Here are five best practices and practical guidance on how to meet various accreditation standards.
1. Determine common survey deficiencies. If possible, ASCs should determine what the most common infection control-related deficiencies surveyors find during CMS-mandated surveys. Carol Blanar, RN, CNOR, executive director of the Indiana Federation of Ambulatory Surgical Centers, says through funding from the American Recovery and Reinvestment Act of 2009, CMS surveys were conducted throughout the state. Some common deficiencies noted by state surveyors were that ASCs had not read the CMS Conditions for Coverage for infection control, did not following manufacturers' recommendations for use of cleaning products and lacked proper documentation on education and training of infection control preventionists, Ms. Blanar says.
"Another aspect surveyors often found was some ASCs had the windows connecting clean rooms with soiled rooms open all day," she adds. "These windows are to be open only for pass through of items and are to be closed otherwise."
From: 7 Steps to Improve Infection Control Programs in ASCs.
2. Pick a standard location for particular information on medical charts. Meg Tomlinson, administrator at Metrocrest Surgery Center in Carrollton, Texas, says her ASC sometimes came across some inconsistencies as to where physicians would write patients' allergy information on their medical charts. In order to remedy this, the ASC established an official spot on the medical chart where physicians can fill in this critical information.
"Allergies were not always consistently placed on the same location on every form. Sometimes it would be in the upper left hand corner or some place else, but we had to put in a place where it would be consistent," she says. "So we researched a spot on the forms and highlighted it in yellow so it is more noticeable and physicians can notice it right away."
From: 3 Quick Tips on Consistent Clinical Documentation.
3. Start measuring infection control quality compliance now. ASCs can benefit greatly from measuring infection control compliance. This way, facilities can obtain a clearer view of which infection control practices, such as hand hygiene compliance or single-use syringe and needle compliance, need improvement. Additionally, Brenda Mastopietro, president of Arizona Ambulatory Surgery Center Association and chief nursing officer for Banner Surgery Centers, says although ASCs are not yet required by CMS to report quality measures, it may be a possibility in the future, so adopting reporting practices early on will be beneficial.
"ASCs will want to start rigorously monitoring various measures, such as antibiotics received prior to surgical procedures, removal of hair from surgical sites, normothermia, hand hygiene, sterilization techniques, proper drug utilization and so on," she says.
From: 5 Best Practices for Strengthening Infection Control Programs in ASCs.
4. Create daily logs for improved monitoring of specimens and pathology results. Linda Beaver, RN, MSN, MHA, administrator at Gateway Endoscopy Center in St. Louis, says her ASC created a daily specimen log, which is kept in each procedure room. The log details all specimens taken daily, specific patient information, biopsy information, what location of the colon the biopsy was taken from, and so on.
"We make a copy and put the copy in a binder so when we get results of the specimens back from the laboratory, we're tracking the results and making sure everything coincides if it is a polyp or biopsy and so on," she says. "This way we can also determine if we haven't received a specimen back where exactly it is."
From: Best Practice: Create Daily Logs to Better Track Specimens and Pathology Results.
5. Provide a separate entry for propofol on patient consent forms. Ms. Beaver says her ASC administers propofol, which is not technically general anesthesia nor monitored anesthesia. An accreditation surveyor suggested that the ASC include a separate entry on patient consent forms for anesthesia.
"We had a lot of discussions with the head of anesthesiology and physicians, trying to describe how propofol should be described because patients are still breathing and they don't know what's going on," she says. "[…] We are working to have conscious sedation in addition to monitored anesthesia and general anesthesia. We have not implemented this quite yet because the consent form is driven by our anesthesia group, but that was one of the things we are currently addressing."
From: Strengthening Propofol Policies and Procedures: Q&A With Linda Beaver of Gateway Endoscopy Center.
1. Determine common survey deficiencies. If possible, ASCs should determine what the most common infection control-related deficiencies surveyors find during CMS-mandated surveys. Carol Blanar, RN, CNOR, executive director of the Indiana Federation of Ambulatory Surgical Centers, says through funding from the American Recovery and Reinvestment Act of 2009, CMS surveys were conducted throughout the state. Some common deficiencies noted by state surveyors were that ASCs had not read the CMS Conditions for Coverage for infection control, did not following manufacturers' recommendations for use of cleaning products and lacked proper documentation on education and training of infection control preventionists, Ms. Blanar says.
"Another aspect surveyors often found was some ASCs had the windows connecting clean rooms with soiled rooms open all day," she adds. "These windows are to be open only for pass through of items and are to be closed otherwise."
From: 7 Steps to Improve Infection Control Programs in ASCs.
2. Pick a standard location for particular information on medical charts. Meg Tomlinson, administrator at Metrocrest Surgery Center in Carrollton, Texas, says her ASC sometimes came across some inconsistencies as to where physicians would write patients' allergy information on their medical charts. In order to remedy this, the ASC established an official spot on the medical chart where physicians can fill in this critical information.
"Allergies were not always consistently placed on the same location on every form. Sometimes it would be in the upper left hand corner or some place else, but we had to put in a place where it would be consistent," she says. "So we researched a spot on the forms and highlighted it in yellow so it is more noticeable and physicians can notice it right away."
From: 3 Quick Tips on Consistent Clinical Documentation.
3. Start measuring infection control quality compliance now. ASCs can benefit greatly from measuring infection control compliance. This way, facilities can obtain a clearer view of which infection control practices, such as hand hygiene compliance or single-use syringe and needle compliance, need improvement. Additionally, Brenda Mastopietro, president of Arizona Ambulatory Surgery Center Association and chief nursing officer for Banner Surgery Centers, says although ASCs are not yet required by CMS to report quality measures, it may be a possibility in the future, so adopting reporting practices early on will be beneficial.
"ASCs will want to start rigorously monitoring various measures, such as antibiotics received prior to surgical procedures, removal of hair from surgical sites, normothermia, hand hygiene, sterilization techniques, proper drug utilization and so on," she says.
From: 5 Best Practices for Strengthening Infection Control Programs in ASCs.
4. Create daily logs for improved monitoring of specimens and pathology results. Linda Beaver, RN, MSN, MHA, administrator at Gateway Endoscopy Center in St. Louis, says her ASC created a daily specimen log, which is kept in each procedure room. The log details all specimens taken daily, specific patient information, biopsy information, what location of the colon the biopsy was taken from, and so on.
"We make a copy and put the copy in a binder so when we get results of the specimens back from the laboratory, we're tracking the results and making sure everything coincides if it is a polyp or biopsy and so on," she says. "This way we can also determine if we haven't received a specimen back where exactly it is."
From: Best Practice: Create Daily Logs to Better Track Specimens and Pathology Results.
5. Provide a separate entry for propofol on patient consent forms. Ms. Beaver says her ASC administers propofol, which is not technically general anesthesia nor monitored anesthesia. An accreditation surveyor suggested that the ASC include a separate entry on patient consent forms for anesthesia.
"We had a lot of discussions with the head of anesthesiology and physicians, trying to describe how propofol should be described because patients are still breathing and they don't know what's going on," she says. "[…] We are working to have conscious sedation in addition to monitored anesthesia and general anesthesia. We have not implemented this quite yet because the consent form is driven by our anesthesia group, but that was one of the things we are currently addressing."
From: Strengthening Propofol Policies and Procedures: Q&A With Linda Beaver of Gateway Endoscopy Center.