Document, Assess, Audit: Improving Infection Prevention Procedures
One way ASCs can improve their infection prevention processes is by keeping their policies and procedures (P&Ps) aligned with standards, regulations, and nationally recognized guidelines.
Phenelle Segal, RN, CIC, FAPIC, a Florida-based infection control consultant often sees outdated P&Ps. “Part of the annual plan should include a facility procedure for review and revision of the policies,” she offers. “It’s important to establish a process for handling outdated policies and procedures. Every facility should establish a process for reviewing and revising these on a routine basis.”
Segal recommends that the schedule should be developed by the individual facility. The facility should review its infection control P&Ps at least every couple of years — if not more often. “They must keep a record of when the policy was approved by their governing body, and that’s usually in the minutes,” she notes. “Keep a record of when specific policies are approved.”
These practices would be important to maintain in the event the ASC ever faces a lawsuit. There are several additional steps ASCs could take to improve their overall infection prevention program:
• Create infection prevention cultures. Atlanta-based consultant Stanford R. Plavin, MD, says surgery centers follow many different models for their operations. The vast majority are licensed, accredited, and provide the highest caliber patient care experiences. Some conduct quarterly evaluations and audit their infection prevention activities regularly. How surgery centers conduct hand hygiene, how they ensure staff wear protective equipment properly, and how they clean and process equipment are scrutinized and evaluated with these ongoing infection prevention processes.
But Plavin says there is a less visible aspect to infection prevention compliance: “For me, it’s important to make sure staff is aligned,” he explains.
A positive change is that recently trained physicians are more familiar with appropriate infection prevention practices. While older physicians tend to have to adapt and change habits according to more regimented guidelines, hand hygiene and other practices are habits new doctors have developed since they began their training. Thus, newer doctors could serve as natural role models for all ASC staff, Plavin notes.
“It all comes down to the leadership,” he adds. “Leaders set the tone and hold staff accountable.”
• Focus on staff education. “Communication is absolutely key,” Segal says. “When issues come about in the surgery center, whether they’re identified from an outside source or within, communicate this information to all staff members.” Everyone in the ASC needs to hear the message and feedback.
“While doing an onsite consult, I recently heard a complaint from a surgery center employee who said, ‘Why don’t we ever see your report?’” Segal recalls. “Whenever outside personnel come in and either do a survey or consult or any discussion, it needs to be communicated to staff and used to educate staff as well.”
Staff education about reprocessing and disinfecting equipment might come from product sales reps, particularly when an ASC purchases new equipment and products. “Get in touch with the sales reps and have them come in and do an inservice,” Segal advises. “That’s a good way to educate staff.”
Infection prevention education also should include periodic updates, often based on the infection preventionist’s observations of staff’s compliance with infection prevention P&Ps. For example, Segal often sees inconsistencies in how surgery center staff handle skin preparation. Whenever the ASC introduces a new product or piece of equipment, there should be an educational session.
“Make sure employees fully understand how to use it, clean, disinfect, and sterilize the equipment,” Segal says. “This also is where the company selling the product can do an inservice.”
Online training also is useful. Sometimes, this is the best option because employees can complete this training when it is most convenient for them.
“They can sign off on the educational sessions electronically,” Segal adds.
ASCs can find great examples of online infection prevention education through the Association of periOperative Registered Nurses (AORN) and the Association for Professionals in Infection Control and Epidemiology (APIC). AORN offers several webinars and publications related to infection prevention, including information about hand hygiene. APIC offers information on the developmental path of the infection preventionist.
Since education really should be ongoing, another easy way to ensure staff maintain cleaning, disinfection, and sterilization compliance is to place instructional posters in key areas, such as the decontamination room and the sterilization room, Segal suggests.
“Keep a binder with all of the manufacturers’ instructions for use [IFU] in a central location that is accessible to every employee,” she adds. “Surveyors will come in and ask where this information is kept.” Another option is to keep manufacturers’ instructions for use available online through a subscription with a company that maintains current and past IFUs.
• Document diligently and thoroughly. The reprocessing department should document their process, including details about monitoring, sterilization, and the physical, chemical, and biological properties that have to be monitored and documented as per guidelines, standards, and manufacturer’s instructions.
• Document all staff education. “Use sign-in sheets for inservices,” Segal says. “Always document who was there, the date, the speaker, the topic, and have everyone sign it.”
• Monitor and audit in house. In-house auditing could be designated to a consultant. This work usually includes assessment of the reprocessing room and central processing department along with monitoring of sterilization processes, Segal explains.
“When I go in as a consultant, the first thing I want to see is their logs,” she says. “Their monitoring of the sterilization processes has to be placed in logs and available for review.”
• Provide annual competencies. When a surgery center’s processes are audited, reviewers typically look at the annual competencies, Segal says. “These include the central processing techs,” she adds. “Infection prevention designees should have annual competencies.” APIC offers a sterilization competency that includes a step-by-step process on central sterilization. Safe injection practices should be monitored by way of a competency.
• Handle breaches. It is important to maintain documentation that can be reviewed in the event of a breach. The infection preventionist can conduct a root cause analysis and also determine if there has been a more far-reaching breach that may require notifying the health department and (possibly) patients.
“If they identify a breach, it’s up to the surgery center to figure it out and take a systematic approach to figure out what went wrong,” Segal says.
ASCs can improve their infection prevention processes is by keeping their policies and procedures aligned with standards, regulations, and nationally recognized guidelines. Experts explain several additional steps centers could take to improve their overall infection prevention program.
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