Infection control and compliance is a hot topic in ASCs at the moment, and regulations are only expected to increase going forward. Here are five things every ASC leader should know about infection control and compliance.
1. First and foremost, read the guidelines. Whichever organization your ASC uses for accreditation, the standards will be readily available, and you should purchase and read them cover-to-cover. Ms. Berreth recommends State Operations Manual Appendix L- Guidance for Surveyors: Ambulatory Surgical Centers, which can be downloaded online. "It not only has the standards, but it has the interpretive guidelines and survey procedures," she says. "Make a commitment to understand and research questions, and get involved with your state association because they have great resources."
Dawn Q. McLane, regional vice president of operations for Health Inventures, agrees that regulatory compliance is essential, especially compliance with 2009 Medicare Conditions for Coverage and infection control standards. She says administrators can find standards from a variety of sources, including the ASC Association website. "Utilize the Surveyor's Infection Control Worksheet to assure you are in compliance with infection control standards," she says.
2. Hire an infection control/QAPI-certified nurse. Most ASC administrators agree that hiring an infection control/QAPI-certified nurse — or growing one within the facility — is essential to building a good infection control program. The infection control nurse can help the center get ahead of the curve when it comes to state and federal demands for reporting programs, as well as monitoring ongoing competencies of staff.
According to Beverly Kirchner, owner and CEO of Genesee Associates, The Joint Commission and state boards recommend that competencies be assessed on an ongoing basis, meaning much more work for an ASC leadership team. "Five years ago, I would have laughed if you told me I needed a full-time employee for this position, but today it is essential," she says.
3. Benchmark your number of monthly QI studies. According to David Kelly, administrator of Samaritan North Surgery Center in Dayton, Ohio, AScs should benchmark internally on the number of continuous quality improvement studies performed each month. He says his center keeps track of this number to make sure at least one study is performed every month. Without this internal benchmark, your center could go several months without actively addressing quality improvement — a problem for a center that wants to stay safe and compliant.
"[Benchmarking internally] keeps us focused continually on doing quality improvement," Mr. Kelly says.
4. Budget for adequate infection control resources. David Daniel, CEO of Lakeland (Fla.) Surgical and Diagnostic Center, says his center's infection control program requires a substantial budget for funding, staffing, equipment, education and training. He advises centers not to skimp on infection control budgeting and says leaders should speak with the center's board to lay out a reasonable budget for the necessary resources.
5. Push for improved patient compliance. According to Louise Dechesser, a surveyor for the Accreditation Association of Ambulatory Health Care, ASCs should also look to patients to stave off infection. She says physicians should clearly communicate with patients the need to comply with orders to prevent infections.
"ASCs are under special circumstances because all the patients go home," she said. "A physician may tell his or her patient not to get their dressing wet, but the patient might decide to go ahead and shower anyway because the dressing is on the belly button and he or she will try to shower with their back to the water. Well, of course the dressing is going to get wet and that's a perfect breeding spot for infection. ASCs have to reiterate specific orders to patients."
1. First and foremost, read the guidelines. Whichever organization your ASC uses for accreditation, the standards will be readily available, and you should purchase and read them cover-to-cover. Ms. Berreth recommends State Operations Manual Appendix L- Guidance for Surveyors: Ambulatory Surgical Centers, which can be downloaded online. "It not only has the standards, but it has the interpretive guidelines and survey procedures," she says. "Make a commitment to understand and research questions, and get involved with your state association because they have great resources."
Dawn Q. McLane, regional vice president of operations for Health Inventures, agrees that regulatory compliance is essential, especially compliance with 2009 Medicare Conditions for Coverage and infection control standards. She says administrators can find standards from a variety of sources, including the ASC Association website. "Utilize the Surveyor's Infection Control Worksheet to assure you are in compliance with infection control standards," she says.
2. Hire an infection control/QAPI-certified nurse. Most ASC administrators agree that hiring an infection control/QAPI-certified nurse — or growing one within the facility — is essential to building a good infection control program. The infection control nurse can help the center get ahead of the curve when it comes to state and federal demands for reporting programs, as well as monitoring ongoing competencies of staff.
According to Beverly Kirchner, owner and CEO of Genesee Associates, The Joint Commission and state boards recommend that competencies be assessed on an ongoing basis, meaning much more work for an ASC leadership team. "Five years ago, I would have laughed if you told me I needed a full-time employee for this position, but today it is essential," she says.
3. Benchmark your number of monthly QI studies. According to David Kelly, administrator of Samaritan North Surgery Center in Dayton, Ohio, AScs should benchmark internally on the number of continuous quality improvement studies performed each month. He says his center keeps track of this number to make sure at least one study is performed every month. Without this internal benchmark, your center could go several months without actively addressing quality improvement — a problem for a center that wants to stay safe and compliant.
"[Benchmarking internally] keeps us focused continually on doing quality improvement," Mr. Kelly says.
4. Budget for adequate infection control resources. David Daniel, CEO of Lakeland (Fla.) Surgical and Diagnostic Center, says his center's infection control program requires a substantial budget for funding, staffing, equipment, education and training. He advises centers not to skimp on infection control budgeting and says leaders should speak with the center's board to lay out a reasonable budget for the necessary resources.
5. Push for improved patient compliance. According to Louise Dechesser, a surveyor for the Accreditation Association of Ambulatory Health Care, ASCs should also look to patients to stave off infection. She says physicians should clearly communicate with patients the need to comply with orders to prevent infections.
"ASCs are under special circumstances because all the patients go home," she said. "A physician may tell his or her patient not to get their dressing wet, but the patient might decide to go ahead and shower anyway because the dressing is on the belly button and he or she will try to shower with their back to the water. Well, of course the dressing is going to get wet and that's a perfect breeding spot for infection. ASCs have to reiterate specific orders to patients."
