IC tips on complying with CMS CfCs for ambulatory surgery centers

By: July 1st, 2009 Email This Post Print This Post

It’s been just over a month since CMS officially implement its new CfCs for Ambulatory Surgery Centers (ASC), but some people are still concerned about whether their facility is meeting the requirements. When I attended the APIC conference a few weeks ago I heard a number of people requesting guidance on this subject.

Below are a few suggestions that might help a new IP at an ASC:

Standard 416.51 (b): “The program is under the direction of a designated and qualified professional who has training in infection control.”

We should applaud CMS for this standard. Not only do ambulatory surgery centers now have to maintain an infection control program, but they also have to designate in writing a qualified professional with training in infection control to lead the organization’s efforts. As we all know, unless responsibility is assigned, no one is often accountable for a job. A lack of oversight in ambulatory care has been a concern in recent outbreaks of infectious diseases in these settings.

But this is not a quick fix. The infection preventionist is a specialist committed to a career of lifelong learning in the field. Ways in which to achieve this training could involve taking courses through the national professional association APIC; joining the national and local chapter of APIC; attending meetings and ongoing training on the numerous infection prevention issues and concerns; and as an APIC member – even having access to free webinars on infection prevention and control. On July 15 Peg Luebbert and I are speaking in the first installment of a three-part Webcast on core training for infection prevention.

The IP for the surgery center should maintain records of initial and ongoing training in their personnel file to document competency. Certification is not required though highly desirable. Information on certification may be obtained through the Certification Board of Infection Control and Epidemiology, Inc. (CBIC).

Standard 416.51 (a): “The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice.”

Every area of the surgery center including waiting areas must be clean. In other facilities, cleanliness is usually monitored by a multidisciplinary team, of which the IP is a member. This can be accomplished with checklists during environmental rounds. Some wonderful resources on infection prevention and the environment include: CDC guidelines for environmental infection control and healthcare facilities, 2003, which also includes a section on construction/renovation; CDC guidelines for disinfection and sterilization and healthcare facilities, 2008; prevention of surgical site infections, 1999; and AORN Standards, Recommended Practices, and Guidelines, 2009.

These are not only great resources for problem solving in ambulatory surgery centers but also address that these were considered and selected by the surgery center as nationally recognized infection control guidelines upon which to build their infection prevention and control program. This should help in the standard that states “the ASC must maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. In addition, the infection control and prevention program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines.”

Some questions you might ask yourself in reviewing your IC program are:

  • Is your surgery center performing surveillance to identify infections in patients and personnel?
  • Is analysis of this data being reported back to infection committee and/or performance improvement so that actions may be implemented to correct deficiencies in practice?
  • Are policies and procedures such as hand hygiene, aseptic technique, and appropriate antibiotic prophylaxis/timing to prevent surgical site infections monitored for compliance and reported back to staff and leadership who can affect a change in outcome?
  • Are there policies for safe injection practices? Are these policies followed?
  • Are practices documented for handling of employee exposures, especially bloodborne?
  • Who has the authority to restrict healthcare workers with communicable diseases? Are these diseases/conditions documented?
  • Is there an infection control plan which is evaluated at least annually to determine if goals and objectives have been met to improve patient safety and prevent infections?

You will have to address each of these questions and more in order to effectively comply with CMS standards. No matter where we receive healthcare, we should be subjected to the same level of care. Especially in surgery!

How are you are implementing the new standards in your surgery center?


The Infection Prevention Core Training Bundle is a comprehensive three-part Webcast series that focuses specifically on IC best practices. With expert advice from OSHA Healthcare Advisor bloggers and IC experts Peg Luebbert and Libby Chinnes, this bundle is your complete solution for staff education on infection prevention, and a solid training foundation for your IC program.


By Nancy King RN on November 24th, 2009 at 12:05 pm

In observing a cataract surgery in an ASC, the technician cleaning the instruments is allowed to wear the fluid resistant gown and eye shield/mask all day. This means when the phaco handpiece is no longer needed, the scrub tech hands it off to the technician to clean in the dirty utility room. The same gown, eye shield/mask is worn for each time a phaco handpiece needs to be handed off to get cleaned and placed in the sterilizer for the next case. So, the same technician is going into a clean case, wearing the same gown, eye shield/mask and getting from the scub tech the phaco handpiece while the case is in progress. Please acknowledge the proper way to address this situation. Thank you.

In regarding the post operative surveillance, can data be collected just from surgeon or has to be collected from both patients and surgeon?


Is there a area/square footage requirement that must be met in the area outside the OR room that is a prescrub area? A redline or taped area that only OR healthcare workers are permitted?

By Libby Chinnes on June 3rd, 2010 at 9:19 am

There is no one way to conduct surveillance. Some facilities collect data from surgeons, some from patients, some from both. A word of caution: the calls you make to patients the day after surgery, for instance, are hepful in many areas but are usually considered too soon timewise in terms of detecting a surgical site infection (surveillance definitions of 30 days after incision and up to one year after insertion of implants). Be sure to ask consistently about certain criteria (ie. the definition of infection)to whomever you communicate.

By Libby Chinnes on June 3rd, 2010 at 11:05 am


Dawn and I think you should talk with an architect or look at AIA(American Institute of Architects) and FGI 2010 book on Guidelines for Design and Construction in Healthcare Facilities. …. but often times state building codes or local codes may influence as well. Check with your local licensing department of health, too.

Libby Chinnes


Leave a Comment


« | Home | »

Subscribe - Get blog updates via e-mail

  • test
  • HCPro Broadcast Events Calendar