Management under fire: Surviving a CMS survey at your ASC

By: November 25th, 2009 Email This Post Print This Post

Technically ambulatory surgery centers (ASC) across the country have been under fire for proper infection control procedures for the last few years, given the number of well-publicized incidents that have brought these issues to the surface.

Still, it wasn’t until May that ASCs came under regulatory fire, when CMS established Conditions of Coverage that included basic infection control procedures.

But now that CMS state surveyors have been awarded $9 million from the federal government, along with a new infection control survey which has been developed with help from the CDC, more than one-third of non-accredited ASCs will see a state surveyor in the next 12 months.

In my opinion, one of the biggest challenges in the field is putting an employee in charge of the infection control program, and then training them appropriately. I have advised the ASCs that I consult to become a member of APIC as soon as possible, which not only gives them access to information and training, but it also links them into a community of infection preventionists, which is often the best way to absorb the most information quickly. Don’t be afraid to ask for help.

It’s important that this person has ownership of the infection control program, not only because it’s a CMS requirement, but also because it provides oversight and accountability, which has been lacking prior to these regulations. Usually clinical staff members know what to do, but without that oversight even the smallest mistakes can become perpetual and harmful.

Consider just a few examples:

  • Many ambulatory surgery centers contract environmental service workers. But these employees often come in at night to clean, so no one is watching over them to ensure they are following your facility’s policy. Do you need to stay late every night and watch them clean? No, but you should be spot checking and at least periodically ensuring they are competent, following IC best-practices, and using facility-approved products.
  • Who conducts reprocessing of equipment (sterilization or high level disinfection)? Watch the procedure from the time the instrument leaves the patient to the time it is reprocessed and returned for use on a new patient. Are proper steps followed each time for every patient?

Often, there may not have been a lot of formal training and employees may have been trained (properly or improperly) by the employee who performed this role in the past. They may not even be aware they aren’t in compliance. The center may delegate this important task to this individual, yet with little oversight on a daily basis. Another issue may be determining who is responsible for reprocessing of instruments if that employee is out sick or on vacation and making sure they are trained and competent.

Remember, people are not infallible. They are bound to make mistakes; but checks and balances must be put in to place that will prevent these occurrences as well as providing a plan of action when they do occur. CMS will expect no less and neither will our patients and families.

Visit the Tools page to download a Sample IC Risk Assessment For Ambulatory Surgery Centers.

You can also get basic infection control training with the Infection Prevention Core Training Bundle, which consists of three one-hour webcasts, and Chinnes’ new bookThe Infection Prevention Handbook.”

 

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