In a webinar hosted by Becker's Healthcare on Nov. 10, Gregory Hickman, MD, medical director and director of anesthesia at the Andrews Institute Ambulatory Surgery Center in Gulf Breeze, Fla., discussed the importance of process standardization in meeting infection control and quality improvement goals.
According to Dr. Hickman, ASCs can apply the "4 E" concept to help drive process standardization. The "4 E" process is an effective collaborative technique that can be used to help ensure staff alignment and implementation of quality improvement projects, such as infection prevention, with standard processes and continual evaluation. The "4 Es" stand for:
1. Engage. "Getting the right team in place is essential," says Dr. Hickman. "So who should be engaged? The short answer is everyone, the ASC board, administration, staff members, nurses, anesthesia staff, surgeons, surgical technicians and, of course, patients and their families." One way to get key stakeholders involved and engaged is to share data, statistics, regulatory requirements and other information related to infection control, and also encourage stakeholders to share their ideas for process and quality improvements.
According to the Centers for Disease Control and Prevention, 1.7 million people acquire healthcare-associated infections in facilities each year, which amounts to approximately 271 deaths per day. However, one-third of HAI-related deaths are preventable.
These CDC estimates are inclusive of all healthcare settings, so the question is — how do ASCs perform relative to HAIs? According to Dr. Hickman, the CDC and CMS did a pilot study, published in the Journal of the American Medical Association in 2010, in three states that looked at five different infection control categories in the outpatient setting. Overall, 68 percent of the facilities they inspected had breaches in at least one of the categories. "They found a significant lapse in infection control processes and regulations from CMS and the CDC have increased," he says. "The bottom line is that if an ASC has significant breaches and does nothing to fix the breaches, they risk being ousted from the Medicare program."
2. Educate. A number of factors contribute to HAIs, including preoperative, organizational and postoperative factors. "One of the biggest challenges in standardizing protocols is that there are numerous variables to manage," says Dr. Hickman. "Also, in multispecialty ASCs there is the added challenge of having doctors practicing in different specialties. And each doctor has his or her own habits."
To highlight the issue of variability, Dr. Hickman shared the application instructions for four different skin antisepsis agents — each agent varied in application method, application time and dry time. Data from a recent study suggested that this translated into improper skin antisepsis technique. According to the data, close to 50 percent of the time, actual practice was non-compliant with skin prep time and prep dry times for these agents. In ASCs it was 75 percent of the time.
It is important that ASC staff share information, observations and evidence like this with their teams regularly. Reducing variability reduces risk, says Dr. Hickman, especially in the multispecialty setting.
"If protocols and processes are standardized, the ASC staff knows what they are required to do no matter which doctor they are working with that day. This helps reduce the possibility of an infection control lapse," he says.
3. Execute. For the execution of any QI project, a champion within the facility can go a long way. "You need someone who can support you and take an idea and run with it," says Dr. Hickman. Also, tools can help to ensure the successful execution of a project. ASCs can use toolkits and checklists, such as the World Health Organization checklists, which can reduce complications and save time, studies have shown.
4. Evaluate. "If you are going to implement a new project, you must regularly assess the progress and measure results," says Dr. Hickman. It is also important that ASC administrators are transparent about what metrics they are tracking and how, and communicate this to their staff. "Remind them how this will improve patient outcomes," he adds. Dr. Hickman pointed to some sources for HAI surveillance and quality tracking tools that included resources on the ASC Quality Collaboration and the Association for Professionals in Infection Control websites as well as tools offered by industry sponsors, such as CareFusion.
According to CMS, ASCs must also develop, implement and maintain an ongoing quality assessment and performance program, and the scope of the project must reflect the scope of the center. "If you run a multispecialty center, you may have to implement more than one project at a time," says Dr. Hickman. "The bottom line is that ASCs are required to give HAIs attention and reducing variability in practices improves quality of care. And the '4 E' methodology is a key process for quality culture change and numerous support tools and resources are out there to help us implement and measure our initiatives.”
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