The COVID-19 pandemic gives accredited surgery centers both a challenge and an opportunity.

Plenty of administrators continue to cope with the fallout of no elective surgeries for two or more months. But there is a ready-made quality improvement (QI) project waiting for attention: Ensuring all policies and procedures are in line with state, federal, and other infection prevention requirements concerning COVID-19.

After collecting data on the center’s performance, managers can write the QI report during any future times when elective surgeries are postponed because of COVID-19 surges, says Crissy Benze, RN, BSN, MSN, senior consultant at Progressive Surgical Solutions in Denver.

“Throughout the quarter, you are gathering all the data on different things occurring in your center, including operational data such as hand hygiene, medication management errors, [and] incident reports,” Benze says. “Then, the thing that can be done when you have down time — like [during] the pandemic — is to take credit for the work you’re doing and write up the study.”

The QI project’s goals will coincide with any new federal and state regulations. For example, some states require all patients to undergo a test for COVID-19 infection before surgery. These requirements, and any policies the surgery center has written, should be part of the policies and procedures customized to the facility.

Benze suggests surgery centers take several steps when performing a COVID-19 QI study:

Designate a coordinator. Typically, surgery centers work with a quality assessment performance improvement (QAPI) committee. For the COVID-19 QI project, managers should designate a coordinator and select employees who will be involved in collecting and analyzing data.

Align practices with regulations. “Make sure all policies and procedures are based on state requirements for universal masking, screening employees and medical staff, screening patients, and doing intubation and extubation,” Benze says.

If a surgery center uses general anesthesia, then there should be a respiratory protection program. Some centers may consider purchasing N95 respirators.

Conduct inservice education. Inservice education about COVID-19 practices and requirements should be given to all employees, regardless of time served.

“Go over all policies and procedures to ensure understanding of what is being implemented and monitored for compliance,” Benze suggests. “It’s easy to say, ‘Yes, we’re universally masking,’ but we know in some facilities the business office staff sits at their desk and they’re not putting on their mask. It’s easy to become complacent on some of these things.”

Education should include practice donning and doffing personal protective equipment (PPE) to ensure staff follow the steps correctly. “Go over screening policies and all new and revised policies,” Benze adds. “Make sure policies are based on nationally recognized guidance and state requirements for conducting elective surgery.”

Surgery centers can refer to videos about how to wear PPE or show staff information provided by the Centers for Disease Control and Prevention (CDC). “There are great videos by the CDC,” Benze says. “Or, you could have signage up at your facility to show the order of donning and doffing.”

Monitor compliance. The QAPI committee should monitor compliance over time, typically in three-month intervals. After collecting data, QAPI leaders should analyze their findings. For example, if there is excellent compliance among facility staff, but not among medical staff, then the solution would be to offer more education for the medical staff, Benze says.

The QAPI committee should select target goals. With COVID-19, these usually will be 100% compliance. “This is not like hand hygiene [in pre-pandemic times] where you knew you would not get 100% compliance,” Benze notes.

Observe behavior. Monitors will collect information about staff’s compliance with wearing masks, washing hands, wearing PPE correctly, disinfecting areas, screening patients, and enforcing social distancing.

If the goal is for all staff to wear masks at all times, then that behavior should be observed. The surgery center might specify when and who needs to wear N95s and PPE. All this must be observed and documented.

“Depending on the surgery center and how easy it is to get PPE, your business staff might wear masks from home,” Benze suggests. “If they are wearing masks from home, then you should go over cleaning protocols and expectations so they are not wearing a cloth mask day after day without washing them.”

Whatever the monitor observes, write it down. “Documentation is the only way you can demonstrate what was done,” Benze adds.

Analyze data, and re-educate. If observation data suggest staff complied only 85% of the time with some requirements, then the surgery center needs to re-educate staff on appropriate areas.

“Maybe everyone is doing a great job with screening for patients and staff, but it’s really around proper PPE that is a problem,” Benze explains. “Conduct more education for staff on how to wear PPE, and you spend the next quarter doing a remeasurement.”

For example, anyone wearing the N95 respirator has to go through an Occupational Safety and Health Administration (OSHA) fit test to ensure it is placed on the face properly. OSHA offers respiratory protection training videos here.

With other PPE, there is a certain order to which the items are put on and taken off. “It’s like with hand hygiene. Make sure they’re using alcohol hand rub or soap and water correctly,” Benze says.

Update policies, as needed. Every surgery center has instituted a new visitor policy. Such policies usually call for visitors to stay in their vehicles until the patient is ready to return home. But these might need to be updated as the pandemic evolves in certain areas or as regulatory requirements change. For example, cleaning nonpatient care areas. This procedure now includes the nursing care station, where staff should be disinfecting phones after each use. Staff also should maintain a cup for disinfected pens, wipe down the reception desk, and monitor bathrooms for frequent cleaning.

Write QI report. “You write it up, and report it to the QAPI committee at quarterly meetings,” Benze says. “The QAPI committee reports it to the governing body. If there is any corrective action needed, it’s discussed at the governing body level.”