Common compliance issues that could be putting your staff at risk

While maintaining a high standard of compliance within an ASC is vital to the health and safety of both patients and staff, common compliance issues can occur no matter how vigilant you are.

In my role as a senior consultant of clinical operations at Cardinal Health, I consult with multiple ASCs and frequently see facilities struggle with the space and resources to comply with recommendations from regulatory agencies. And sometimes, small changes can make a big difference in solving these problems and preparing these centers for the future.

Consider where you’re storing common items to improve compliance

The use of protective equipment in the procedure area seems easy to accomplish, but I’m often surprised to find that facilities aren’t utilizing their PPE properly or in the most effective way. Sometimes, they simply forget to use the appropriate gear because it’s not easy to access.

One common issue is related to eye protection. When a staff member is scrubbed in, that individual should be wearing eye protection. If a scrub tech is exposed to bodily fluids, this becomes not only an issue for that employee’s health, but also a liability for the entire facility as a workmen’s compensation case. 

Whether it’s a face shield or goggles, wearing the proper gear is an easy fix that can prevent a multitude of problems. My suggestion is that facilities store their eye protection at the scrub sinks. With this minor change, staff have a visual reminder to don their gear and it becomes part of their routine. This makes it easy for staff to be compliant and safe. 

Make sure your facility is keeping up with the times and the most recent data        

It’s not only important to follow existing protocols, but also to be aware of data that provides new options for “best practices”. One such best practice is double gloving. While double gloving isn’t a rule, it is a highly recommended safety precaution. Each year, 385,000 sharps injuries occur1 and up to 83% of glove breaches may go unnoticed.2 This puts your staff at risk for exposure to bodily fluids and your patients at risk for a surgical site infection.

Double gloving can reduce needlestick injuries by as much as 82%, so I recommend it as a best practice for all facilities.2 This can be a difficult change to make if surgeons are accustomed to the tactile feel of a single glove, so the best approach for implementing double gloving is to start from the top. Managers should champion this change and share documentation and resources regarding its importance with staff. 

Create a culture of open communication

It’s no use identifying compliance issues within your facility if you lack an open flow of communication   to share solutions. It may be difficult to address compliance issues with staff but ensuring that safety procedures are being followed appropriately is vital. In order to create a dialogue that doesn’t feel like scolding, managers must encourage open communication and frame their suggestions as supportive rather than accusatory. 

To lead by example within your facility, model different ways of addressing compliance issues that staff can adopt amongst their peers. For example, if a scrub tech does forget proper eye protection, consider saying, “I noticed you don’t have your goggles nearby- would you like me to grab you some?” 

Adapt your quality auditing process

Many facilities may not have a dedicated QI staff member in charge of educating staff about procedures and products that support compliance. If compliance issues are something your facility struggles with, consider increasing the number of quality audits performed in your facility each month. Let staff help select topics and criteria that are important to them and their safety. It can also be helpful to tie staff or patient exposure metrics to compliance solutions. This can provide the evidence needed to support change.

Look to the future

As new procedures like total joint and cardiovascular operations enter the ASC space, new safety standards will accompany them. Make sure you monitor accreditation requirements that surveyors will want to observe for compliance and share these requirements with staff. Even if you don’t plan on implementing total joint procedures today, adopting some of the safety standards that accompany them can make the transition easier for you down the road and open new avenues to success.

In my experience, all ASC staff are striving for the same outcome: happy, healthy patients in a safe, supportive environment. By making minor changes to existing processes and keeping staff well-informed, you can take steps to ensure that this desire becomes a reality.

To learn more about how Cardinal Health can support your ASC, visit

2Thomas S. et al, Postgrad. Med. J. Intraoperative glove perforation—single versus double gloving in protection against skin contamination. 2001:77 458-460 doi:10.1136/pmj.77.909.458.

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