Those three issues popped to the top for ASCs during the CMS/DOH surveys. Today, let’s look at Infection Control and Quality Assessment & Performance Improvement.

Is your ASC Infection Control program in compliance? Your ASC needs to go beyond having solid Infection Control policies and practices in place, you also need an IC officer – a licensed healthcare professional, such as a RN. An effective IC program will replicate guidelines from a nationally recognized one, such as APIC regarding hand hygiene, injection practices, sterilization guidelines and monitoring of environmental and infection control practices. Ongoing training is key to instilling good hygiene habits. Display hand washing posters, wash hands before and after meeting with a patient and use hospital approved germicide cleaners.

Have a program in place? Review the survey to see how well you’d do!

Quality Assessment and Performance Improvement programs require an ongoing effort of data collection, observation, documentation, reporting trends, findings and outcomes to the Governing Body Meetings – all in an ongoing effort to improve patient care services and the quality of that care. Implementing an ASC QAPI program takes time, and for it to work, vigilance. Begin with a specific topic and work through to the end of the current process, note issues, safety concerns, how often they occur, and how often they are in compliance (or not) with the ASC’s policy. Conduct a policy review meeting with staff to report findings and concerns, as well as train (and re-train). Then conduct regular follow-ups. Document the same process, and hold a Review meeting.

The data tells all! Have issues improved, or not?

Next time, Patient Rights – the often unintentionally neglected process. How does yours measure up?

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Is your ASC compliant with CMS? We can get you there!

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