccurring," she says.

5. Involve physicians as much as possible. Ms. Dembski Hart encourages ASC administrators to involve physicians in infection prevention and accreditation processes, a task that can be challenging when physicians have busy schedules. She says administrators should start by tackling the "low hanging fruit" — those physicians who naturally want to be part of center safety and accreditation processes. "You can be very diplomatic and encourage physicians to have commitment, and some people will understand that and really appreciate that statement," she says. "About 30 percent of physicians will really get it, and that leaves the other 70 percent."

For the other ASC physicians, who may feel they are too busy to participate fully in infection control and accreditation processes, Ms. Dembski Hart suggests emphasizing the necessity of their participation. "You have to emphasize that it's the regulations, and if accreditation is truly your priority, physicians have to maintain or acquire that training," she says.

6. Collect data to understand how you're performing.
To make sure your surgery center is compliant with federal and accreditation body regulations, track data to understand your progress over time. Ms. Dembski Hart gives the example of hand-washing, which continues to pose a problem for ASCs due to lack of compliance. She recommends ASC leaders observe a cross-section of employees throughout the ASC environment to make sure hand-washing is performed at appropriate intervals. "That could mean your nurse anesthetists, surgeons, endoscopy techs, medical assists or receptionists," she says. "You should put together a list of appropriate intervals when hand washing should occur and then perform a random survey of individuals over a period of time."

Once you have collected legitimate data on your center's compliance, meet with your staff and present the facts. "Don't name names — that would be done in private — but have lunch or a quick in-service and discuss your compliance," she says. "You may say, 'We're at 60 percent compliance, and our goal is 100 percent, so how can we get there?"

Related Articles on Surgery Center Accreditation:
Montana Hospital Fined for Nuclear Safety Violations
State Regulators: Florida Physicians' Lax Infection Control Caused Hepatitis Outbreak
IDPH Reports Illinois Hospitals Reported Fewer Infections in 2010

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