At the 18th Annual Ambulatory Surgery Centers Conference in Chicago on Oct. 29, LoAnn Vande Leest, RN, CEO of The Surgery Center in Franklin, Wis., and Fawn Esser-Lipp, RN, infection preventionist and OR manager at the center, discussed CMS' infection prevention mandate and how to stay compliant.
Ms. Vande Leest likened an ASC's infection control program to a live human being. For instance, as a human requires food, air and other necessities, an infection control program requires strong leadership. "The governing body provides those basics to a thriving program," she said. "The governing body is responsible for the development and approval of the IC program. At the end of the day, [the governing body] is viewed by CMS as the responsible party."
Some key elements to maintaining compliance with CMS' infection control guidelines include the following:
• Infection prevention professional. "The good news is CMS is very clear regarding expectations of the infection prevention professional — you need to have one and [he or she] needs to be educated in infection control," Ms. Vande Leest said.
• Policies. It is essential that physicians' and staffs' behaviors reflect the center's documented policies on infection control, according to the presenters. Ms. Vande Leest suggested interviewing staff to ensure the policies are clearly communicated and that staff follow them. In addition, the ASC's policies should be based on national guidelines and should cite these sources. Documenting the links between national guidelines, the center's policies and staff's behavior is key to meeting CMS' requirements.
• Education. Education on infection control practices needs to include everyone, from office personnel to techs to physicians, according to Ms. Esser-Lipp. ASCs often do not spend enough time educating physicians, she said. "They [can be] stuck in their ways. You have to provide evidence-based information," she said.
• Surveillance. ASCs should test whether infection control practices are being followed. For instance, Ms. Vande Leest said The Surgery Center tested high-touch areas and found that the light handles were not cleaned adequately. The center's leaders were then able to go to environmental services, explain the situation and remedy the problem. Data collected in surveillance should also be documented and tracked to identify trends.
• Implants. CMS requires ASCs track implants for a year after the procedure. Ms. Esser-Lipp said The Surgery Center created a form they give to patients explaining that the center will be calling back to ask about the implant. Notifying patients ahead of time encourages them to call if they move or if they have a problem, the presenters said.
Effective Clinical Benchmarking and Infection Control
Common Mistakes in ASC Infection Control
Ms. Vande Leest likened an ASC's infection control program to a live human being. For instance, as a human requires food, air and other necessities, an infection control program requires strong leadership. "The governing body provides those basics to a thriving program," she said. "The governing body is responsible for the development and approval of the IC program. At the end of the day, [the governing body] is viewed by CMS as the responsible party."
Some key elements to maintaining compliance with CMS' infection control guidelines include the following:
• Infection prevention professional. "The good news is CMS is very clear regarding expectations of the infection prevention professional — you need to have one and [he or she] needs to be educated in infection control," Ms. Vande Leest said.
• Policies. It is essential that physicians' and staffs' behaviors reflect the center's documented policies on infection control, according to the presenters. Ms. Vande Leest suggested interviewing staff to ensure the policies are clearly communicated and that staff follow them. In addition, the ASC's policies should be based on national guidelines and should cite these sources. Documenting the links between national guidelines, the center's policies and staff's behavior is key to meeting CMS' requirements.
• Education. Education on infection control practices needs to include everyone, from office personnel to techs to physicians, according to Ms. Esser-Lipp. ASCs often do not spend enough time educating physicians, she said. "They [can be] stuck in their ways. You have to provide evidence-based information," she said.
• Surveillance. ASCs should test whether infection control practices are being followed. For instance, Ms. Vande Leest said The Surgery Center tested high-touch areas and found that the light handles were not cleaned adequately. The center's leaders were then able to go to environmental services, explain the situation and remedy the problem. Data collected in surveillance should also be documented and tracked to identify trends.
• Implants. CMS requires ASCs track implants for a year after the procedure. Ms. Esser-Lipp said The Surgery Center created a form they give to patients explaining that the center will be calling back to ask about the implant. Notifying patients ahead of time encourages them to call if they move or if they have a problem, the presenters said.
Related Articles on the 18th Annual Ambulatory Surgery Centers Conference:
Infection Prevention in ASCs: Looking AheadEffective Clinical Benchmarking and Infection Control
Common Mistakes in ASC Infection Control
