One Way to Address New Joint Commission Standard on Measuring Surgical Site Infection Rates

Nancy Burden is director of ambulatory surgery for BayCare Health System.

Q: What are some steps we can take to meet the new Joint Commission standard in the ambulatory National Patient Safety Goal NPSG.07.05.01 EP 5: "Measure surgical site infection rates for the first 30 days following procedures that do not involve inserting implantable devices and for the first year following procedures involving implantable devices. The organization’s measurement strategies follow evidence-based guidelines. Note: Surveillance may be targeted to certain procedures based on the organization’s risk assessment."

Nancy Burden: Our centers have addressed the one-year follow up after implanted devices in two ways. First, in the monthly letter to all physicians asking for details of infections or complications of the prior month’s patients, we have added a query about any patient within the last year having come back to the physician for signs of an infection.

Additionally, we created a process for telephoning 30 percent of appropriate patients from that month in the prior year. A script is followed to solicit information that might lead us to identify the possibility of an infection. Not only are we soliciting information about infection, but we are also making a new connection with our patients and finding out their opinions and experiences in other areas of our care — a win-win!

Submit your accreditation questions to Rob Kurtz at rob@beckersasc.com.

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