SDS Accreditation Update

With Jan. 1 deadline bearing down, are you ready to comply with NPSG on infections?

Outpatient surgery managers in hospitals, surgery centers, and offices still have a lot of questions about The Joint Commission's (TJC's) National Patient Safety Goal (NPSG) on reducing the risk of health care-acquired infections, despite the fact that this goal must be fully implemented in a few short months.

By Jan. 1, 2010, hospitals, ambulatory surgery centers, and offices are expected to be in full compliance with these goals:

NPSG.07.04.01, central line-associated bloodstream infections;

NPSG.07.05.01, surgical-site infections.

Also, hospital-based programs are expected to be incompliance with NPSG.07.03.01, which focuses on multidrug-resistant organisms (MDROs).

"By Jan. 1, it's not a phase-in anymore," says Kathleen A. Catalano, RN, JD, FHIMSS, director of health care consulting for Perot Systems Corp., a Plano, TX-based provider of information technology services and business solutions.

Michael Kulczycki, executive director for ambulatory programs at TJC, says, "It's important to focus on, that by Jan. 1, they need to have entire program in place."

Meeting the deadline isn't the only reason to get your infection control program in order, Catalano says. There is an epidemic of Clostridium difficile (C. diff), according to the Centers for Disease Control and Prevention (CDC). The CDC estimates there are 500,000 cases of C. diff infection annually in the United States, up from 150,000 cases in 2001, and they contribute to 15,000-30,000 deaths. Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) are seeing the same types of growth, Catalano says.

To get your program in compliance, consider these common questions, with answers from TJC staff:

How do I meet the requirements for best practices?

The Joint Commission goal says providers need to implement best practices for preventing surgical-site infections, but some providers aren't certain what constitutes a "best practice," says Virginia McCollum, MS, RN, associate director of standards interpretation.

The definition is a practice that probably has found an effective way to implement an evidence-based guideline, McCollum says. For example, strategies that have been developed to meet CDC guidelines and that have been successful would be considered best practices, she says.

What is an evidence-based guideline?

The best example of an evidence-based guideline is from a group such as the CDC that has published guidelines that, based on research and evidence, are considered to be effective, "rather than perhaps someone's opinion on what might work," McCollum says.

Groups considered to be good sources for evidence-based guidelines include Healthcare Infection Control Practices Advisory Committee (HICPAC,, the Centers for Medicare and Medicaid Services (CMS,, and the Institute for Healthcare Improvement ( The Association of periOperative Registered Nurses (AORN), another good source, has tools including Recommended practices for prevention of transmissible infections in the perioperative practice setting. (For more information or to order, go to Under "Practice Resources," select "AORN Standards And Recommended Practices.")

Secondly, managers must provide the resources needed, Fugate says. Infrastructure requirements are personnel, education, and decision support and reminders.

What are the education requirements?

To comply with the NPSG, patients who are undergoing a surgical procedure and their families must be educated about surgical-site infection prevention before the procedure.

Educating staff about prevention of surgical-site infection should be given upon hire, annually, and when new surgical procedures are added, McCollum says.

Some freestanding surgery centers have assumed that the education must be conducted by someone who is certified by an infection prevention society, Kulczycki says. "Certification is not a requirement," he says. The Centers for Medicare & Medicaid Services also has clarified that certification is not required as part of their Conditions for Coverage. "They just need to demonstrate in some way that they have education or additional training that demonstrates their expertise," Kulczycki says.

How do we meet the challenge to measure and report the infection rates for 30 days following a procedure?

The goal requires providers to report and measure infection rates for the first 30 days following procedures. Implantable devices are to be followed for one year.

"Gathering that data for ambulatory and outpatient departments can be a challenge, depending on your relationship with the surgeon and providers," McCollum says.

The issue is that technically, the surgery center doesn't "own" the patient, Kulczycki says. "It's the physician's patient," he says. Thus, is takes a combination of effort by the outpatient surgery program and the physician to determine if there's been a post-surgical infection, Kulczycki says. For example, the center can ask the physician's office if it has had any communication with the patient about post-surgical infections.

McCollum says as you collect that data, "you can do a root-cause analysis, a performance improvement activity, to see if you're having an infection rate trend upward."

SDS Accreditation Update

Step-by-step guide for stopping SSIs

Meeting the National Patient Safety Goal (NPSG) on surgical-site infections (SSIs) is important, and not just from an accreditation standpoint, said Kelly Fugate, ND, RN, associate project director-specialist in the Division of Standards and Survey Methods at The Joint Commission.

SSIs are a concern because they add postoperative hospital days, increase risk of death, require lifestyle interruptions, cause suffering, and cost money, says Fugate, who spoke on "Strategies to Prevent Surgical-Site Infections" at the Perioperative Care Symposium sponsored by Joint Commission Resources earlier this year.

To address SSIs, use the "Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals" ( from The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). The compendium addresses SSIs, central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections, ventilator-associated pneumonia (VAP), Clostridium difficile, and methicillin-resistant Staphylococcus aureus (MRSA).

To use the compendium, follow these steps, Fugate suggests:

• Start with a risk assessment.

• Determine your focus/goals based on identified risks.

• Compare organizational practices with NPSG requirements (see NPSG.07.03.01, NPSG.07.04.01, and NPSG07.05.01).

• Refer to the compendium for further clinical detail on strategies to prevent health care-acquired infections (HAIs).

• Identify gaps.

• Plan and implement actions to align organizational practices with the compendium strategies.

• Evaluate effectiveness.

This approach is not required and will not be used during accreditation surveys by The Joint Commission, Fugate emphasizes.

The basic practices for SSI prevention and monitoring, according to Fugate, are:


Provide feedback on SSI surveillance and process measures to leaders, licensed independent practitioners, nursing staff, and other clinicians, she says.

Clinical practice.

Clinical practices to follow include antimicrobial prophylaxis, hair removal if necessary, blood glucose level control. Managers should provide feedback on compliance with process measures. Also, programs should implement policies and practices aimed at reducing SSI risk that meet regulatory and accreditation requirements and are aligned with evidence-based standards.


Educate surgeons, perioperative staff, patients, and families about preventing SSIs, Fugate says.

There are patient guides on HAI available at Under "download the patient guides," you can click on "surgical-site infections," then select "Central Line-Associated Bloodstream Infection," "Catheter-Associated Urinary Tract Infection," "Methicillin-Resistant Staphylococcus aureus" (MRSA), "Vancomycin-Resistant Enterococcus" (VRE), or other topics. Large print/English and large print/Spanish are available.


Leaders must establish priorities for performance improvement (PI). They must identify the individual(s) responsible for the infection prevention and control program, and they must evaluate the effectiveness of the infection prevention and control plan. Also, leaders allocate needed resources for the infection prevention and control program.

Accountability doesn't stop with the CEO or the senior managers, Fugate emphasizes. It includes staff in areas such as housekeeping and equipment processing, staff and family educators, and staff that support infection prevention and control programs, the laboratory, and the IT department.