Bernard McDonnell, DO, a retired physician and current surveyor for Healthcare Facilities Accreditation Program, identifies 20 questions ambulatory surgery centers need to ask themselves to help ensure they have a viable, acceptable 2011 standard of practice infection prevention and control program.
1. Do we even have an infection prevention program? "If not, get one going yesterday, and make sure it's formalized," says Dr. McDonnell.
2. Does our program follow nationally recognized infection control guidelines?
3. Are we looking at and considering Surgical Care Improvement Project (SCIP) guidelines?
4. Do we have a designated infection control officer? "You don't need to have a certified infection control officer but you have to have a designated person with background and experience to direct [your program]," he says.
5. Are we documenting all of the elements of our infection prevention program? Documentation should include clearly written policies and procedures, surveillance reports and data to be used for reporting and quality improvement.
6. How do we ensure that personnel and physicians in the ASC have the education and competencies to comply with our infection prevention program standards? "ASCs need to know the background and training [of employees and surgeons] … and they need to know if their nurses are receiving annual competencies in infection control, if they receiving competencies in SCIP," for example, says Dr. McDonnell.
7. Do we have a hand hygiene program?
8. Do we have a process to isolate a patient if necessary? "What if you have a MRSA patient?" Dr. McDonnell says. "There's a lot of chronic MRSA around; you need have isolation precautions [in place] for such a patient."
9. Do we have mandatory operating room traffic control policies? "Is your OR a place where surgeons wander in and out in their street clothes?" he says.
10. Do we have a process to identify when and why an infection occurs?
11. Are we tracking infections which occur in our ASC?
12. Are we and how are we reporting infections?
13. Do we have a process for treating and helping patients care for infections?
14. What are we doing to change our practice to prevent future infections?
15. Are we giving patients the appropriate perioperative antibiotics?
16. Are we clipping hair instead of shaving it? "If you have to prep an area that has hair, now you need to clip it," he says.
17. Are we properly reusing disposables? "There are companies you can ship disposables to for reprocessing with FDA approval," says Dr. McDonnell. "You should absolutely not be doing it yourself."
18. Do we have a process to ensure proper resterilization? "If you're using standard resterilizable instruments, you need to know how sterilization is being performed, who is monitoring the autoclaves and if you are doing the test strips the way you are supposed to," he says.
19. Are we following proper flashing rules? "If something drops on the floor and you must have it for the case, and you flash properly, that's acceptable," Dr. McDonnell says. "But if you are flashing eye trays because a surgeon is doing 15 cataracts in one day and you don't have enough trays, that's unacceptable." You also want to make sure your ASC is keeping a detailed flash log.
20. Are we complacent with our infection prevention? It's easy for the staff of an ASC to fall into a routine but this cannot negatively impact efforts to improve infection prevention and stay atop new rules and regulations. "It can't be so routine that [infection prevention] becomes automatic and forgotten," he says.
Learn more about Healthcare Facilities Accreditation Program.
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