Covering Compliance with The Joint Commission, AAAHC, and Medicare Standards

Minor surgery can equal major infection control woes


A report from the Pennsylvania Patient Safety Authority showed that 84% of the 733 events related to infection-control that were reported from ambulatory facilities from March 2004 through July 2012 were healthcare-associated surgical site infections (SSIs) that were a "complication of a procedure/treatment/test."

• Perform a risk assessment that includes training and experience of your s staff members and the procedures that are performed at your facility.

• Look to the manufacturers' instructions and sales reps for information, especially when devices change.

• Educate staff at hire, annually, and as needed.

• Ensure your inventory of equipment and devices is large enough.

A patient in Pennsylvania developed an infection six days after cataract removal, and the result was complete loss of vision. Another Pennsylvania patient underwent a bunionectomy, and 10 days later tested positive for osteomyelitis with a resistant organism. The patient's big toe had to be amputated.

These actual cases at ambulatory facilities, reported to the Pennsylvania Patient Safety Authority, show how seemingly minor surgical procedures can have major infection control problems. In fact, 84% of the 733 events related to infection-control that were reported from ambulatory facilities from March 2004 through July 2012 were healthcare-associated surgical site infections (SSIs) that were a "complication of a procedure/treatment/test." (To access the authority's free report, "Strategies to Fully Implement Infection Control Practices in Pennsylvania Ambulatory Surgical Facilities," go to

There has been no standardized surveillance definition for many higher-volume procedures performed in ambulatory facilities, the authority says. The current standard for some definitions is the National Healthcare Safety Network (NHSN). Expect federal action on this front shortly. By Dec. 31, the Department of Health and Human Services (HHS) will develop a set of ASC procedures for which SSI definitions and methods should be developed for ambulatory surgery centers (ASCs).

Another challenge for ambulatory surgery programs is meeting infection control standards. For the first half of 2013, 47% of hospitals, 37% of ambulatory care facilities, and 26% of office-based surgery facilities were out of compliance with The Joint Commission standard IC.02.02.01, which requires the facility to reduce the risk of infections associated with medical equipment, devices, and supplies. Additionally, 28% of ambulatory facilities were out of compliance with IC.01.03.01, which requires the organization to identify risks for acquiring and transmitting infections. To improve compliance and reduce infections at your facility, consider these suggestions:

• Perform a risk assessment before you create a written targeted infection prevention program.

Risk assessment includes items such as the training and experience of your staff members and the procedures that are performed at your facility, says Marsha Wallander, RN, associate director of the Accreditation Association for Ambulatory Health Care (AAAHC).

"You can hire a nurse who has an excellent background in infection prevention, but if she doesn't have a background in high-level disinfection and sterilization, you can't put her in charge of those processes until she's been educated," she says.

Every facility's risks are different, Wallander says. "It's hard to have a canned infection control program," she says. "It doesn't take into account the uniqueness of each patient population and staff training level."

Adhere to the manufacturers' practice instructions.

The engineering and design of equipment changes over time, Wallander says. For example, an endoscope manufacturer might add a lumen to a scope, she says.

"If you don't take the time to read the instructions, this version of the same company's piece of equipment may need a different cleaning process, a different push in teaching," Wallander says. "If you try to do to a new piece of equipment what you did to the old piece of equipment, you might not end up with a piece of sterile equipment."

Take the time to read the instructions, Wallander advises. Also, make sure you have a resource for questions and concerns, such as the manufacturer's sales rep, she says.

• Educate your staff.

Ensure the staff member assigned to perform cleaning or disinfection process is competent.

"The staff has to be educated," Wallander says. "That takes time."

The manufacturer's rep or technical staff can be a good resource for documented inservices, sources say.

AAAAHC standards require infection control prevention and training during initial orientation, at least annually, and as needed, Wallander says. "As an example, if you're hired as an employee today, I'll see you have that infection prevention and safety training tomorrow or this week, then I'll see you have pertinent refresher training on an annual basis," she says. "If I buy a new piece of equipment in three months or six months, I also have to train the staff on that."

Employees can demonstrate their competence at least annually, Wallander says. For example, a sterile processing tech can demonstrate the step-by-step process needed to clean a specific high-risk piece of equipment according to written policy and manufacturer instructions, she says.

Ensure appropriate inventory of surgical tools and instruments.

"If an organization doesn't have an appropriate inventory, it's very difficult for sterile processing to keep up with the reprocessing turnaround time," Wallander says.

Don't use shortcuts, she emphasizes. "Cutting corners compromises the safety of the patient and the staff," Wallander says. "I don't want to work with a sharp instrument that hasn't been sterilized."


Under recent changes from the Centers for Medicare and Medicaid Services (CMS), you cannot have a blanket statement in your advance directive policies saying that your facility doesn't honor them but that the facility will transfer a patient to a higher level of care if needed.

• You can decline to implement elements of an advance directive on the basis of conscience, if permitted by state law.

• Any limitations to following advance directives must be stated clearly in your advance directives policies.