Where to focus your compliance efforts: Part one

In a recent article, Anne Dean of The ADA Group reivews where you should focus your compliance efforts.

Accreditation provides external validation of patient safety, clinical quality improvement processes, and valuable ideas for improving patient safety and quality of care. Achieving accreditation has a number of benefits for any ASC, including improved community confidence in the center, stronger risk management and reduction, and it can be a requirement for reimbursement from Medicare and private payors.

ASCs are a unique healthcare environment, and they come with a unique set of challenges that must be overcome to meet the standards of accrediting bodies like The Joint Commission and the Accreditation Association for Ambulatory Health Care (AAAHC).

Based on my experiences working with ASCs, accreditation surveyors have been paying closer attention to the following areas during their site visits: infection prevention, environment of care, and meetings and minutes.

This four-part article will discuss why these particular areas are challenging for ASCs and potential solutions to help improve compliance with standards.

Part I: Infection Prevention

ASCs struggle with infection prevention in a number of areas.

Risk Assessment

There is a fundamental lack of understanding by many ASCs about performing an infection prevention risk assessment. Surveyors want ASCs to find and prioritize their potential infection vulnerabilities and continually work to improve them.

For example, ASCs often identify skin preps as a potential infection vulnerability associated with orthopedic procedures. To perform the vulnerability assessment, ASCs should, at a minimum, take the following the steps:

  1. Determine the severity of the vulnerability (high, moderate, or low-risk).
  2. Determine the potential impact on patients and the organization. How prepared is the ASC to prevent the risk?
  3. Analyze and assess why the vulnerability is a challenge and communicate this reasoning in the assessment.

A very common vulnerability for ASCs is handwashing, as it is difficult to achieve 100% compliance. ASCs should have handwashing as a top priority on their vulnerability list.

Sterilization and instrument processing

ASCs often struggle with sterilization and instrument processing. This is primarily due to a lack of education for the team members performing this task.

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