Every ASC has an infection control program, for both meeting mandatory safety and reporting requirements and maintaining quality patient care.
During a Sept. 1 webinar hosted by Becker's ASC Review, Lee Anne Blackwell, vice president of clinical services with Practice Partners in Healthcare, discussed four key components within five primary objectives for creating and maintaining an effective ASC infection control program. She presented the IC Plan in 10 key components to comply with the CMS conditions for coverage 416.51 b.
1. Building the plan. CMS condition for coverage 416.51 b requires ASCs to "maintain an infection control program that seeks to minimize infections and communicable diseases." The key components of a successful IC plan, according to Ms. Blackwell, include:
• A purpose statement identifying the IC plan based on guidelines from authorities. "Look around you. What steps and actions do you take every day that are based on guidelines from infection control authorities?" says Ms. Blackwell.
• Identify what role the entire organization plays in the IC plan. "The governing body must review the plan at least annually," she says. "Leadership must committed and supportive." Leadership's participation in the plan's creation and maintenance should be documented.
• Include an authority statement. Each ASC's IC program will be led by an infection control professional. Whether this individual is a nurse or in another role, the IC plan must include a document recognizing this person's authority as the IC leader.
• List goals that tie back to the ASC's mission and values.
• Define the scope of the IC plan. "The plan needs actionable strategies for all healthcare workers, including physicians, contractors and vendors," says Ms. Blackwell.
• Establish a clear, consistent process for retrieving infection information, as well as a clear process for infection control surveillance.
• Address risk and risk assessment measures. Once risks are identified, prioritize them. Set goals to mitigate those risks.
• Create strategies to respond to risk assessment results. "Review patient processes and patient outcomes to identify best practices," says Ms. Blackwell. "Collaborate with other team members, such as the safety officer." Even consider collaborating with outside organizations. For example, Ms. Blackwell invited the local Occupational Safety and Health Administration office to a center to present on workplace safety.
• Institute an education plan for employees, medical staff, contractors, vendors, guests and patients for all IC issues; hand hygiene, infectious waste management, sharps safety, medication infection control practices, etc.
• Set processes for accurate infection data reporting. "You need internal communication processes and external processes for reporting to state and regulatory bodies," she says.
2. Leadership. The governing board-approved infection control professional standing at the helm of an ASC's IC program has many responsibilities. This individual is responsible for the facility-wide IC plan, including:
• Providing IC education and training
• Maintaining documentation of training and education
• Seeking guidance from leading authorities on IC best practices
• Administering ongoing evaluations of IC practices at the center
• Performing risk assessments
• Completing investigations of reported infections
3. Where surveyors focus. The CMS Infection Control Surveyor Worksheet for ASCs was last updated in June. The worksheet is updated periodically and available online. This worksheet serves as a key resource for ASCs preparing for a survey. Top areas of focus to consider are hand hygiene, personal protective equipment, safe injection practices, single-use devices, sterilization, high-level disinfection, environmental cleaning and point of care devices. Citations for these areas are not uncommon.
Surveyors will also look at a center's approach to IC education and training. Are the resources used pertinent to the particular ASC's setting? For example, a GI/endoscopy-driven center would do well to use IC resources from the Society of Gastroenterology Nurses and Associates.
"All of these areas are addressed in the CMS IC worksheet," Ms. Blackwell says. "Have you completed this worksheet in your center?"
4. Resources. Resources for maintaining proper infection control compliance, to name a few, include:
• Accreditation Association for Ambulatory Health Care
• Association of PeriOperative Registered Nurses
• Association for Professionals in Infection Control and Epidemiology
• CMS ASC Quality Reporting Program Quality Measures Specifications Manual
• Centers for Disease Control
• The Joint Commission
• OSHA
• SGNA
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