OR Manager - August 2018 - 25

AMBULATORY
SURGERY CENTERS
with the authority to manage the CMSrequired
infection control program and
to enforce it throughout the center, she
adds.
In addition to authority from the governing
board, the IP also needs the time
and training to do the job effectively,
Vassallos says. One of the weaknesses
she frequently sees in hospitals, and
particularly in ASCs, is a lack of time for
education and training for all employees,
including the IP.
IP and QAPI integration
CMS requires ASCs to integrate their infection
control program into their Quality
Assurance Performance Improvement
(QAPI) program and to ensure ongoing
coordination between the two entities.
The infection control program must
be based on a documented risk assessment
profile of the specific ASC,
with staff input. A risk assessment
tool, available on the CMS website,
can be customized to an ASC's needs,
Geier says (http://www.ascquality.org/
Library/handhygienetoolkit/Hand%20
Hygiene%20-%20What%20CMS%20Surveyors%20Are%20Looking%20For.pdf).
The
assessment identifies factors
such as:
* type of procedures performed at the
ASC
* patient characteristics
* size of facility and geographic location
* area-specific endemic infections
* other center-specific risks.
The goal of the IP and QAPI is to
identify, prevent, and manage infections
and communicable diseases. CMS requires
that both groups communicate
regularly.
" You can't just show up at the
governing board meeting once a year
and talk about infection control, " says
Mack. She recommends providing the
governing boards with quarterly reports
that include data on infections, trends,
www.ormanager.com
and results of the monitoring infection
control tools. An ASC that does not
track infections will be unable to determine
whether its infection control program
is working or needs modification.
CMS surveyors will ask specific
questions about an ASC's cleaning, disinfection,
and sterilization procedures,
including looking under the sinks and in
refrigerators, Geier says.
Typical outcome measures include
complication rates, healthcare-associated
infection rates, transfers to hospitals,
and wrong-site surgeries.
If any surgical site infections are
discovered, the plan must include a
method to immediately begin taking corrective
actions.
" Infection tracking is needed to see
if there are any unusual results different
than your benchmark, " Mack says. " If
you have three infections in one month
in podiatry cases, you want to know
that sooner rather than later, especially
when the solution may be as simple as
changing the surgical prep, " she says.
IP responsibilities
The IP is responsible for updating
the staff about the quarterly reports,
whether through a morning huddle or a
communication log book.
Other responsibilities include:
* providing guidance to staff about
infection concerns
* encouraging clinical staff to participate
in infection prevention activities
* seeking guidance from leading authorities
for ongoing education, training,
management, and updates related
to infection control
* selecting a QAPI member to provide
infection control data, reports, and
ongoing activities
* identifying strategies to mitigate
risks and improve outcomes
Continued on page 26
OR Manager | August 2018 25
Choose credentialing
guidelines carefully
Ambulatory surgery centers are required
to develop an infection control
program that is based on nationally
recognized infection control guidelines,
according to the Centers for Medicare
& Medicaid Services (CMS).
Although CMS does not designate
which infection control guidelines to
use, whichever ones an ASC chooses
must be consistently implemented.
" Decide which guidelines you want to
use, " says Deborah Mack, BSN, RN,
CASC, CNOR, a healthcare consultant
for QRS Solutions, which is based in
California. " Know how to use them,
and follow them as described. " She
notes that the most straightforward
guidelines come from the Centers
for Disease Control and Prevention,
whereas those from AORN tend to be
more complex.
Alternative guidelines can be used for
a particular area of infection control,
such as sterilization procedures. In
this case, note in your ASC's plan that
these guidelines are from a different
organization, Mack says. Here are the
guidelines to choose from.
➤ Society for Healthcare Epidemiology of
America, https://www.shea-online.org/
➤ AORN, https://www.aorn.org/
➤ Association for the Advancement of
Medical Instrumentation, http://www.
aami.org/
➤ Association for Professionals in Infection
Control and Epidemiology, https://
apic.org/
➤ Centers for Disease Control and Prevention,
https://www.cdc.gov/
➤ Society of Gastroenterology Nurses and
Associates, Inc, https://www.sgna.org/
➤ Occupational Safety and Health Administration,
https://www.osha.gov/
http://www.ascquality.org/ https://www.shea-online.org/ https://www.aorn.org/ http://www http://www.aami.org/ http://https:// http://www.apic.org/ https://www.cdc.gov/ https://www.sgna.org/ https://www.osha.gov/ http://www.ormanager.com
OR Manager - August 2018

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