Surgery centers will fulfill the requirements of an infection prevention program if they focus on all aspects regulators and accrediting agencies require. For instance, there must be a licensed healthcare professional serving as the designated infection preventionist in the ASC, says Phenelle Segal, RN, CIC, FAPIC, president of Infection Control Consulting Services in Delray Beach, FL.

The designee does not need to be certified in infection control, according to CMS regulations. The designated infection control person must document his or her ongoing education and training (annually) in infection control practices, according to Medicare’s Conditions for Coverage (42 CFR 416.51). The position also does not have to be full time, but an ASC should be prepared to tell a surveyor how many hours the infection preventionist spends working on prevention and control, Segal says.

“It’s expected that the person in charge of the program spends sufficient time on site directing the program,” she notes. Segal outlines the following key components of an infection prevention program that should be developed and maintained by an ASC infection prevention manager:

1. Develop an annual infection prevention and control plan. The annual plan should include: surveillance strategies, scope of program activities, quality/performance improvement indicators, program objectives, surveillance and reporting, responsibilities of administration/medical staff and infection control committee, job description for the infection prevention designee, communications, environment of care, care monitoring, and intervention protocols to interrupt transmission of infectious diseases, including healthcare-associated infections.

2. Develop annual facility risk assessment. This should be based on the ASC’s geographic location, population served, and services, Segal says.

“This is the requirement that I often see as incomplete,” she notes. The plan and risk assessment must be evaluated annually — or more often when risks significantly change, Segal says. “Once risks are identified, they need to be prioritized. Most people don’t know this, but it’s part of developing an appropriate risk assessment.”

ASCs sometimes conduct inadequate risk assessments, which can result in problems when they are surveyed by CMS or an accreditation organization. The risk assessment might include the following: review of overall infection prevention program; surveillance efforts; infection control priorities; evaluation of potential infection, contamination, and exposure risks; and description of the ASC’s community, including geographic location and population.

3. Develop annual, written goals and objectives. The annual risk assessment can produce information that helps an ASC prioritize its goals and objectives. These priorities are developed into written goals and objectives for the year. For example, if the ASC’s region recently experienced a CRE hospital outbreak, then staff education about CRE can become a top priority. Or, if the facility’s surveillance finds a pattern of inadequate handwashing, that can become a top prevention priority.

4. Integrate the infection prevention program into quality assurance/performance improvement (QAPI) initiatives. “The program is expected to identify key areas that need improvement,” Segal says. “So, we are very focused in today’s day and age and outpatient arena on performance improvement, quality assurance, and performance improvement, and these include infection prevention.” On a regular basis, such as quarterly or annually, the infection prevention designee should choose a QAPI project that is based on the surgery center’s risks, she says. “The purpose of integrating the infection prevention program into quality assurance is to make sure the facility, as a whole, understands the importance of performance improvement,” Segal explains. “Accreditation agencies always look for performance improvement projects, conducted on an ongoing basis, to make sure the facility understands there is always room for improvement. If an ASC does targeted projects, then they need to make sure it’s part of the overall infection control performance program.”

5. Assign competencies responsibility to infection prevention designee. The infection control point person should evaluate staff, assessing their competency. This includes evaluating staff on central processing, anesthesia, infection prevention practices, and environmental services, Segal says. Competencies can be performed annually or more often, if needed.

6. Follow nationally recognized guidelines and standards. As the infection prevention designee develops the program, nationally recognized guidelines and standards, including accreditation agency standards, should be followed. These will include Association of periOperative Registered Nurses (AORN), the CDC, and others.

7. Provide staff education at least annually. Infection prevention designees are responsible for educating their facility’s staff at least annuallyEducation can be provided through online modules or inservices. However, this education is different than that required for the infection control officer.

8. Oversee prevention practices. The infection prevention point person is responsible for overseeing staff’s aseptic and sterile technique, hand hygiene, and medical device reprocessing.

Oversight also includes monitoring the organization’s influenza vaccination program and acting as a liaison between departments, employees, and medical staff. Post-discharge surveillance also is part of the role and responsibility, Segal says.

9. Identify outbreaks and clusters. “ASCs should be familiar with identifying outbreaks or clusters of infections of surgical site or procedure-related infections,” she says. “Part of surveillance activity is to pull out the trends.”

10. Conduct root cause analyses. “The infection prevention designee should be familiar with how to conduct a root cause analysis,” Segal says.

According to the Six Sigma technique, a root cause analysis can start with five “whys,” as the analyzer follows this methodology: define, measure, analyze, improve, and control. The idea behind the five questions is that when someone asks the first “why” question, the answer will lead to a second “why” question, and so on (

11. Use isolation precautions appropriately. The ASC’s infection preventionist must institute and monitor appropriate use of isolation precautions, as indicated, Segal says.

“If the facility admits patients with multidrug-resistant organisms, then employees have to take isolation precautions,” she adds.

12. Report to the state. “In conjunction with the contract laboratory, you need to be familiar with how to report state-reportable diseases or conditions to the health department,” Segal says.

Consulting Editor Mark Mayo, CASC, MS, an administrator at an Illinois ASC, notes that another Medicare requirement calls for the incorporation of the infection control program into the ASC’s overall Quality Assessment and Performance Improvement (QAPI) Program. It must be evaluated annually for effectiveness by the ASC’s governing body, which has direct oversight and accountability for the entire QAPI program and plan (42 CFR 416.41).

Additionally, Mayo says Medicare ASC Conditions for Participation require that the infection control process be ongoing, proactive, comprehensive, data-driven using performance measures, and should focus first on high-risk, high-volume, and problem-prone areas (42 CFR 416.43).