Effective quality improvement and infection control programs are the cornerstone of an ASC's reputation. They are also an essential aspect to gaining and maintaining accreditation or certification.
Here are six important steps for creating and implementing an infection control program in an ASC:
1. Gain familiarity with regulations and standards. According to Jennifer Eason, RN, CASC, regional vice president at SurgCenter Development, it is important for administrators to be familiar with state and CMS regulations as well as accreditation standards to ensure they are developing and implementing an infection control program that meets all requirements.
2. Look to infection control societies for guidance. Include guidelines from nationally recognized infection control societies such as the CDC, Association of periOperative Registered Nurses and Association for Professionals in Infection Control and Epidemiology, in your infection control program, says Ms. Eason. Also, make sure ASC staff members have access to those guidelines.
3. Identify an infection control champion in your organization. In 2009, CMS began requiring ASCs to train one licensed staff member, typically a registered nurse, to oversee the center's infection control program. Initial and ongoing training is required for this individual to effectively manage the program.
"A number of organizations provide training for the infection control RN, such as APIC for example," Ms. Eason says.
4. Follow the plan you put in place. Once you have an infection control plan that meets all requirements, the next step is to implement it. Ms. Eason suggests taking time to observe your staff, including physicians, to see if they are following the policies and procedures your center has put in place to meet the infection control program's objections. Ensure postoperative infection reports are collected and analyzed monthly and conduct audits for surveillance of processes, including hand washing, injection practices and the use of personal protective equipment. Ms. Eason says to be sure the results of this data are routinely shared with the center's quality council, medical executive committee and governing body.
5. Annually review the program. CMS requires that ASCs annually evaluate the infection control program and gain approval from their governing body, says Ms. Eason. It is important that the infection control nurse collaborate with the center's quality council and medical executive committee to review the plan's effectiveness and make recommendations to the governing body.
6. Create a culture around infection control. Involve the entire team. Ensure the entire team is aware of the infection control program and its goals and objectives. Get your team's buy-in and input when creating the program.
"Celebrate your successes," says Ms. Eason. "By engaging physicians and staff in infection control efforts, you can ensure your facility has an infection prevention culture and is committed to providing quality care."
